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Rural/urban disparities in quality of care in VHA users with ischemic stroke
Jia H, Chumbler NR, Li X, Phipps M, Williams LS, Bravata DM, Vogel B, Castro JG. Rural/urban disparities in quality of care in VHA users with ischemic stroke. Poster session presented at: VA HSR&D Rural Health / VA Office of Rural Health Field-Based Meeting; 2010 May 5; Portland, ME.
This is the first examination of rural/urban disparities in stroke quality indicators in the VHA. We sought to determine whether there existed rural/urban disparities in acute stroke care quality among a national sample of VHA users diagnosed with ischemic stroke.
In this retrospective, observational study, a national sample of VHA users was randomly selected. All these patients (N = 3,931, excluding 50 patients with Puerto Rico ZIP codes and additional 6 patients with invalid ZIP codes) were diagnosed with ischemic stroke within the VHA system during fiscal year 2007. Outcomes included the following 14 inpatient stroke quality indicators: (1) dysphagia screening before oral intake, (2) NIH Stroke Scale (NIHSS) completed, (3) tPA given, (4) deep vein thrombosis (DVT) prophylaxis, (5) antithrombotic therapy, (6) early ambulation, (7) fall risk assessment, (8) pressure ulcer risk assessment, (9) rehabilitation consultation, and (10) antithrombotic therapy at discharge, as well as (11) atrial fibrillation management, (12) lipid management, (13) smoking cessation counseling, and (14) stroke education. The commonly used Rural-Urban Commuting Areas (RUCA) codes (version 2) were applied to define each patient's rural-urban status. Statistical inference (chi-square tests on categorical data, t-tests on numerical data) was performed to compare the characteristics between the two groups of patients (rural, urban). Multivariate logistic regression model was fitted to assess the rural/urban disparities for each of the 14 quality indicators, adjusting for patients' age, race/ethnicity, stroke severity measured by Apache score and NIHSS, medical comorbid conditions, smoking status, as well as the complexity and workload of the VAMCs that provided the care.
Among the 3,931 study patients, the RUCA codes yielded 73.5% urban and 26.5% rural VHA patients. Compared with their urban counterparts, the rural patients were significantly older (mean age 69 vs. 67 years), were more likely to be white (84.5% vs. 63.2%), have higher 6-month post-index mortality (9.6% vs. 7.7%), and have a higher average NIHSS (5.1 vs. 4.4). The VHA facilities that provided the care to the rural patients as compared to the urban patients had lower complexity (56.4% vs. 81.6%). All these results were at a significant level of p < 0.05. After adjusting for patient demographics, disease severity and structural characteristics, we found that there existed rural/urban disparities in 6 of the 14 inpatient stroke care quality indicators. Compared with their urban counterparts, the rural patients were significantly (p < 0.05) less likely to complete NIHSS (19.4% vs. 26.2), to receive DVT prophylaxis (71.7% vs. 7.9%), to receive antithrombotics at discharge (95.8% vs. 96.3%), and to receive smoking cessation counseling (90.1% vs. 94.3%). However, the rural patients were more likely to document to document FIM assessments (86.9%) and to receive lipid management (19.3% vs. 15.2) than urban patients.
Stroke is the second leading cause of death and a major cause of functionality impairment among the general US population as well as the VHA enrollees. Understanding the implementation rate of different evidence-based inpatient quality indictors among patients with different residential settings not only helps the policy makers and clinicians comprehend the gaps in acute stroke care, but also helps strategize our implementation plan in order to improve stroke survivors' functional recovery.
Our findings help the VA policy makers, clinicians and implementation scientists understand the rural/urban disparities in inpatients care indicators. Improving the NIHSS assessments, DVT prophylaxis and antithrombotics management, and smoking cessation counseling among rural VHA patients with ischemic stroke would help improve care quality for these patients.