BACKGROUND/RATIONALE:
Stroke is among the leading causes of death and is a major cause of serious and long-term disability in the United States. Within the VHA system, approximately 80,000 veterans are stroke survivors. Each yeat, about 11,000 veterans are hospitalized with a newly acquired stroke, and 2,500 VHA stroke patients receive acute rehabilitation services. Further, stroke is the third most frequent hospital diagnosis, and stroke-related diseases consume an estimated $1 billion for VHA each year. In order to provide the best quality of care across the continuum and to prevent secondary or recurrent stroke in our veterans diagnosed with stroke, it is important for policy makers, researchers, and clinicians to understand the geographic distribution of stroke cases and the residential setting of the patients. (We originally proposed to study three groups of Veterans diagnosed with acute stroke -- VHA users only, Medicare users only, and VHA-Medicare dual users. However, we were unable to obtain the needed Medicare data, and this report was prepared based upon project revisions and using VHA data only.)

OBJECTIVE(S):
The objectives were to: (1) define the characteristics of the overall study patients; (2) calculate and compare the prevalence of acute stroke and crude mortality among the patients in Stroke-Belt states (Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Virginia) and the rest of the states in the mainland US; (3) determine comparison groups (rural patients vs. urban patients; ischemic stroke patients vs. hemorrhagic stroke patients) and compare the characteristics between each pair of patient groups; (4) assess risk-adjusted differences in five different health service utilization outcomes; and (5) estimate risk-adjusted differences in three health-related outcomes between each pair of comparison groups.

METHODS:
This was a retrospective study, and the sample included all VHA patients who had an acute stroke diagnosis recorded in the 2001-2002 VHA inpatient database (PTF). A high specificity stroke algorithm using ICD-9 codes was applied to determine patients' stroke status. The five utilization outcomes were: 12-month all-cause hospital stays, outpatient clinic visits, hospital readmissions for recurrent stroke, hospital stays for preventable medical conditions, and rehabilitation therapy use. The three health outcomes included: 12-month mortality, bone fracture, and discharge disposition from patients' index stroke hospitalization.

FINDINGS/RESULTS:
Among the 9,691 VHA acute stroke patients in 2001 and 2002, 88.5% were ischemic and a third lived in rural areas. The ischemic and rural patients were significantly different from their hemorrhagic and urban counterparts, respectively, in several aspects of demographic and clinical characteristics. The traditionally defined Stroke Belt for the general population also existed within the VHA system in terms of higher acute stroke prevalence (2.7/1,000 VHA users in the Stroke Belt states vs. 1.9/1000 VHA users for the rest of the states and DC) and higher crude mortality (25.3% Stroke Belt stroke patients vs. 23.3% stroke patients in the rest of the states/district). Our risk-adjusted analyses showed that rural stroke patients faced less desirable discharge dispositions from their index stroke hospitalization, had less average number of outpatient clinic visits, and were less likely to receive rehabilitation therapy within the 12 months poststroke hospitalization as compared with their counterparts who lived in urban areas. As we expected, the ischemic stroke patients (vs. the hemorrhagic stroke patients) were more likely to be discharged home from the index stroke hospitalization, to be readmitted for recurrent stroke inpatient care, to receive rehabilitation therapy, and to visit outpatient clinics in the 12 months post-index stroke, after adjusting for the risk factors.

IMPACT:
The systematic profile of the characteristics of the VHA acute stroke patients, and the results from Stroke Belt analyses, and rural-vs-urban and ischemic-vs-hemorrhagic patient comparisons, provide important reference information for VHA policy makers, researchers and clinicians in the field of stroke. Adequate access to needed post-stroke care of rural patients would enhance the patients' stroke recovery.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Jia H, Cowper Ripley DC, Wu SS, Vogel WB, Litt ER, Tang Y, Chen GJ. Stroke and preventable hospitalization: Who is most at risk? Federal practitioner : for the health care professionals of the VA, DoD, and PHS. 2010 Dec 1; 27(12):14-20. [view]

Conference Presentations

1. Jia H, Cowper Ripley DC, Tang Y, Wu SS, Vogel WB, Chen GJ. A Study of Mortality among Veterans with Acute Stroke. Poster session presented at: AcademyHealth Annual Research Meeting; 2010 Jun 28; Boston, MA. [view]
2. Chuang HC, Jia H, Cowper Ripley DC, Vogel WB, Wu SS, Chen JG, Litt E, Reker DM. Factors Related to Preventable Hospitalization among VHA Stroke Patients. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 15; Baltimore, MD. [view]
3. Jia H, Cowper Ripley DC, Tang Y, Vogel WB, Wu SS, Litt ER, Wilson LK, Chen GJ. Post-acute stroke rehabilitation utilization: Are there difference between rural-urban patients and taxonomies? Poster session presented at: VA HSR&D National Meeting; 2011 Feb 16; National Harbor, MD. [view]
4. Jia H, Cowper Ripley DC, Tang Y, Wu SS, Vogel B, Chen GJ, Tang Y. Rural/urban Veterans with stroke: who is counting what? Paper presented at: VA HSR&D Rural Health / VA Office of Rural Health Field-Based Meeting; 2010 May 6; Portland, ME. [view]
5. Jia H, Cowper Ripley DC, Tang Y, Litt ER. The Stroke Belt: Does it also exist among VHA users? Poster session presented at: AcademyHealth Annual Research Meeting; 2010 Jun 28; Boston, MA. [view]

DRA: Health Systems
DRE: Epidemiology
Keywords: Access, Chronic disease (other & unspecified), Outcomes, Stroke, Utilization patterns
MeSH Terms: Outcome and Process Assessment (Health Care)