Association Between Stroke-Related Hospital Discharge Status and Socio-Demographic Characteristic in Tennesse

To the School of Graduate Studies and Research:
I am submitting herewith a thesis written by Edward M. Davis Jr. entitled:

"ASSOCIATION BETWEEN STROKE-RELATED HOSPITAL DISCHARGE STATUS,
SOCIO-DEMOGRAPHIC CHARACTERISTICS, INSURANCE STATUS AND URBANRURAL RESIDENCE IN TENNESSEE." I have examined the final copy of this thesis
for form and content and recommend that it be accepted in partial fulfillment of the
requirements for the degree of Master of Science in Public Health in the Division of
Public Health Practice.
Director, MSPH Program

We have read the thesis and
recommend its acceptance:
Chair
Accepted for the Graduate School
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Dean, School of Graduate Studies and

Research
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
ASSOCIATION BETWEEN STROKE-RELATED HOSPITAL DISCHARGE STATUS,

SOCIO-DEMOGRAPHIC CHARACTERISTICS, INSURANCE STATUS AND URBANRURAL RESIDENCE IN TENNESSEE
A Thesis
Presented for the
Masters of Science and Public Health Degree
Meharry Medical College
Edward Mitchell Davis Jr.

May 2010
UMI Number: EP31636
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ii
DEDICATION
This thesis is dedicated to my sisters, Erica Megan Davis and

Michelle Nichole Brady-Davis.
iii
ACKNOWLEDGEMENTS
I would like to thank God for giving me the strength and focus to complete this
thesis project. I would like to thank my thesis committee: Dr. Green Ekadi, Mr. Paul
Henkel and Dr. Chau-Kuang Chen, for helping me mold this project into its present form.
Finally, I would like to thank my family for their constant encouragement and support,
thank you for providing me with the opportunities to attain my dreams.
ABSTRACT
Background: In the United States, more than 795,000 Americans suffer from a new or
recurring stroke. The southeastern region of the United Stated, known as the "stroke
belt", has a disproportionate rate of stroke cases compared to other areas in the United
States.
Problem: Tennessee ranks fifth in the nation in stroke prevalence. Research shows that
African-Americans (AA) have an increased risk of stroke incidence and severity
compared to Caucasian Americans (CA).
Objective: This study investigates what factors help to predict where stroke patients will
be discharged to when they complete stroke related in-hospital stays,
Methods: Patient discharge status, the dependent variable, classified as discharge to:
home, assisted living facility (ALF) or inpatient rehabilitation facility (IRF). Independent
discharge variables included; age, race, sex, insurance, and urban-rural residence.
Multinomial logistic regression was used for analysis.
Results: Determinants of ALF discharge versus home were: stroke type (hemorrhagic
[OR 6.38], ischemic [OR 4.38]) and public insurance [OR 1.20]. Determinants of IRF
discharge versus home were: stroke type (hemorrhagic [OR 24.71], ischemic [15.85])
and urban residence [OR 1.18]. AAs and Women aged 70 years were more likely to be
discharged home versus any other discharge destination; possibly due insurance,
income, and family support. Stroke-related discharge incorporates associations that are
important to the public health impact of stroke in Tennessee.
v
TABLE. OF CONTENTS
CHAPTER
PAGE
I.
INTRODUCTION
II.
REVIEW OF SELECTED LITERATURE
III.
METHODOLOGY
32
IV.
RESULTS
41
V.
DISCUSSION
48
REFERENCES
57
APPENDICES
63
VITA
67
vi
LIST OF ABBREVIATIONS
Intracerebral Ischemic Stroke
ICH
Subarachnoid Hemorrhage
SAH
Transient Ischemic Attack
TIA
African-American
AA
Caucasian-American
CA
Hospital Discharge Data System
HDDS
Assisted Living Facility
ALF
Inpatient Rehabilitation Facility
IRF
vii
INTRODUCTION
Background
Each year more than 795,000 Americans suffer from some type of new or
recurring stroke. In the United States, the number of deaths due to stroke averages
more than 143,000 each year (Lloyd-Jones, 2009). Stroke is currently the third leading
cause of death in the United States, third only to heart disease and cancer
("FASTSTATS - Deaths and Mortality", 2009). About 25 percent of those who suffer
from strokes die at the time of the event, or soon after, and 15-30 percent remain
permanently or severely disabled.
More than one million Americans and their families live with the disabling
effects of stroke. Over the years, researchers have observed trends in prevalence and
incidence in stroke cases among certain races and age groups in the United
States.("The Paul Coverdell National Acute Stroke Registry," 2009) The most significant
of these trends are observed among African-Americans 35 years and older. In addition
to these trends observed in age and race, there are also geographical trends observed
in certain areas of the United States where there are increased prevalence and
incidence of stroke victims.
Nature of the Problem

There is a severe disparity of stroke-related hospital admissions and
discharges among African-Americans due to greater severity of cerebrovascular disease
type. The southeastern region of the United States has had the highest incidence and
mortality of stroke (Alberts, 1995). Several states in this region are collectively known as
the "stroke belt". This region of the United States consists of an eleven state regions
including Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, Mississippi, North
Carolina, South Carolina, Tennessee and Virginia. These states have been classified as
the stroke belt due to the significantly greater incidence of stroke in these states
compared to the United States collectively. Tennessee has the fifth highest prevalence
of stroke in the nation ("Prevalence of Stroke - United States 2005," 2007). In 2005, the
deaths due to stroke in Tennessee versus the United States population were 63.0 per
100,000 of population and 46.6 per 100,000, respectively (Vital Health Statistics, 2008).
The CDC Atlas of Stroke Mortality reports higher deaths due to stroke
among males than females, however females experience a greater number of lifetime
events and hospitalizations (Casper, 2003). However there is great degree of
controversy regarding sex differences in stroke incidence and severity (Petrea, 2009).
Similar to national data and statistics, stroke is the third leading cause of death in
Tennessee, accounting for 7% of the deaths in 2004.("Tennessee Heart Disease and
Stroke Prevention Program: Statistics and Reports," 2006). For African-Americans and
Caucasian-Americans in Tennessee, the age-adjusted rate of death due to stroke is
higher among Caucasian-Americans. However, in Tennessee, this requires more
research due to lack of data reported for locations with low populations, especially
among minority populations.
Significance of Study
Incidence and prevalence of stroke in Tennessee are among the highest
in the United States. In addition, in 2008, Tennessee was among the states in the South
that had the highest population living below the poverty line (DeNavas-Walt, Proctor, &
Smith, 2009). This is significant in terms of access to care, insurance coverage, and
incidence of illness. According to the demographic features of this regional population
and measure of overall disparity among the population at risk for cerebrovascular
populations, there is a correlation between risk and severity of disease that must be
researched further. With population characteristics such as these it is important to
better understand the association between these factors and severity of stroke to
determine the best care procedures. Stroke related hospital admission and discharge
are an important source of data to analyze in order to determine the threats and
characteristics which contribute most to the occurrence of stroke among different
demographics of Tennesseans.
This study will compare stroke incidence based on case severity with factors
such as urban-rural residence in Tennessee, socio-demographic characteristics,
insurance status, and patient status at discharge to better understand and address the
disparity of health care access and quality of care to rural and urban communities.
Previous studies, which focus on measuring stroke severity, have evaluated the impact
of stroke using differently methods of measurement. In this study however, severity is
determined based on the outcome of each individual stroke-related hospital discharge.
Where a patient was discharged to (level of care) will suggest how severe his or her
stroke event was. Each patient's severity of illness is attributed to each patient's
diagnosed condition, and is highly dependent on where the patient was discharged.
Post-discharge, each level of post-stroke care suggests an implied level of self-care. An
3
individual who is discharged to his or her home is able to complete all activities of daily
living or require assistance with which another member of the household can provide
assistance. A stroke-patient discharged to an inpatient rehabilitation hospital has little or
no ability to provide care for himself or herself. An intermediate care facility, which
provides assisted living care, allows some patient independence, and self-care.
In this study, the results will attempt to outline a pattern of stroke occurrence
based on stroke type, origin of admission (residence), and patient demographics.
Analyzing the factors that contribute to health status is important in investigating how
health related predictor variables contribute to understanding linkages among behavior,
lifestyle and population health.
Theoretical Framework for Study

The Population Health Model forms the theoretical framework for this study, it
has been in existence since the time of Hippocrates, and has been instrumental in
explaining causes of disease and providing health care ever since (Radzyminski, 2007).
The Population Health Model incorporates theories regarding two broad perspectives,
the understanding of macro-level trends in health status, and the evaluation of the
performance of the healthcare system (Singer & Ruff, 2001). These perspectives are
important because they target behavior and lifestyle, as they relate to the onset and
outcomes of disease. The Population Health Model is useful to frame this research
project because it considers relationships among an individual's biologic characteristics,
and their interactions with peer groups and families. In addition, the economic, cultural,
social, and physical environmental conditions at the local, national and global levels
(Fielding, Teutsch, & Breslow, 2010).
This study is modeled after the Population Health Model framework, because it
plans to determine a relationship between the predominant input variables of the Model
including: biologic, geographic, social economic status (SES) and socio-demographic
factors. The contextual trends associated with certain diseases are important to study
instead of simply the biologic trends of a disease. Supporters of the Population Health
Model have emphasized the importance of the Model addressing health disparities
because, "although human biology is relatively uniform across the species, thus lending
itself to the medical model, human behavior, culture, and social change are not,...good
health depends on much more than adequate diagnosis, treatment, and patient
knowledge of health care issues" (Radzyminski, 2007)
Objectives of Study
The objectives of this study are: (1) to evaluate the association between
Tennessee stroke-related hospital discharges and socio-demographic characteristics
such as age, sex and race, (2) to evaluate the association between stroke-related
hospital discharges and rural-urban residence, (3) to evaluate the association of strokerelated hospital discharges with insurance status.
REVIEW OF SELECTED LITERATURE
Stroke Type and Severity Measures

Stroke, a disease that affects the blood vessels leading to and within the brain,
can manifest itself in three forms, two primary stroke forms, and a tertiary "stroke-like"
attack; hemorrhagic, ischemic, and transient ischemic attack, respectively. Each of
these stroke types will be identified further and in detail in this study. Transient ischemic
attack (TIA), or transient cerebral attack, is classified as a clinical syndrome caused by
inadequate cerebral or ocular blood supply due to arterial thrombosis or embolism (blood
clot) byway of arterial, cardiac, or hematological disease.(M. Correia, M. Silva, R.
Magalhaes, L. Guimaraes, & C. Silva, 2006)
The primary descriptive trait of a TIA is that it is usually resolved within 24 hours,
and is often characterized as a "warning stroke."("What you need to know about TIAs,"
2009) In terms of each of the three stroke types, a TIA is the least severe of
cerebrovascular attacks because there is no permanent injury to the brain and, as the
definition states, it resolves itself within 24 hours.fWhat you need to know about TIAs,"
2009) Ischemic attacks, however are a more severe manifestation of stroke in
comparison to TIAs, due to the fact that they are not resolved in short periods of time.
Ischemic strokes occur as a result of an obstruction within a blood vessel supplying
blood to the brain, either through cerebral thrombosis (blood clot) or cerebral embolism
(transport of blood clot)("Types of Stroke," 2009). The most severe manifestation of
6
cerebrovascular attack involves hemorrhage of vessels in the brain or in the vessels

leading to the brain. There are two types of cerebral hemorrhage that may occur;
subarachnoid or intracerebral cerebral hemorrhage (American Heart Association, 2009).
Primary intracerebral hemorrhage (PICH), also called simply intracerebral hemorrhage,
ranges from 78-88% of all hemorrhages of small vessels damages by chronic
hypertension or amyloid angiopathy (Paolucci, et at., 2003).
Cerebrovascular disease hemorrhage is estimated to affect an extensive
population worldwide each year. Most individuals affected by this form of stroke are
disabled or require rehabilitation services and in some cases die due to its effects on the
brain. In comparison to ischemic stroke, or cerebral infarction, there is a higher risk of
fatality due to hemorrhage stroke. However, in a study regarding the outcomes of
cerebrovascular disease cases, researchers found that stroke survivors diagnosed with
hemorrhagic stroke had better neurologic and functional progress than ischemic stroke
patients (Chae, Zorowitz, & Johnston, 1996). A similar study, which aimed at clarifying
the rehabilitation results between ischemic and hemorrhagic patients also found that
there was better functional recovery among intracerebral hemorrhage stroke patients, in
comparison to ischemic stroke patients. In fact, the in the matched comparison the
researchers also found that hemorrhagic patient also had better discharge status
following inpatient discharge as well (Paolucci, et al., 2003). The most significant factor
that was accounted for in the in the Paolucci study is stroke severity. Stroke severity is
considered the most powerful prognostic factor, and can describe the reason why many
patients who experience ischemic stroke, have worse outcomes that those who
experience hemorrhagic stroke.
The-level of stroke severity is a measure that is difficult to determine based on
the stroke diagnosis alone. This is supported by the fact that some hemorrhagic stroke
7
patients experience better outcomes that ischemic stroke patients. One would infer that
the exact opposite would be the case; however this is not accurate in all situations.
Many researchers have made use of stroke scales to determine severity of patient
strokes. Some of the most popular and widely used stroke scales to determine severity
or level of disability are, the Scandinavian Stroke Scale (SSS) (Anderson, Olsen,
Dehlendorff, & Kammersgaard, 2009), the NIH Health Stroke Scale (NIHHS) (Schlegel,
Tanne, Demchuk, Levine, & Kasner, 2004), the Barthel Index (Horner, Matcher, Divine,
& Feussner, 1991) and the All patient refined diagnosis related group (APR-DRG)
subclass severity of illness. While the APR-DRG subclass severity illness is a measure
related to all hospital related diagnoses and procedures, not just stroke, it is a good
measure for any procedure which takes place in a hospital setting. TIA will be classified
as a "warning stroke" and will be included in analysis in terms of the risk factors
contributing to its onset, however because it is the least severe, by definition resolving
itself in 24 hours and not indicative of an official stroke classification, it will be classified
as the least severe stroke type for this thesis project (Shen & Washington, 2007).
Hemorrhagic stroke types, including subarachnoid and intracerebral hemorrhage,
are the most severe stroke types in comparison to ischemic infarction. In a recent study
comparing the two cerebrovascular disease types, hemorrhagic has found to be most
severe and detrimental to patients. In this study the SSS stroke scale was used to
determine the effects of stroke on patients. Stroke scales differ based on the variables
used to measure level of severity; the SSS scale evaluates level of consciousness, eye
movement, power in arm, hand and leg orientation, aphasia and facial paresis.
Collectively these measures calculate an aggregate score which is given to each patient
upon evaluation to measure stroke severity. This is an important function of treatment
and care, because stroke case severity in many cases determines destination of
8
discharge among other things. In the study by Anderson et a, 2009, patients with
hemorrhagic stroke were found to be more severe when compared to ischemic infarct.
The SSS stroke scale is measured using a 0-58 point scale, 0 being the most severe
case. The mean SSS score of ischemic infarct and hemorrhagic stroke were 28.3 and
42.9 respectively (p<0.001). This supports that hemorrhagic stroke cases are
significantly more severe than ischemic attacks. The level of stroke severity directly
coincided with hemorrhagic stroke; in fact only 2% of hemorrhagic stroke had the lowest
severity while 30% had the highest severity (Anderson, Oisen, Dehlendorff, &
Kammersgaard, 2009).
In a similar study, the researchers reported that hemorrhagic stroke is directly
associated with higher mortality among these patients (Shen & Washington, 2007).
These results were also found in a study which measured rehabilitative recovery of
patients post-stroke. Stroke has debilitating effects on stroke patients based on severity
of each stroke case. Among patients who suffered from hemorrhagic stroke, there was
more significant functional impairment than among the ischemic infarct patients (Kelly, et
al., 2001). This study confirms the clinical validity that hemorrhagic strokes are
considered a more severe stroke type than ischemic stroke. Severity in most cases
increases based on the amount of relevant risk factors recorded for each patient. The
most significant risk factors observed are those that contributed most to severity of
hemorrhagic stroke were high alcohol intake and smoking (Anderson, Olsen,
Dehlendorff, & Kammersgaard, 2009). These results show that based on patient's
health behavior and practices, many people experience difference levels of stroke
events.
Another stroke scale used to measure severity and determine the rehabilitation
effects based on stroke diagnosis is the Barthel Index, which measures ability to
9
complete activities of daily living. The rehabilitation rate based on stroke type is a
measure which is important to severity and for determining the "best" discharge setting
for post-stroke patients. Using the Barthel Index as a measure of stroke severity, the
research hers found that the outcome determinants for rehabilitation included age and
onset-admission interval (OAI) which determines the patient's status at admission to the
treating hospital. Each of these factors contributes to the functional outcome for each
patient. To distinguish severity by stroke type, stroke cases were grouped and matched
by diving cases into two stroke types: ischemic stroke and hemorrhagic stroke. By
matching the stroke types, a clear characterization of the role of each prognostic factor
on functional outcome of severity on rehabilitation of stroke patients was observed and
the role of the association of the prognostic factors which contribute to outcome in
analysis was minimized (Paolucci, et al., 2003). Using the Barthel Index, results of this
study showed that better functional recovery was observed among hemorrhagic stroke
patients in rehabilitation compared to ischemic patients. Hemorrhagic stroke patients
showed significant functional gains at a faster rate than ischemic patients. The results
among hemorrhagic patients' recovery is significant because using a severity measure
towards recovery, is useful to improving knowledge on rehabilitation among stroke
survivors.
A third example of a stroke scale used to determine stroke severity is the
National Institutes of Health Stroke Scale (NIHSS). The NIHSS is a scale which
measures neurological deficit and has been used as a predictive outcome measure for
stroke events (Lyden, et al., 1994). This scale considers several different stroke related
effects to determine severity and discharge outcome in its calculation. These effects
include level of consciousness, gaze, visual fields facial palsy, motor strength, ataxia,
sensation, language, dysarthia, and inattention, and have been found to be effective in
10
predicting hospital discharge disposition in prior studies (Schlegel, Tanne, Demchuk,

Levine, & Kasner, 2004).
Another method for determining case severity is through the "severity of illness",
subclass from the prospective payment system (PPS) diagnosis related groups (DRG)
developed by Yale University. The DRG system takes all possible diagnoses from the
ICD-9-CM system and classifies them into 25 major diagnostic categories by organ
system (Cleverley & Cameron, 2007). The DRG system is a classification system that
hospitals use to relate types of patient hospital treatments (i.e., its case mix) to the costs
incurred by the hospital. There are three different forms of DRG classes that hospitals
use to determine case mix: the basic DRG (used by the Centers for Medicare and
Medicaid Services (CMS) for hospital payment for Medicare beneficiaries), All Patient
DRGs (an expansion of the basic DRGs to be more representative of non-Medicare
populations) and All-Patient Refined DRG (only grouping which incorporates severity of
illness in patient classification) (3M Health Information Systems, 2003).
The APR-DRG was expanded with severity of illness and risk of mortality
because no other DRG classification system addresses these pertinent characteristics of
patient care. The APR-DRGs expand the basic DRG structure by adding four
subclasses to each DRG. The addition of the severity of illness is important to hospital
patient care, and has represented solid measures in determining hospital illness and
severity well in practice. In a study which tested the differences and accuracy of
inpatient severity of illness, code-based severity scales performed significantly better
than clinical measure to assess severity. Diagnosis codes indicating postoperative, lifethreatening conditions contribute to the superior predictive power of code-based
measures (Lezzoni, Ash, Shwartz, Landon, & Mackiernan, 1998). Odds ratios were
derived from the data in the previous study, and the results showed that code-based
11
measures performed statistically better. These results are highly significant in proving
the accuracy of the code-based severity measures, compared to other stroke scale
measures. Though the DRG related severity of illness is not explicitly stroke specific as
many of the other stroke scales, it is a reliant predictor of severity and is useful in
determining patient guidelines.
A final measure of stroke severity is the utilization of post-stroke rehabilitation
facilities such as nursing homes and rehabilitation inpatient hospitals. In 2001,
approximately half of all stroke survivors were discharged to an institutional setting (18%
inpatient rehabilitation, 30%skilled nursing facility) (Deutsch, et al., 2006) This statistics
suggest that a large percent of stroke surviving patients were not well enough to return
home. The major difference between these two rehabilitation destinations is the level
care offered to each patient, and can be considered a measure of stroke severity.
Experts recommend that the selection of rehabilitation care should be primarily based on
each patient's motor and cognitive functioning, physical activity, endurance, and social
support. There has been little research done to investigate the relationship between;
stroke type, severity and rehabilitation setting (Brown, et al., 1999), (Deuts.ch, et al.,
2006). Using post-stroke discharge setting as a severity measure outcome will
contribute evidence regarding this topic.
Hospital Discharge and Stroke Outcomes

Hospital discharge status is a measure that can be used in several ways to
determine the severity of an illness and the long term impact of a disease on a patient.
Stroke can be a devastating disease, depending on severity and stroke type. Many
/
stroke victims may be subject to weeks or months of rehabilitation services based on

discharge status. At discharge, hospitals determine discharge status based on ability to
12
function at the next level of care (Schlegel, Tanne, Demchuk, Levine, & Kasner, 2004).
That may include home/self-care, intermediate/assisted living, or transfer to another
institution/hospital. Hospitalizations may be prolonged because of the need for
comprehensive assessment of physical, occupational, and speech therapists, as well as
approvals by patient's families, insurers, and rehabilitation sites before discharge
(Schlegel, Tanne, Demchuk, Levine, & Kasner, 2004). Many variables can affect
patients discharge status, and each of these variables contributes to the final post-stroke
outcome and overall condition of each patient.
There is not a great deal of information describing the influence of discharge
functional status on the rehabilitation measures (Reistetter, et al., 2010), however they
have been a handful of studies which have attempted to determine the correlation
between the two. Stroke is a leading cause of disability among adults, (Rosamond, et
al., 2008), and is the most frequent impairment category as a result inpatient
rehabilitation (/\ data book: health-care spending and Medicare program, 2009). Due to
the level of impact that negative outcomes of inpatient stroke admissions can lead to,
hospitals attempt to create the most positive outcome for each patient, through effective
care, diagnosis and treatment and based on these outcomes determine discharge
setting. Stroke studies which classify the most favorable post-stroke discharge settings
are a topic which has met much a great deal of debate. Some researchers classify
discharge to home, or "community," as the'most favorable discharge status. Whereas
other studies however, define discharge to a rehabilitation facility as the most desirable
post-stroke discharge setting. In a study by Reistetter et al., discharge to community
was described "as a global goal for all patients and an important quality indicator for
program evaluation and accreditation reviews," suggesting that the most favorable
outcome of a stroke event at discharge is to home. The views of this author favor the
13
position that a non-rehabilitation setting is not the most favorable outcome of hospital
discharge. In this study the authors are considering the additional dangers that
accompany institutional care such as, infections, falls, and reconditioning which can
present even more negative effects on the patient.
Conversely in a similar study, with different views on the subject of post-stroke
patient discharge, researchers classify discharge to rehabilitation facility as the most
favorable discharge outcome following a stroke inpatient hospitalization rather than to
home or any other post-stroke setting for patients who need these services
(Ottenbacher, Campbell, Kuo, Deutsch, Ostir, & Granger, 2008). Levels of rehabilitative
care do depend heavily on insurance coverage and family instructions, however, the
when rehabilitative care is enabled positive long-term outcomes for the patient are likely
to follow.
Differences in discharge setting have been observed among stroke patients who
experience ischemic and hemorrhagic stroke measured by severity of stroke admission
and level of inpatient recovery. As mentioned earlier in this chapter, increasing level of
severity is associated with greater likelihood of discharge to rehabilitation or nursing
facilities (Schlegel, Tanne, Demchuk, Levine, & Kasner, 2004). In a study which used
the Rochester Epidemiology Project to evaluate the use of nursing homes after stroke
and assess the dependence of discharge to nursing homes based on stroke type and
level of disability (severity), will be useful in showing trends of between discharge, stroke
type and severity. Among the study population of stroke cases based on level of
severity, the results were consistent with the notion that the less severe stroke cases
were not discharged to nursing homes, while more severe cases were. 59% percent of
severe stroke cases ended up in nursing home setting, compared to only 5% of less
severe cases discharged to nursing homes. Severity of stroke also had implication on
14
the amount of time that a patient spent in nursing home and assisted living care. In a
five year time span after initial event and entrance into the care of a nursing home, 21%
of severe stroke cases were still in nursing home care, compared to only 9% of minor
stroke cases (Brown, et al., 1999). Differences between stroke type, among
hemorrhagic stroke types, patients diagnosed with intracerebral hemorrhage were much
more likely to be in a nursing home, compared to patients diagnosed with subarachnoid
hemorrhage. Severity has a significant role in discharge status setting based on level on
independence. The care that patients receive in these facilities is intended to mimic
hospital care and improve or recondition activities of daily living. In the Brown et al,
study, the researchers found that increasing age and severity were directly related to
discharge and length of stay in nursing home settings. The occurrence of stroke among
elderly populations and severity of illness are major contributions to discharge setting.
Other associations that have been identified to contribute to discharge are race and
ethnicity.
A study which analyzed the post-acute hospital outcomes between racial and
ethnic groups highlighted stroke hospital discharge outcomes among African-Americans
and non-Hispanic Caucasian-Americans. The researchers hypothesized that the
functional status among non-Hispanic African-Americans will be higher (or have more
favorable outcomes), than other racial/ethnic groups. In addition to this, the study also
hypothesized that racial and ethnic differences would be observed based on discharge
setting, i.e., the patient is discharged to return home versus to a secondary care facility,
that ethnic groups with non-Hispanic Caucasian-Americans would be discharge home
more frequently than African-Americans. The independent variable listed in this study,
was race/ethnicity, while the dependent variables listed in this study included: functional
status, length of stay, efficiency and discharge status.
15
In this analysis discharge stats was designated as discharge to "home" and "not
to home", where "not to home" was included various secondary healthcare facilities.
Results of this study showed that there was a significant racial difference in the
percentage of non-Hispanic Caucasian-American and African-American patients
discharged home. Sixty-six percent of Non-Hispanic Caucasian-Americans were
discharged home while; Seventy-four percent of all African-American patients were
discharge home. Analysis showed that among non-Hispanic Caucasian-Americans who
receive rehabilitation after stroke, were older, less likely to have Medicaid, and less likely
to have had a hemorrhagic stroke (Ottenbacher, Campbell, Kuo, Deutsch, Ostir, &
Granger, 2008).
These characteristics are consistent with many of the high prevalence stroke
cases among African-Americans. In previous studies, African-Americans have
consistently experienced a higher degree of hemorrhagic stroke and were younger.
Discharge to home is usually viewed as a positive outcome, ana is considered an
indicator of quality care. However, in this study, the researchers suggest that patient
and family preferences play an important role in discharge planning and placement. To
support this assertion, in a study which analyzed African-American attitudes about longterm care, African-Americans tend to view nursing homes negatively, and the percent of
persons from these the African-American community are low(Miller, McFall, & Campbell,
1994). The disparities among racial/ethnic groups are significant and in this example,
the researchers show how post stroke outcomes are also observed among minority
populations (Ottenbacher, et al., 2008).
Socioeconomic status (SES) and race are additional demographics that
contribute to observed disparities in outcome and discharge status. As stated in the
previous study, access to certain rehabilitation services due to SES are major
16
contributors to occurrence and ability to health and recover from cerebrovascular

disease events (Asylanyan, Weir, Lees, Reid, & Gordon, 2003). Differential access to
timely acute and post acute services play a major role in recovery after discharge due to
patient discharge status. Stroke patients who receive prompt stroke rehabilitation
services following stroke discharge have been associated with having better recovery of
physical function in the immediate and following years (Indredavik, Bakke, Slordahl,
Rokseth, & Haheim, 1999). In certain cases, the most favorable destination after
discharge is to a rehabilitation facility, based on the stroke severity. However, under
certain circumstances access to rehabilitation healthcare services is not as easily
accessible for patients with discharge statuses that require these services. The racial
differences in the process and outcomes of stroke rehabilitation after discharge are
addressed in a study which analyzed the racial differences in access to stroke
rehabilitation and degree of physical functional status. Results showed the post-stroke
environment affected racial/ethnic groups differently. On average, African-Americans
recovered physical function at a slower rate during the first year after stroke. This was
directly associated with the delay in access to inpatient rehabilitation services that
Africans Americans experienced. Income and socioeconomic status was evaluated as a
contributing factor worse outcome. Low-Income African-Americans experienced a
greater delay in functional recovery due to stroke incidence. The pace of recovery from
stroke is more likely inhibited by aspects such as poverty, absence of supportive social
services, such as in-home care, or rehabilitation services, at discharge. (Horner,
Bosworth, & Matcher, 2003) It is important to explore to the outcomes at discharge and
post-discharge status of patients and trends between stroke patients to improve the
services available to encourage the best possible outcomes for each patient.
17
The capacities to perform activities of daily living (ADL), activities which show
personal independence and self-care abilities) at discharge are one of the measures that
health care organizations use to determine effects of stroke events and future care. In
this study, the researchers analyze the differences in physical and functional
impairments related to outcome of ischemic stroke by race. The study population
included 146 patients with ischemic stroke: 41 (28%) African-American and 104 (74%)
Caucasian-American patients (one American Indian ischemic stroke patient was
excluded from analysis). From the breaking down of the patient population, there is a
significant difference amount of African-American ischemic stroke cases, which suggests
that African-Americans do not suffer from ischemic stroke as often as CaucasianAmericans. In addition to this, the researchers also found that a history of transient
ischemic attack (TIA) among African-Americans was less prevalent, than CaucasianAmericans, (p=0.055). These two observations are important in explaining the trend of
prevalence of hemorrhagic stroke among the African-American population. Additionally,
a greater amount of stroke admissions came from urban communities. Physical
impairments and negative outcomes due to ischemic stroke were profound among the
African-American population. The median level of physical impairment was significantly
greater among African-Americans, 30, 90, and 180 days after initial event. During
statistical analysis, the researchers found race to be an important independent prediction
of physical impairment, (p=0.045). Among African-Americans, physical impairment from
ischemic stroke was greater among African-Americans that in Caucasian-American.
However, in terms of functional ability as measured by activities of daily living,
Caucasian-Americans had a longer approximated recovery time those AfricanAmericans stroke patients. The rate of recovery based on activities of daily living among
Caucasian-Americans was 3-6 months after acute event. Rate of recovery and physical
18
and functional results of stroke differ between the races. There is no concrete evidence
as to solid reasoning as to why this has been observed, however, race has been
associated a contributing factor to outcome after ischemic stroke.
Caucasian-Americans are less likely than non-Caucasian-Americans to be
discharged to nursing homes. This me be due to their stroke-type was less severe or
they responded better to stroke treatment than other races/ethnicities. Individuals aged
65 years and greater, have a higher probability of discharge to a nursing facility
increased by 2.5. Patients may be less able to care for themselves and may be more
commonly require long-term placement and care. This is supported by the fact that 90%
of nursing facility residents is older than 65 years of age.
Racial/Ethnic Cerebrovascular Disease Trends

Continuing the discussion of cerebrovascular disease as it related the race and
ethnicity, there is a significant disparity among certain groups in the incidence and
prevalence of cerebrovascular disease that must be mentioned. The 30-day case
mortality rate for ICH cases is 40% to 50%, for each patient in which ICH occurs (Woo,
et al., 2002). Several studies have found that the ICH stroke type occurs most
prevalently among African-Americans and Caucasian-Americans. Studies have
suggested that Caucasian-Americans are more likely to develop occlusive disease if the
large extra cranial vessels (carotid, vertebral, basilar), while African-Americans, are
more likely to develop occlusions of the intracranial (especially intracerebral) blood
vessels(Klatsky, Armstrong, & Friedman, 1991).
This study uses a population of both African-American and Caucasian-Americans
who received health examinations from cerebrovascular disease hospitalizations.
Discharge diagnostic codes used in this study however were International Classification
19
of Disease Codes, Eighth edition. Cerebrovascular codes used for analysis were codes
430-438. These codes included hemorrhage subtypes, ischemic, and acute ill-defined
cerebrovascular disease. Following analysis, and categorization by race, AfricanAmericans, compromised 30.8% of the study population, and were overrepresented
among the hemorrhagic cerebrovascular disease cases (31 of 69, 44.9%) and slightly
underrepresented among the occlusive cerebrovascular disease cases (72 of 292,
24.7%). A consistent male versus female preponderance was found among both racial
groups favoring higher rates of cerebral thrombosis among makes. The age-adjusted
relative risk of hospitalization for hemorrhagic cerebrovascular disease, AfricanAmerican versus Caucasian-American, was 2.64, (95% CI 1.62-4.30). Among AfricanAmericans participating in this study, results were consistent suggesting that they had
significantly higher risk that Caucasian-Americans for subarachnoid and intracerebral
hemorrhage stroke types (Klatsky, et al., 1991).
In one study in particular, of a study population of 1,051 patients with ICH cases,
98% of these patients were either African-American or Caucasian-American. This study
demonstrates the significance of ICH cases among young and middle-aged AfricanAmericans. This disparity observed through the relative risk of ICH for African-Americans
versus Caucasian-Americans, which was 1.6 (95% CI, 1.4-1.8).
Additionally, risk was
also observed as greater among Africans Americans aged 35-54 years of age (young
and middle-age). The age mean of age those diagnosed with ICH among both races
was 61.9 years of age versus 72.1 years of age. The authors of this research study
suggest that the findings of this study suggest that the higher rates of ICH in AfricanAmerican are likely attributable to the difference in prevalence and control of
hypertension, which besides the age of each patient, produces the greatest attributable
risk for ICH among this racial group. (Flaherty, et al., 2005) Hypertension is one of the
20
primary causes of many stroke types, and most significant the reason that stroke occurs
in African-Americans.
Another study analyzing the severity and long term effects of intracerebral
hemorrhage found that, primary intracerebral hemorrhage (PICH) is associated with
poorer outcomes than cerebral infraction, or ischemic stroke. Strokes which involve
complete hemorrhage of vessels can lead to mortality in many more situations than
other stroke cases. This has been determined by researchers who have observed
poorer outcomes among those who suffer from intracerebral hemorrhage. In a study
which matched intracerebral hemorrhage and ischemic attack, results showed that
greater neurological damage and mortality occurred among individuals who suffer from
intracerebral hemorrhage, than those suffering from ischemic stroke. (M Barber, 2004) In
a study reporting on the differences between the two hemorrhages formations, AfricanAmericans have a higher incidence of cerebral infraction, subarachnoid hemorrhage and
intracerebral hemorrhage (Gorelick, 1998). These rates are generally more
disproportionate for African-Americans at relatively younger ages (Broderick, 1992).
Neurological damage is one of the possible outcomes of cerebrovascular, disease, and
as described here was associated with PICH stroke types more than any other. In a
similar study however, the physical and functional impairments that can result from any
cerebrovascular stroke type can arise from ischemic stroke as well.
To further emphasize the disparity observed among cerebrovascular hemorrhage
cases in the African-American Population, a study was performed using the South
London Stroke Register, which included an area defined by census data in 2001, with
271, 817 participants. This was further broken down into, 63% Caucasian, 28% African
(9% Caribbean African, 15% African Undefined). In this study, both hemorrhagic
strokes, and primary intracerebral hemorrhage were analyzed to determine most
21
significant prevalence between racial groups. Among the study population there were
566 (395 PICH and 171 SAH) patients who were diagnosed with first-ever hemorrhagic
stroke. The results after analysis for greatest significance of hemorrhagic stroke, found
that 60% of Caucasian decent and 70% of African descent had a history of hypertension.
Additionally, hypertension was most prevalent among ethnic groups in patients younger
than 65 years of age 52% Caucasian, 74% African-Caribbean, 70% African-Undefined.
Between the hemorrhagic stroke types, African Caribbean's had almost twice the crude
incidence rate when compared to African-Undefined and Caucasians. However, overall,
all patients of African descent in the study had consistently higher risk of PICH when
compared to Caucasian-Americans. This was signified by the IRR for stroke types PICH
and SAH were 2.86 and 1.22, respectively. IRR was consistently higher for patients of
African descent among individuals 65 years of age or less. The other hemorrhagic
stroke subtype, subarachnoid hemorrhage (SAH), has been shown to be more frequent
among Caribbean Africans, than Caucasians or African-undefined in the London Stroke
Registry(Smeeton, et al., 2007). SAH is frequently associated with intracranial
aneurysm, and there is some evidence of a genetic link between intracranial aneurysm
and SAH (Markus & Alberts, 2005). These results support the assertion that.patients of
African descent are disproportionately more likely to experience hemorrhagic stroke type
hospitalizations (Smeeton, et al., 2007).
About 80% of strokes are caused by focal cerebral ischemia (ischemic stroke)
due to arterial occlusion, and the remaining 20% are caused by hemorrhages, (van der
Worp & van Gijn, 2007) Despite the statistic that a greater percentage of stroke cases
are less severe, ischemic stroke cases, the smaller more severe case ratio cannot be
neglected because these cases are effecting certain populations more than others, i.e.
22
hemorrhagic stroke cases among certain racial and ethnic groups. Differences have
been observed among certain ethic groups of the outcomes of stroke type.
Trends among Stroke and Insurance Status

Health insurance is seen as an important means of offering financial protection
for healthcare services sought by the general population. Insurance coverage play a
major role in stokes care and rehabilitation care. The accessibility and availability of
rehabilitative care with some of the most sever stroke cases is the driving factor which
supports full, partial, or no recovery from stroke patient. Another important relationship
involving patient insurance is post-stroke patient discharge. "Hospitalizations may be
prolonged because of the need for comprehensive assessments by physical,
occupational, and speech therapist as well as approvals insurers, families, and
rehabilitation sites" (Schlegel, Tanne, Demchuk, Levine, & Kasner, 2004).
Lack of health insurance among Americans has become increasingly problematic
for both families and individuals. The rates of uninsured among nonelderly Americans
have grown rapidly. The Henry Kaiser Foundations points out that, "not having health
insurance makes a difference in people's access to needed medical care and their
financial security. The barriers the uninsured face in getting the care that they need
means they are less likely to receive preventive care, are more likely to be hospitalized
for conditions that could have been prevented, and are more likely to die in the hospital
than those with insurance." This observation is highly noteworthy when stroke-related
events occur. 17% of the nonelderly population is uninsured, and 42% of this group is
classified as having no access to preventive care (The Henry Kaiser Family Foundation,
2008). Health insurance coverage serves as a mode of patients to readily receive.
healthcare treatment however, due to the financial and social barriers associated with
23
attaining insurance coverage, many people are left without adequate coverage. Prior
studies have shown the unfavorable impact on health status that lack of health coverage
can create (Institute of Medicine , 2002). In fact, evidence has directly implicated
uninsured patients as being less likely to receive the required care they need and
experience poorer outcomes than other patients as a result no insurance coverage
(Shen & Washington, 2007). In 2002, the cost of treating stroke patients was estimated
at 56.8 billion, of which 35 billion was directly associated with medical treatment (Shen &
Washington, 2007). As can be expected, due to these annual charges, hospital inpatient
stays due to stroke can be extremely expensive and without insurance cause many
patients to not qualify to receive necessary rehabilitative services post-stroke. Not only
does insurance affect post-stroke discharge status, but it also affects care prior to stroke
leading up to a stroke event. Regular healthcare services are an important part of living
healthy and monitor the stroke risk factors to minimize the odds of stroke.
However, stroke related insurance disparities are not only observed among the
uninsured. In a study which analyzed the occurrence of stroke among the AfricanAmerican population, results found that since 1990, the gap for excess incidence of
stroke among African-American men and women who are Medicare beneficiaries, when
compared to Caucasian-Americans of the same payer classification. (Gorelick P. B.,
1998) This data finds that stroke does not only affect those patients who are uninsured;
instead it affects a multitude of people, with different levels of access to healthcare
services.
A study that evaluated the outcomes of stroke events by stroke attempted to
determine the behavior of insurance coverage on stroke outcomes. The results of this
study showed that uninsured patients experienced the most negative effects due to
stroke in comparison to their insured counterparts. The researchers measured stroke
24
outcomes based on neurologic impairments and mortality. This was an adequate

measure because of the effects that stroke has on the brain. The study states that,
"differences in both age and severity levels seem to be an indication of inadequate
access to preventive services" (Shen & Washington, 2007). To support this statement,
in a report by the Kaiser Family Foundation, almost half of America's population (42%)
had no access to preventive care (The Henry Kaiser Family Foundation, 2008).
Deeper into the insurance disparity among stroke patients, variations are observed
between insurance companies. The Shen and Washington results found that privately
insured patients are more likely to undergo primary or secondary prevention in the
absence of acute stroke symptoms. This directly supports the fact that insured
individuals are subject to have better outcomes post-stroke due to stroke. Additionally,
these findings also suggest that differences in services are present between public,
private and uninsured patients. Results have shown that uninsured patient is subject to
the most negative outcomes, however in some cases, "disparities...between patients
with Medicaid and privately insured patients existed in some cases..." (Shen &
Washington, 2007). The differences between insured individuals are an interesting
statistic to note. Among insured patients who received a carotid endarterectomy, a
procedure performed on stroke patients to enable oxygen to get to the brain" privately
insured patients received the treatment more often than public insurance (Medicaid)
patients (Shen & Washington, 2007).
The relationship between patients post-stroke discharge setting and insurance is
coverage is varies based on several factors that can affect the recovery of the patient.
In 2001, approximately half of all stroke survivors discharged from acute care hospitals
were admitted to institutional post acute care setting, including 18% admitted to inpatient
rehabilitation facilities and 30% admitted to skilled nursing facilities (Deutsch, et al.,
25
2006). When patients are not able to return home after discharge, alternative care must
be sought for patients. In this study by Deutsch et al, the researchers compare the
outcomes and reimbursements for care provided in institutional rehabilitation facilities
(IRF), and skilled nursing facilities (SNF). Differences in care between these two care
facilities are, IRF's provide intensive rehabilitation treatment to patient during a short,
whereas the sub acute rehabilitation provides various levels of treatments typically over
a longer period of time. These differences in care are indicative of the level of severity,
and patient discharge status. The authors reported that patients treated in IRFs had
better outcomes, with patients showing higher level of motor function, or discharge at
conclusion of rehabilitation was better when compared to SNFs. Patients motor function
was an important factor of rehabilitation however, intensive IRF service did not result in
better outcomes for patient with minimal motor disabilities. Nearly all patient with
minimal motor disabilities returned to the community setting, regardless of the
rehabilitation setting (IRF or SNF). Additionally, significant differences were found
between Medicare reimbursements between both post stroke rehab settings showed.
Among IRFs the payment per patient was almost double that of SNFs, with $12,320 and
$6,215 respectively. Despite the observation that IRF payments were higher than SNF
payments, the median IRF length of stay was significantly shorter than the median
length of stay in SNFs (Deutsch, et al., 2006). This observation suggests that despite
the higher expense of care in IRFs patients care was better due to the more favorable
results in IRFs than SNFs.
Several studies have identified hypertension as a primary risk factor for cause of
stroke. Hypertension has been identified as a significant contributor to stroke especially
among African-Americans. Additionally, previous stroke studies have shown that
hypertension is a significant risk factor for intracerebral hemorrhage and subarachnoid
26
hemorrhage (Woo, et al., 2002), (Kissela, et al., 2002). Due to this observation that
hypertension piays a significant role in the occurrence of stroke, then it can be
concluded that control of this risk factor will reduce the occurrence of stroke. In a study
by Woo et al, the researchers attempt to observe the effects of treated and untreated
hypertension on hemorrhagic stroke. The underpinnings of this analysis deal primarily
with insurance coverage availability, and how access to quality healthcare to treat risk
factors of stroke are integral to controlling and greatly reducing the risk of stroke. One
would presume that grater control of blood pressure would lead to a greater reduction in
risk of stroke (Woo, et al., 2004). In this study 549 hemorrhagic stroke cases were
identified, 322 SAH and 227 ICH.
The major disparities identified among hemorrhagic stroke patients (either SAH
or ICH) was, 71% had hypertension. Furthermore, 23% of African-Americans in this
population suffered from untreated hypertension. When comparing these results of nonAfrican-Americans included in these study, African-Americans tended to have higher
rates of hypertension and untreated hypertension than non-African-Americans. In this
study, treatment of hypertension meant that subjects were on medication to lower blood
pressure. Also, when considering only subjects with hypertension, 33% were AfricanAmericans not being treated this condition, compared with 26% of non-AfricanAmericans not being treated for hypertension. This study exerts results that show that
untreated hypertension is associated with both hemorrhagic stroke types, in addition to
lower education level and previous ischemic stroke. Untreated hypertension has several
implications to patient socio-demographics. Insurance coverage is determinant of
several factors but many of them have to deal with socioeconomic status, and health
history. In this study, researchers observed that insurance status among self-pay and
Medicaid patients, untreated hypertension than treated hypertension patients. These
27
results equate to access to healthcare for patients without insurance (self-pay) or on

Medicaid were more likely to be in the untreated hypertension group rather than the
Medicare or private insurance patients (Woo, et al., 2004). These results are highly
significant is connecting the risk factors of which cause to the actual onset of stroke
cases. Hypertension, is still reported to be a major contribute to stroke, however as
seen from the study describe previously, stroke is much less prevalent among patient
whose hypertension is treated.
In another study which highlighted the association between stroke and insurance
status, researchers observed that primary intracerebral hemorrhage was associated with
higher mortality; however greater neurological damage among this population was not
an observational trait across health insurance status. However, among the uninsured
population in this study, those who suffered from hemorrhagic stroke symptoms were
found to have greater chances of mortality.
Urban-Rural Residence and Stroke Incidence Trends

Epidemiological studies have researched the racial/ethnic geographical trends of
stroke incidence. These studies have investigated the relationship between the types
and occurrences of stroke that plague individuals in with varying results. Research has
found that varying trends between urban and rural residences are observed among
stroke patients and cases. The urban-rural composition of the United States favors the
non-Hispanic, Caucasian-American population. The total urban population in the United
States consists of 60.6% non-Hispanic, Caucasian-Americans. Conversely, the total
rural population in the United Sates consists is 83.5% non-Hispanic, CaucasianAmerican. These percentage of non-Hispanic Caucasian-Americans, heavily favors in
rural populations, which suggests that many of the stroke trends observed among this
28
racial/ethnic group should be favored in these regions of the United States. AfricanAmericans compose a considerably less amount of the total population in both urban
and rural settings in the United States. In urban populations, Among African-Americans
comprise 14.2% of this area. Whereas in rural communities, African-Americans
comprise only 6.4% of this total population (U.S. Census Bureau, 2007). The members
of the population in the urban and rural comminutes in the United States are important to
the results observed among cerebrovascular disease patients in these areas.
In a study performed in a rural community in Georgia, similar to the differences in
the racial/ethnic make-up the United States, this rural community consisted primarily of
Caucasian-Americans (60%). This results of this studied did not have an urban
community to compare its results to, however, despite this the trends observed in the
rural community, mimics the population trends that are observed among Africans
Americans in other populations. The African-Americans in this rural Georgia community,
suffered from higher stroke incidence rates in comparison to Caucasian-Americans in
this same community. African-American women have nearly 3-times the rate of stroke
as Caucasian-Americans. The incidence of stroke increased with age; however the
increase was not as significant as the rate of stroke observed among the AfricanAmerican population (Heyman, et al., 1971). This study was one of the first of many
race/ethnic comparisons on the basis of stroke incidence. The fact that it focuses on
rural residence makes it an important study and enables comparison to more recent
stroke studies which have observed some of the same characteristics among the stroke
population today.
Regional stroke care in terms of urban and rural residence has important
implications on outcome and discharge of stroke patients. As stated previously, the
incidence of stroke is disproportionally distributed among the African-Americans
29
population, in comparison to Caucasian-Americans. However, in southwestern region of

the United States, a different disparity is observed. A study done in a South Carolina
hospital found stroke admissions to be highest among African-Americans compared to
Caucasian-Americans in age groups less than 85 years of age (Feng, 2009). Mortality
due to stroke has shown similar findings. A report further highlighting the disparity of
stroke within the American population stated, "Despite the enormous and growing
burden of stroke...the disease does not receive the attention it deserves"(Bonita, 2007).
Further examination of the geographical, age, racial and long term effects of this
disease, particularly as they relate to African-Americans, is important and will be the
focus of my research.
In contrast to the strong relationship of more severe cerebrovascular disease
among African-Americans, Caucasian-Americans have been found to have a greater
association with cerebral embolism, or transient ischemic attack (TIA), which is a less
severe stroke type(Gorelick, 1998). Variation of stroke occurrence has been observed
based on regional differences as well. On a global scale, transient ischemic attack (TIA)
has been found to prevalent in rural communities in north Portugal. The annual
incidence of TIA was slightly higher in rural communities, compared to urbah areas. In
this study, age proved to be a major factor of incidence of TIA. Patients 65 years and
older were at greatest risk of stroke occurrence following TIA with 12.8% of the
population experiencing a stroke event at within seven days of the TIA event (95% CI,
7.3 to 18.3) and within a year, 21.4% of this population experiencing stroke events (95%
CI 14.6 to 28.1) showing a significant difference stroke occurrence between populations
(M. Correia, M. R. Silva, R. Magalhaes, L. Guimaraes, & M. C. Silva, 2006). There is a
pattern of increased stroke related mortality in rural communities than in urban
communities in developed countries, or among countries in the world, where the risk of
30
stroke is higher among economically disadvantaged populations (Zhang, Guan, Mao, &
Liu, 2007) Stroke was 1.45 times more prevalent in rural areas than in urban areas in
the United States, 15.1 per 1000 (rural) and 10.4 per 1000 (urban). However, there is
little data on effective implementation of stroke care in rural systems of many developed
countries with care that encompass all aspects of stroke management such as the
United States(Joubert, 2008). More research must be done in the United States on rural
stroke management and data reporting.
31
METHODOLOGY
Type and Source of Data

Tennessee hospitals have the option to participate in the Tennessee Department
of Health, Division of Health Statistics Hospital Data Discharge System (HDDS).
Annually, in intervals separated into quarters, hospitals may submit their discharge data
to either the Tennessee Hospital Association Health Information Network (THA-HIN), or
the HDDS database. Patient records for the HDDS system are extracted from the UB04 form locator. This form is used for billing purposes and includes patient information
required for hospital admission and discharge. This patient data reporting option was
created through the requirements of T.C.A., Section 68-1-108 which states, "Each
licensed hospital shall report all claims data found on the UB-04 form or a successor
form on every inpatient and outpatient discharge to the commissioner of health"
(Tennessee Department of Health, Division of Health Statistics, 2007).
The purpose of the HDDS is to "collect and summarize hospital claims data so
charges for similar types of services may be analyzed and compared in order to promote
a more price competitive environment in the medical marketplace" (Tennessee
Department of Health, Division of Health Statistics, 2007). The data from the data
system and UB-04 form may also be used as a tool to gauge the delivery of healthcare
services to patients and has broad policy implications for shaping the future of our health
delivery system. Required discharge records included in the HDDS are all inpatient
32
records, emergency room records, ambulatory records, and diagnostic service records.
The stroke-related discharges included in this study are all patients admitted to the
hospital by any of these modes of entry.
Secondary data hospital discharge records have been used for this study. All
data includes records from discharges beginning January 1, 2000 through December 31,
2006. The first quarter of the HDDS system year begins January 1st and the final
quarter of the year ends on December 31st. Since all data was collected prior to 2008,
each year included in the study has the complete data from each quarter from 2000
through 2006. All personal identifiers were removed prior to receipt of the data due to
privacy regulations, and requirements of the Division of Health Statistics Institutional
Review Board approval (Appendix A). The study was approved by the Tennessee
Department of Health Institutional Review Board as well as the Meharry Medical College
Institutional Review Board.
The cerebrovascular disease patient discharge records were all accessed via the
HDDS. Patient records selected for analysis based on their primary diagnosis as
defined by ICD-9-CM code. The ICD-9-CM code describes the principal diagnosis,
which is the condition chiefly responsible for the admission of the patient for care. The
principal diagnosis code should reflect the information contained in the patient medical
record for their hospital stay (Tennessee Department of Health, Division of Health
Statistics, 2007). Only those ICD-9-CM codes that represented cerebrovascular disease
related to hemorrhagic, ischemic, or TIA were included in analysis. Hemorrhage
(subarachnoid hemorrhage (SAH) and intracerebral hemorrhage ICH): 430, 431,
respectively; ischemic stroke including: 433.01, 433.11, 433.21, 433.31, 433.81, 433.91,
434.01, 434.11, 434.91, 436; and transient ischemic attack (TIA): 435.0, 435.1, 435.2,
435.8, 435.9 (Practice Management Information Corporation, 1994) (Appendix B)
33
Patient discharge status records were also considered in this analysis. Patient
patients discharge status (dependent variable), in the HDDS system included several
twenty-three different discharge codes. Patient discharge status was grouped in to three
different groups based on the patients discharge destination. Patient discharge status
was a dependent variable in the analysis. The patient discharge status is a code given
to each patient upon release from the hospital by their treating physician. Patient
discharge status was grouped into three primary groups: (1) those who were discharged
home; (2) those who were discharged to an assisted living facility or intermediate care;
and; (3) those who were discharged to an inpatient rehabilitation hospital or
institutionalized care.
Discharges were grouped based on the type of care and services available, and
patients' level of independence at discharge. All possible discharges in the HDDS
varied based on the condition of the patient at discharge, the type of insurance of each
patient, whether the patient refused care or died in the hospital. In this study however,
patients who died in the hospital due to stroke admission and those who "left against
medical advice," were not included. The independent predictor variables used to
determine associations with hospital discharge status were: (1) patient's principal
diagnosis code, (2) patient's state of residence, (3) patient's zip code address, (4)
patient's date of birth, (5) patient's sex, (6) primary payer, (7) patient's race/ethnicity.
Each patient's principal diagnosis is based on the ICD-9-CM code describing the
principal diagnosis (i.e., the condition chiefly responsible for the admission of the patient
for care). The principal diagnosis code reflects the information contained in the patient
medical record for their hospital stay. Each patient's primary diagnosis was classified as
a three level categorical variable in the analysis: "hemorrhagic", "ischemic", or "transient
ischemic stroke".
34
Each patient's state was also extracted from the HDDS and considered in
analysis. All discharge records in analysis originated from Tennessee hospitals,
resulting in state not being included in the statistical model for data analysis. Also
extracted from the UB-04 from was, "patient's zip code address", which was defined by
the payer organization. This data is used to properly classify each patient county of
residence and to allow for analysis by place of residence. Data restrictions and patient
privacy limitations required that zip codes be listed as 3-digit zip codes for analysis. As
a result, only 3-digit zip codes were used to determine each patient's residence and
were classified as a categorical variable by either "urban" or "rural". Urban and rural
residence was determined based on data obtained from the 2000 Census summary file
3 (SF3) (U.S. Census Bureau, 2010). Total population urban and rural data was broken
down into levels based on characteristics of the 3-digit zip code. Characteristic levels
included total: urban area, inside urbanized area, inside urbanized clusters, rural area,
farm area, and non-farm area.
The Bureau of the Census defines urban as comprising all territory, populations,
and housing units located in urbanized areas and in places of 25,000 or more
inhabitants outside of urban areas. Urbanized areas (UA) are those that are
continuously built-up with a population of 50,000 or more. These areas were included in
the urban category. Rural places and territory are described as any incorporated place
or census designated places with fewer than 2,500 inhabitants located outside an
"urbanized area". These areas were included in the rural category. A place is either
entirely urban or entirely rural, except for those designated as an extended city, large
expanses of sparsely populated territory (U.S. Department of Commerce, Geography
Division, 1994). Based on the total population, patient's zip codes were coded based on
percentage of rural households in the region, or percentage of non-urban households.
35
Patient date of birth was also extracted from the HDDS to determine the age of
each stroke patient admitted. Patients included in the data set ranged from 1-99 years
of age. Age was split into three separate categorical groups based on stroke trends in
previous studies where age played a significant role, 18-39, 40-69, and 70-99 years of
age (Correia M. , Silva, Magalhaes, Guimaraes, & Silva, 2006). Patients aged 0-17
were excluded from analysis. Each patient's age is based on data collected at time of
admission. However, due to privacy and protected health information policies enforced
by Tennessee Division of Health Statistics, patients 90 years of age arid above are listed
as 99 years of age. This consideration will be taken into account in the analysis of data
and mentioned again in the discussion as a limitation of the study. Patient's age has
been classified as a continuous variable for data analysis.
Patient's sex was also taken into account in analysis of the stroke data. In some
stroke cases recorded and reported on the UB-04 forms, patients are listed as male,
female, or unknown. All cases listed as unknown were taken out of the data set for this
study and excluded from analysis. Patient's sex was classified as a categorical variable
in data analysis.
Primary payer (insurance provider) was also a variable from the UB-04 from used
for analysis. The primary payer organization is defined as "the name or type of payer
organization from which the hospital first expects payment for the bill" (Tennessee
Department of Health, Division of Health Statistics, 2007). The UB-04 form allows up to
three payers to provide payment for hospital services; however, the primary payer is the
most important because it is the first payer on each patients account. Each patient's
payment classification was divided into three general groups; public insurance
(TennCare, Medicare), private insurance (Other Insurance) and no insurance. Patients
who were classified as "self-pay" were coded as uninsured. Patient's payer
36
classifications were coded as categorical variables for analysis. Patients whose UB-04
form identified their primary payer classification as "free-care" or "unknown" were
excluded from analysis
Patient race/ethnicity is another variable used in analysis however it does not
appear on the UB-04 form. The field is required to be reported in addition to the data
elements contain on the UB-04. The patient race/ethnicity is included from the patients
chart, due to the fact that it is not included on the patient's record Patients whose
race/ethnicity listed as "unknown" were excluded from analysis. Other groups excluded
from analysis are listed in the Patient's race/ethnicity was classified as a categorical
variable in data analysis. In this study, only African-Americans and CaucasianAmericans were considered.
Study Design
Analysis of hospital stroke-related data was conducted using a "betweensubjects" outcome based study design. Cerebrovascular ICD-9-CM diagnoses were
matched and grouped based on category of stroke and type. ICD-9-CMs of interest are
430, 431(hemorrhage), 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11,
434.91, 436 (transient ischemic attack) 435.0, 435.1, 435.2, 435.8,435.9 (acute
ischemic attack). These codes correspond to each category of the two groups of stroke
types and transient ischemic attack. Patient discharge status was categorized into three
levels of discharge based on desirability. The most favorable discharge setting is
discharge to home, and least favorable discharge setting is discharge to an inpatient
rehabilitation hospital or facility. The most favorable discharge status was held as the
reference group in the model, because it is associated with the most desirable strokerelated hospital discharge conditions.
37
Independent variables: Insurance, stroke type, rural-urban residence, sex, age,

race/ethnicity, were analyzed to determine stroke-related discharge significance. Urbanrural residence is based on 3-digit zip codes classification, age is determined by using
patient's birthdates, but patients ninety (90) years of age and above are reported as
ninety-nine (99). Insurance status was determined based on primary payer information
gathered from the admitting hospital, while race/ethnicity was collected based on
information reported from patient's hospital chart.
Statistical Model
Multinomial logistic regression was used to evaluate the dependent discharge
variable and independent predictor discharge variables with statistical software package
SPSS 18. The multiple logistic regression model incorporates one outcome variable
with multiple levels of outcome (i.e., patient discharge -to home, -to assisted living, -to
inpatient rehabilitation facility). The first outcome category (discharge to home), is set as
the reference group because it is the most favorable hospital discharge outcome, and for
the purposes of this study, creates the most significant comparison for association of
discharge statuses and patient characteristics.
Each of the independent predictor variables of the patients (age, race, sex,
insurance, and urban-rural residence) were ran in the regression model at the same
time. Multiple logistic regression statistical model enables estimation of multiple
outcomes with several different predictor variables. The logistic regression model
included two separate equations: patient discharge to an assisted living facility rather
than discharge home; and discharge to an inpatient rehabilitation facility rather than to
home (Appendix C). Discharge to home was held as a reference group in the model
because it was the most favorable hospital discharge outcome.
38
Analysis was carried out on all discharge records for all seven years in these two
multinomial logistic regression model equations to determine predictor variable
significance. Significance was defined using P-values and 95% CI. Non-significant
variables were removed one by one, by p-value, removing the largest first, until all
remaining variables in the model were significant. Significant variables were defined as
p<0.05. Odds ratios were used to determine direction and strength of variable
significance.
Research Hypotheses
Null Hypothesis (HOi)
There is no statistical relationship between the socio-demographic variables (race, sex,
and age), and stroke-related discharge status among Tennessee hospitals between the
years of 2000-2006.
Alternative Hypothesis (Ha!)

There is a significant statistical relationship between the socio-demographic variables
(race, sex, and age) and stroke-related discharge status among Tennessee hospitals
between the years 2000-2006.
Ho2: There is no statistical relationship between stroke patients' area of residence (ruralurban), and hospital discharge status by Tennessee hospitals
Ha2: There is a statistical relationship between the area of residence of stroke patients
and hospital discharge status in Tennessee, using the period, 2000-2006.
39
HO3: There is no statistical relationship between the hospital discharge status of stroke
patients and health insurance status in Tennessee, using the period, 2000-2006.
Ha3: There is a statistical relationship between the hospital discharge status of stroke
patients in Tennessee and health insurance status, using the period, 2000-2006.
40
RESULTS
Among all hospitals in Tennessee who participated in the HDDS system between
2000 through 2006, there were 118,205 cerebrovascular cases reported to the
Tennessee Health Department's Division of Health Statistics. After excluding cases
based on previously mentioned criteria, the final study population consisted of 99,513
patients. This population was further broken down into groups based on discharge
status from the hospital as seen in Table 1. A majority of the patients discharged from
inpatient care were diagnosed with ischemic stroke and discharged to either a nursing
facility or an assisted living site.
This finding is in alignment with many of the studies of ischemic stroke and
rehabilitation discharge setting (Paolucci, et al., 2003). Patients whose primary
diagnosis was hemorrhagic stroke were discharged more often to either an
inpatient/hospital setting (13.9%) or to a nursing home or assisted living (9.5%). These
percentages are to be expected, admission to nursing homes following a hemorrhagic
stroke is less likely than other discharge settings (Brown, et al., 1999). Among patients
discharged to assisted living settings, over half (75%) of this population's primary
diagnosis was ischemic stroke rather than any other stroke type. More than half of the
patients diagnosed with stroke in the study population were diagnosed with ischemic
stroke. The average age of all patients discharged in the study was 70.6 years. Over
half of the population was female (58.3%), and the majority of the patients among any
41
discharge group were African-American (81.3%). These characteristics are consistent

with findings of previous studies which evaluated the impact of cerebrovascular disease
among African-American populations. Among both African-Americans (52.2%) and
Caucasian-Americans (13%), ischemic stroke was the most prominent primary diagnosis
for all patients discharged between 2000 through 2006. Among patients diagnosed with
ischemic stroke, a significantly larger amount of patients were assigned the primary
diagnosis code "436" (acute-but ill defined cerebrovascular disease). In comparison with
other diagnosis codes for ischemic stroke (25%), this was the most highly assigned
primary diagnosis. This could be due to regional differences in diagnosis patterns
between physicians, or a decline in physician's diagnosing other types of ischemic
stroke symptoms. All other stroke cases were similar in terms of occurrence from 2000
through 2006.
Between the years 2001 and 2002, there was a slight increase in all types of
stroke-related cases, hemorrhagic, ischemic or TIA, admitted and discharged from
Tennessee hospitals. Among hemorrhage stroke cases, subarachnoid (SAH) cases
made up the majority of hemorrhagic events with 7,010 cases (72.5%) between 2000
through 2006. Among transient ischemic attack (TIA) discharged cases, the majority of
the diagnosed patients were assigned the ICD-9-CM code 435.9, "unspecified transient
cerebral ischemia" Appendix B. This ICD-9-CM diagnosis comprised the majority of the
TIA discharged cases, consisting of 92.7% of all TIA diagnoses.
There were significant differences in urban and rural residence based on patient
discharge. In each discharge setting, there was a significant amount of patients
discharged to each location, although, nursing settings was had the majority of
discharges. Discharge to home and to hospital facilities was the discharge destination of
many people; however the majority came from rural zip-codes.
42
Table 1: Comparison of Cerebrovascular Disease Discharge Status for

Demographic and Other Risk Factors.
Home
No.= 48,003
No. (%)
Factor
Primary Diagnosis
Hemorrhagic
3,135(6.5)
Ischemic
25,034(52.2)
TIA
19,834(41.3)
Missing
0
Nursing or Similar
No. = 35,223
No. (%)
Inpatient Hospital
No. =16,287
No. (%)
3,355 (9.5)
26,478 (75.2)
5,390 (15.3)
0
2,212(13.6)
13,354 (82.0)
721 (4.4)
0
Sex
Male
Female
Missing
21,846(45.5)
26,157 (54.5)
0
12,509 (35.5)
22,714 (64.5)
0
7,073 (43.4)
9,214 (56.6)
0
Age
18-39
40-69
70-99
Missing
1,722 (3.6)
24,916(51.9)
21,365 (44.5)
0
286 (0.80)
8,845 (25.1)
26,092 (74.1)
0
315(1.9)
6,442 (39.6)
9,530 (58.5)
0
Race/Ethnicity
Black
White
Missing
38,934 (81.1)
9,069 (18.9)
0
29,327 (83.3)
5896 (16.7)
0
12,607 (77.4)
3,680 (22.6)
0
Residence
Urban
Rural
Missing
15,044 (31.3)
32,796 (68.3)
163 (0.40)
8,858 (25.2)
26,297 (74.7)
68 (0.10)
6,165 (37.9)
10,070 (61.8)
52 (0.30)
Primary Payer
Public
Private
No.lnsurance
Missing
29,036 (60.5)
12,881 (26.8)
6,086 (12.7)
0
27,393 (77.7)
3,303 (9.4)
4,527(12.9)
0
10,946 (67.2)
3,145(19.3)
2,196(13.5)
0
Using multinomial logistic regression model, all variables were assessed to

determine significance to discharge status, (Tables 2,3), significant variables were
determined based on p-value<0.05. Table 2 reports all significant variables in the model
which are statically significant to post-stroke event, patients discharged to home or
43
under self-care. All variables in this initial analysis proved to be significant with a p-value
of .000. Variables with a positive association included, hemorrhagic stroke (OR 6.39,
95% CI 5.99-6.791), ischemic stroke (OR 4.65, 95% CI 4.78-4.82), and having a "public"
insurance carrier (OR 1.20, 95% CI 1.15-1.26). Based on the model, these three
variables most significantly contributed to discharge to an assisted living facility, rather
than discharge to home. A positive association with discharge to an assisted living
setting suggests that when an individual is diagnosed with an ischemic or hemorrhagic
stroke, and has public insurance, there is a strong-likelihood of that patient being
discharge to an assisted living setting, instead of being discharged home. Variables with
a negative association were urban residence (OR 0.68, 95% CI 0.66-0.71), male sex
(0.72, 95% CI 0.70-0.74), African-American race (OR 0.84, 95% CI 0.81-88), private
insurance coverage (OR 0.57, 95% CI 0.53-0.60), and individuals ages 18-30 (OR 0.15,
95% CI 0.13-0.17) and 40-69 (OR 0.33, 95%CI 0.32-0.34).
There was a negative interaction of variables was determined using the
regression interval "B". When the regression interval is negative, this suggests an
inverse relationship between discharge statuses. This inverse relationship reveals that
instead of these variables favoring discharge to an assisted living facility, there is an
association with discharge to home. Urban residence, male sex, African-American race,
having private insurance, and individuals younger than 69 years of age have a stronger
likelihood of being discharged home rather than to an assisted living facility. This is the
inverse of the positive relationships.
44
Table 2: Patient Hospital Discharge to Assisted Living Facility
95%
Confidence
Interval for
Exp(B)
Exp(B)" Lower Upper
1
df Sig. EXP(B)
Bound Bound
Std.
Error Wald
-.639
.034
352.119
.000
[Urban]
-.386
.019
427.724
.000 .680
1.471
.655
.705
[Male]
-.332
.016
433.976
.000 .718
1.393
.696
.740
[Hemorrhagic] 1.853
.032
3399.351 1
.000 6.381
5.996
6.791
[Ischemic]
.019
6644.858 1
.000 4.648
4.479
4.823
.022
60.114
.000 .842
1.188
.806
.879
Intercept
1.536
MC
- ^r
[AA]
[Public]
.182
.023
61.952
.000 1.200
1.146
1.255
[Private]
-.570
.031
342.612
.000 .566
1.767
.532
.601
[18-39]
-1.880 .067
794.148
.000 .153
6.536
.134
.174
[40-69]
-1.109 .018
3715.178 1
.000 .330
3.030
.318
.342
The reference category is: Discharge TO HOME.
A secondary determinant of significance was based upon the 95% confidence

intervals. Significance was determined based on whether 1.00 was outside of both the
lower and upper bounds of the intervals. In all significant variables in the equation
comparing assisted living discharge to discharge home, this was apparent.
Table 3 reports all variables that were significant to the relationship of patients
being discharge to an inpatient rehabilitation facility versus discharged home. A positive
relationship was also found again with hemorrhagic stroke (OR 24.71, 95% CI 22.4927.15) and ischemic stroke (OR 15.84, 95% CI 14.66-17.13) diagnoses.
45
Table 3: Patient Hospital Discharge to Inpatient Rehabilitation Facility
95%
Confidence
Interval for
Exp(B)
Std.
Lower Upper
1
Exp(B)"
df Sig. Exp(B)
Bound Bound
Error Wald
-2.938
.053
3038.004 1
.000
[Urban]
.169
.022
58.632
.000 1.184
1.134
1.237
[Male]
-.096
.020
23.889
.000 .909
1.100
.874
.944
[Hemorrhagic] 3.207
.048
4455.145 1
.000 24.713
22.492 27.154
[Ischemic]
2.763
.040
4824.830 1
.000 15.849
14.660 17.134
[AA]
-.141
.026
29.284
.000 .868
1.152
.825
.914
[Public]
.045
.029
2.423
.120 1.046
.988
1.108
[Private]
-.215
.035
37.213
.000 .806
1.241
.752
.864
[18-39]
-1.168
.067
306.916
.000 .311
3.663
.273
.354
[40-69]
-.665
.022
874.177
.000 .514
2.032
.492
.537
Intercept
The reference category is: Discharge TO HOME
Similar to the first equation, public insurance (OR 1.05, 95% CI 0.99-1.11) had a
positive association with discharge to an inpatient rehabilitation facility, rather than
discharge to home. Variables that were found to have a positive association with
discharge to an inpatient rehabilitation facility, instead of being discharged home were a
significant contributor to determination of discharge destination. All of the same
variables that had a negative relationship with discharge to an assisted living setting
(male [OR 0.91, 95% CI 0.87-0.94], African-American race [OR 0.87 95% CI 0.83-0.91],
private insurance coverage [OR 0.81, 95% CI 0.75-0.86), ages 18-39 [OR 0.31, 95% CI
0.27-0.35] and ages 40-69 [OR 0.51, 95% CI 0.49-0.54], were found to also have a
negative relationship with discharge to an inpatient rehabilitation facility. However, unlike
the assisted living versus home equation, urban residence (OR 1.18, 95% CI 1.13-1.23)
46
had a positive association with discharge to an inpatient rehabilitation facility, instead of

discharge home.
47
DISCUSSION
The trends in discharge status among stroke survivors in Tennessee between

2000 through 2006 showed that a majority of patients were discharged home. Table 1
shows that nearly half (48.2%) of stroke survivors were discharged home. This finding
suggests that stroke patients who were well enough to return home were able to
successfully complete the activities of daily living, suggesting that their individual stroke
severity was not indicative of discharge to an intermediate or inpatient rehabilitation
facility. In this study, patient with any combination of the following patient characteristics
consistently contributed to discharge home rather than to any other discharge setting
included patients who were male, African-American, have a private insurance carrier,
and are 69 years of age or younger. Patients with these characteristics, based on these
results, have tend to either have the most favorable outcomes post stroke, or have other
contributing factors that inhibit discharge to a rehabilitation facility. Which also
introduces the possibility that discharge home may not be indicative of the most
favorable post-stroke outcomes, instead this could be due to lack of insurance or assets
to provide for post-hospital discharge care.
Ischemic stroke is the most common subtype of stroke* (Asylanyan, Weir, Lees,
Reid, & Gordon, 2003), Table 1 also reflects these results, in that ischemic stroke made
up at least half of the population in each discharge destination. However, as can be
assumed, a larger amount of patients were discharged home who were diagnosed with
48
transient ischemic attack, rather than the other discharge destinations. There were a
larger amount of female stroke survivors, in comparison to males, and patients with
public insurance were discharged to each destination more often than any other
insurance carrier.
African-Americans composed a significant portion of the study population. Each
discharge destination was exceedingly populated by African-Americans; discharge to
home, to assisted living, and inpatient rehabilitation facility. This trend in racial
differences in the study population partially explains the differences observed in payer
classification. The majority of stroke surviving patients discharged had a public
insurance carrier. Several studies have pointed out that Caucasian-Americans were
more likely not to have a public insurance carrier, (Gorelick P. B., 1998), (Ottenbacher,
Campbell, Kuo, Deutsch, Ostir, & Granger, 2008). Rural residents composed the
majority of the population, meaning that several stroke surviving patients' originate from
rural area. These results however cannot be generalized to other areas because the
urban-rural coding classification system was not 100% reliable.
Patient Discharge to Assisted Living Setting vs. Home

Through multinomial logistic regression, statistical relationships were found
between predictor variables and discharge status. For statistical analysis, discharge to
home was set as the reference group, because it was considered the most favorable
discharge outcome post-stroke. Through analysis of discharge to assisted living care
versus discharge to home, the results showed positive and negative relationships
between many of the variables. Among those variables with a positive relationship,
patients diagnosed with hemorrhagic stroke had a strong relationship with discharge to
nursing facility, rather than discharge to home. Hemorrhagic diagnosed patients
49
suffered six times more risk of being discharged to an assisted living environment, rather
than being discharged home. Also, among predictor variables with positive
relationships, patients diagnosed with ischemic stroke were about five times more at risk
of being discharged to assisted living care, rather than to self-care at home. Based on
the literature, (Paolucci, et al., 2003), these results are to be expected because stroke
severity is considered the most powerful prognostic factor. Both disability and
neurologic impairment are consequences of stroke onset among ischemic and
hemorrhagic stroke types. The final variable with a positive relationship among
discharge to assisted living care versus discharge to home was public payer
classification. Patient's who insurance carrier was a public entity were 1.2 times more at
risk of being discharged to an assisted living environment rather than to home. Public
insurers in this study included Medicare and TennCare, and according to these results,
stroke patients with either of these insurance carriers were more likely to be discharged
to assisted living rather than to home.
Additionally, other variables significant to the assisted living and discharge to
home relationship were urban residence, male, African-Americans, private insurance,
and the age groups 18-39 and 40-69. Patients who were from an urban residence
based on their three digit zip code found that patients from urban residences were 1.5
times more likely to be discharged home rather than to an assisted living environment.
As opposed to rural, this is to be expected from the literature which found that more
severe stroke cases are observed in rural areas (Zhang, Guan, Mao, & Liu, 2007).
These results equate to several different factors that deal with access and availability of
different levels of post-stroke services. In rural areas, the level of access is much
different from that available in urban area. As a result many stroke patients are either
left to find alternative modes of the treatment.
50
Males were found to be, 1.5 times more likely to be discharged home, rather than
to be discharged to assisted living facilities. According to the literature, these results are
supported, in that previous studies have also found that pre-stroke and post-stroke
disability and institutionalization rates were significantly higher among females. Since
sex differences in stroke began to be recognized, the particular influence of estrogen
and testosterone on the endothelium and the vascular system, the role of risk factors
unique to women such as the use of oral contraceptives, hormone replacement therapy,
and pregnancy, systemic delays in the recognition, and insufficient treatment of
conventional stroke risk factors in women have all been considered as probable
explanations (Petrea, Beiser, Seshadri, Kelly-Hayes, Kase, & Wolf, 2009). AfricanAmericans were found to have a negative relationship with discharge to both assisted
living and inpatient rehabilitation settings. In fact, African-American Tennesseans were
found to be almost two times as likely to be discharged home, rather than any other
discharge setting when compared to Caucasian-American Tennesseans. This can be
due to several different factors, including limitations from insurance coverage, or lack of
assets to afford post hospital stroke care. This is important to distinguish because the
assumption that African-Americans experience better outcomes in comparison to
Caucasian-Americans simply because they are discharged home post-stroke instead of
to an intermediate or intensive care settings is not entirely accurate in all situations. In
an study which analyzed the racial impact of post-stroke outcomes found that AfricanAmerican Stroke patients has greater functional impairment initially and improved more
slowly in comparison to Caucasian-Americans (Horner, Matcher, Divine, & Feussner,
1991)
The other side of this result of African-Americans post-stroke discharge is that
African-Americans have access to care from family or loved ones at home. A study
51
which supports these results is observed in a study that found Caucasian-Americans to

be less likely discharged home in comparison to African-Americans, 66% vs. 75%,
respectively (Ottenbacher, Campbell, Kuo, Deutsch, Ostir, & Granger, 2008). These
results are not as one would expect, because African-Americans have been found to
suffer from more severe strokes than Caucasian-Americans. However, discharge
disposition is a complex variable with many potential mediating factors; in this case it is
possible that family support and social network structure are much significant in AfricanAmerican households. Patient and family preferences play a major role in patient
discharge and placement. African-American tend to view nursing homes more
negatively, in addition the patient population consisting of minorities in nursing facilities
are quite low (Miller, McFall, & Campbell, 1994).
As a result, African-American families may be more willing to encourage home
placement for stroke survivor's care rather to utilizing assisted living facilities. Private
insurers also contributed a negative relationship to discharge to assisted living settings.
Privately insured patients who were stroke survivors were almost two times as likely to
be discharged to home, rather than to an assisted living facility. This is congruent with
the literature because privately insured patients are more likely to undergo primary or
secondary prevention in the absence of acute stroke symptoms (Shen & Washington,
2007). Many patients who are privately insured have access to services uninsured and
publicly insured patients do not have, as a result, many the stroke cases among this
population of patients have better outcomes (Shen & Washington, 2007).
Lastly, among variables that have a negative relationship to the equations,
discharge to an assisted living environment versus discharge home is age, specifically
patients 18-39 and 40-69. Patients in these two groups are the youngest in the study
and were found to be almost seven times as likely to be discharged home (18-39 years
52
of age) rather than to a nursing facility, and three times as likely to be discharged home
(40-69 years of age) rather than to an assisted nursing facility. These results are to be
expected among younger individuals. A majority of stroke cases are found in the age
group 65 years of age and older, with the worst outcomes. In addition, the primary
composition of rehabilitation facility consists of patient in this age group (Schlegel,
Tanne, Demchuk, Levine, & Kasner, 2004). These results are congruent with that of
previous studies.
Patient Discharge to Inpatient Rehabilitation Setting vs. Home

In this study, discharge to an inpatient rehabilitation facility was considered the
most severe post-stroke outcome. This was classified as such because discharge to an
inpatient rehabilitation facility calls for intensive treatment, and usually at initial discharge
suggests that the patient is not able to care for himself or herself at any level. Similar to
the assisted living discharge and home, several variables also had positive and negative
relationships with discharge to inpatient rehabilitations setting and discharge to home.
Variables which had a positive relationship discharge to inpatient rehabilitation facilities
were urban residence, hemorrhagic or ischemic primary diagnosis and public insurance.
Based on three digit zip codes, patients from urban residences had 1.2 times the
risk of being discharged to an inpatient rehabilitation facility instead of to home. Rural
patients had a better chance of being discharged home post-stroke than non-rural
residents. There is little research available on the distinction between discharge
between urban and rural residence, however these results suggest that patients from
rural residence are able to be discharge home. These results also suggest that due to
the lack of complete comprehensive care in rural areas, the availability of intense
rehabilitative care may not be readily available in rural areas. For this reason, some
53
patients may not be able to go directly to a high level of care such as .an inpatient
rehabilitative setting. Primary diagnosis was found to be a strong predictor of discharge
to inpatient rehabilitation facility. Hemorrhagic stroke had a strong positive relationship
with discharge to inpatient rehabilitation versus discharge to home. Hemorrhagic stroke
patients had 24 times greater risk of being discharged to rehabilitation settings as
opposed to home. In addition, ischemic stroke patients also had a significantly
increased risk of being discharged to an inpatient rehabilitation facility. Ischemic stroke
patients had 15 times greater risk of discharge to an inpatient rehabilitation environment
as opposed to discharge to self-care at home.
Once again, these results are to be expected, in that these two stroke categories
are the most severe manifestations of cerebrovascular disease, and cause neurological
impairment and disability. As a result these patients are at a greater risk of being
discharged to an inpatient rehabilitation facility (Paolucci, et al., 2003). Similar to
patients discharge to assisted living setting, patient whose primary payer was a public
insurer had a onetime increased risk of being discharged to an inpatient rehabilitation
facility, as opposed to being sent home post-stroke.
Patient predictor characteristics that had a negative relationship stroke discharge
to an inpatient rehabilitation setting were: males, African-Americans, and age 18-39 and
40-69. Males were one times more likely to be discharged home, rather to an inpatient
rehabilitation facility. This is an important observation because similar to effects due to
stroke observed among women; men have a greater likelihood of being discharged
home. A study that explored the short-term follow up disability and outcomes at 3 and 6
months after stroke, found that women were more likely to be disabled than men, and
the rates of institutionalization significantly favored women, with almost 4 times as that of
men (Petrea, Beiser, Seshadri, Kelly-Hayes, Kase, & Wolf, 2009). The rates of
54
discharge "to home", as opposed to discharge to an inpatient rehabilitation facility by

race/ethnicity, found that African-Americans 1.2 times more likely to be discharge home,
rather than to an inpatient rehabilitation facility when compared to Caucasian-Americans.
Similar to results found among patient discharged to assisted living settings, this trend
among African-Americans in likely due to social and family support to encourage
discharge to home rather than to inpatient rehabilitation.
Lastly, age had a negative relationship as a predictor variable of discharge to an
inpatient rehabilitation setting. Patients 18-39, were 3.6 times as likely to be discharged
home rather than to be discharged to a rehabilitation facility. Also, patients 40-69 were
2.0 times as likely to be discharged home instead rather than to an inpatient
rehabilitation setting. The strength of association is not as strong as the association
observed in discharge to an assisted living setting, however the trend is observed.
Younger stroke survivors are more likely to be discharge home rather than to require a
form of rehabilitation. This is to be expected because many of age is a strong predictor
to cause stroke and require rehabilitative services.
Study Strengths and Limitations

Study Limitations
The use of secondary data in this study was a limitation of the research. Each of
the variables that were used had a predetermined standard of its composition. The
study was restricted to variables that were only listed on the UB-04 form in the data used
for the study. Hpwever, using the HDDS system was also strength of this study was
well. The data collection system is uniform for all hospitals that participate in the data
system. Since there is a uniform design to data collection, the system variables are
more reliable for analysis of data. Another limitation of the study was the urban-rural
55
classification system. Due to data restrictions and privacy regulations, for analysis urban
and rural distinctions were made based on 3-digit zip codes. Using 3-digit zip codes to
classify urban and rural residence is net a 100% accurate classification system. Also,
the classifications for urban-rural residence in this study were made using 2000, census
data. As a result, the urban-rural classifications may not be as accurate in each year.
Finally, this study did not account for double counting in coding and classification. As a
result, some patients discharged from one hospital may also be counted as new patients
from another hospital.
Study Strengths
There were several strengths of this study that contributed to the reliability and
significance of the results. These strengths included:
1) A major strength of this study was the large sample population used. The
sample size of 99,513, may have significantly contributed to the significance of
many of the variables used.
2) An additional strength of this study is the use of ICD-9-CM diagnosis codes.
Previous studies have pointed out the reliability that diagnosis codes have in
classifying patients, specifically patients with hemorrhagic stroke and transient
ischemic attack (Benesch, Witter, Wilder, Duncan, Samsa, & Matchar, 1997).
3) A final strength of this study was the geographic difference in Tennessee
regarding the urban and rural areas. Tennessee has a large rural population,
and the distinctions between these two areas in the state are significant. The
research in this study shows the differences between these two areas as far as
stroke discharge is concerned, however more research should be done regarding
the urban and rural regions in Tennessee.
56
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57
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62
APPENDICES
63
APPENDIX A
MEHARRY
M E D I C A L
C O L L E G E
OFFICE FOR RESEARCH
Institutional Review Board

Februaiy 24,2010
Edward Davis Jr.
Division of Public
Health Practice
Meharry Medical
College Nashville, TN
37208
RE:
Association of stroke-related hospital discharges with socio-demographic

characteristics, insurance status, and urban-rural residence in Tennessee (MSPH
thesis)
;
Dear Mr. Davis:
The Institutional Review Board has determined that the project above is exempt based on
category 45CFR 46.101(b) (4) of the federal regulations concerning the use of existing
records, data, pathological specimens or diagnostic specimens when the information is recorded
by the investigator in such a manner that subjects cannot be identified. No consent form is
needed.
If you have any questions regarding this please feel free to contact me or Cynthia
Weaver at 6735. Sincerely,
2/24/2010
Cynthia Weaver
Cynthia Weaver, MT(ASCP), MSPH
Human Protections Administrator
100219ED034
1005 Dr. D.B. Todd Jr. Boulevard
Nashville, Tennessee
37208-3599
T:615.327.6735 | F:615.327.6391 | www.mmc.edu
64
APPENDIX B
ICD-9-CM Cerebrovascular Disease Diagnosis Codes

ICD-9
Code
430
Subarachnoid hemorrhage
ICD-9
Code
434.91
431
Intracerebral hemorrhage
435.0
433.01
Occlusion and Stenosis of basilar

artery with cerebral
Occlusion and Stenosis of carotid
arten/ with cerebral infarction
Occlusion and Stenosis of
vertebral artery with cerebral
infarction
multiple and bilateral precerebral
arteries with cerebral infarction
Occlusion and Stenosis of other
specified precerebral artery with
cerebral infarction
unspecified precerebral artery
with cerebral infarction
Cerebra) thrombosis with cerebral
infarction
Cerebral embolism with cerebral
infarction
435.1
433.11
433.21
433.31
433.81
433.91
434.01
434.11
DescriDtion
Descriotion
Cerebral artery occlusion
unspecified with cerebral
infarction
Transient cerebral ischemia of
basilar artery syndrome
Transient cerebral ischemia of
vertebral artery syndrome
Transient cerebral ischemia
subclavian steal syndrome
Transient cerebral ischemia
and other specified transient
cerebral ischemia
Transient cerebral ischemia or
unspecified transient cerebral
ischemia
Acute, but ill-defined,
cerebrovascular disease
435.2
435.8
435.9
436
65
APPENDIX C
Equation 1, 2: Multiple Logistic Regression Model for Hospital Discharge
Description
Equation
Discharge to Assisted Living Facility / Discharge to

Home
[P(Y=yji|x
_p X +p X
e j1 1 j2 2
Discharge to Inpatient Rehabilitation Facility /

Discharge to Home
[P(Y=yj2|x /[P(Y=yc|x
-p x +p x +p x +p x +p x
e j1 1 j2 2 j3 3 j4 4 j5 5
)r/P(Y=y |x)r = e
J1
)r
j2
X +p X +p X
j3 3 j4 4 j5 5
)r=e
*Where[P(Y=yjlx)] =e>/[e^,,2.Lj= 1, 2,..c
"j" - indexes the outcome categories: 1= Discharge to assisted living facility ,

2= Discharge to inpatient rehabilitation facility.
"cij
and p/' - are unknown parameters
"X" - is the explanatory variables (i.e., age, race, sex, insurance, urban-rural residence)
66
VITA
Edward Mitchell Davis Jr., was born on September 24, 1982 in San Diego,
California. Edward also attended high school in San Diego, at St. Augustine High
School and graduated with his high school diploma in June of 2001. Following high
school, Edward attended Fisk University in Nashville, Tennessee, to pursue a Bachelors
of Science degree in Biology, which he received in May of 2006. He earned his Master
of Science in Public Health in May of 2010, from Meharry Medical College, which is also
located in Nashville, Tennessee.
At various points throughout his graduate education at Meharry Medical College,
he was awarded several academic accolades. During the 2008-2009 academic school
year he was awarded the honor of "Who's Who Among Graduate Students." During the
2009-2010 academic school year he was once again awarded "Who's Who Among
Graduate Students" and also received the "Multi-Greek Scholarship" given to a graduate
student for school participation while maintaining a impressive academic marks.
Many of Edward's professional interests have been shaped by his strong interest
in public health, patient care, and racial-related health disparities. Each of his
professional experiences has also been rooted in these interests as well. Between July
and May of 2009, he worked as an administrative assistant at Erlanger Health Systems
in Chattanooga, Tennessee provided by Tennessee Hospital Association (THA). This
was an opportunity to work with and develop diversity hospital policies and procedures.
67
From September 2006 to August 2008, Edward worked at an occupational and industrial
clinic in San Diego, California named South Coast Medical Clinic.
Edward's research experience began in 2006 while at Fisk University in
Nashville, Tennessee with an independent genetics based research project that involved
analyzing various stages of gestational development of the Xenopus Laevis (African
clawed frog), when eggs are exposed to different media.
Edward's future career goals and objectives are to become a public health
dentist; addressing the problems of oral health on the population level both through
patient care and policy implementation. In addition, he plans to address the oral health
disparities that affect African-Americans most prevalently, while improving dental and
oral health related disparities in low income urban communities.
Edward has a strong desire to serve his community which is shown through his
community service efforts and community involvement. In November 2008 and 2009,
Edward participated in "Community Day" at Meharry Medical College in Nashville,
Tennessee. He also volunteers with "Feed the Children" in Nashville, Tennessee, an
organization that is responsible for collecting and distributing food to families in need
domestically and internationally. Also in October of 2008 and 2009 he helped organize
two service drives; at Meharry Medical College, as a member of Kappa Alpha Psi
Fraternity named, "Kandy for Kids," and a men's clothing drive.
68

Association Between Stroke-Related Hospital Discharge Status and Socio-Demographic Characteristic in Tennesse

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Association Between Stroke-Related Hospital Discharge Status and Socio-Demographic Characteristic in Tennesse

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To the School of Graduate Studies and Research:

I am submitting herewith a thesis written by Edward M. Davis Jr. entitled:

Director, MSPH Program

Accepted for the Graduate School

Dean, School of Graduate Studies and

ASSOCIATION BETWEEN STROKE-RELATED HOSPITAL DISCHARGE STATUS,

Edward Mitchell Davis Jr.

UMI Number: EP31636

All rights reserved

Copyright 2010 by Edward M. Davis Jr.

This thesis is dedicated to my sisters, Erica Megan Davis and

REVIEW OF SELECTED LITERATURE

Intracerebral Ischemic Stroke

Transient Ischemic Attack

Hospital Discharge Data System

Assisted Living Facility

Inpatient Rehabilitation Facility

Nature of the Problem

Theoretical Framework for Study

REVIEW OF SELECTED LITERATURE

Stroke Type and Severity Measures

cerebrovascular attack involves hemorrhage of vessels in the brain or in the vessels

predicting hospital discharge disposition in prior studies (Schlegel, Tanne, Demchuk,

Hospital Discharge and Stroke Outcomes

stroke victims may be subject to weeks or months of rehabilitation services based on

contributors to occurrence and ability to health and recover from cerebrovascular

Racial/Ethnic Cerebrovascular Disease Trends

Additionally, risk was

Trends among Stroke and Insurance Status

outcomes based on neurologic impairments and mortality. This was an adequate

results equate to access to healthcare for patients without insurance (self-pay) or on

Urban-Rural Residence and Stroke Incidence Trends

population, in comparison to Caucasian-Americans. However, in southwestern region of

Type and Source of Data

Independent variables: Insurance, stroke type, rural-urban residence, sex, age,

Alternative Hypothesis (Ha!)

discharge group were African-American (81.3%). These characteristics are consistent

Table 1: Comparison of Cerebrovascular Disease Discharge Status for

Using multinomial logistic regression model, all variables were assessed to

Table 2: Patient Hospital Discharge to Assisted Living Facility

The reference category is: Discharge TO HOME.

A secondary determinant of significance was based upon the 95% confidence

Table 3: Patient Hospital Discharge to Inpatient Rehabilitation Facility

The reference category is: Discharge TO HOME

had a positive association with discharge to an inpatient rehabilitation facility, instead of

The trends in discharge status among stroke survivors in Tennessee between

Patient Discharge to Assisted Living Setting vs. Home

which supports these results is observed in a study that found Caucasian-Americans to

Patient Discharge to Inpatient Rehabilitation Setting vs. Home

discharge "to home", as opposed to discharge to an inpatient rehabilitation facility by

Study Strengths and Limitations

1. 3M Health Information Systems. (2003). All Patient Refined Diagnosis Related

35. Practice Management Information Corporation. (1994). International

OFFICE FOR RESEARCH

Institutional Review Board

Association of stroke-related hospital discharges with socio-demographic

Dear Mr. Davis:

ICD-9-CM Cerebrovascular Disease Diagnosis Codes

Occlusion and Stenosis of basilar

Equation 1, 2: Multiple Logistic Regression Model for Hospital Discharge

Discharge to Assisted Living Facility / Discharge to

Discharge to Inpatient Rehabilitation Facility /

*Where[P(Y=yjlx)] =e>/[e^,,2.Lj= 1, 2,..c