Urban-Rural Differences in Service Utilization and Costs of Care for Racial-Ethnic Groups Hospitalized With Poststroke Aphasia

doi:10.1016/j.apmr.2018.06.033

Archives of Physical Medicine and Rehabilitation

Volume 100, Issue 2, February 2019, Pages 254-260

https://doi.org/10.1016/j.apmr.2018.06.033 Get rights and content

Abstract

Objective

Although residence is a key contributor to cost and utilization in stroke patient care, its contribution to the care of persons with aphasia (PWA) is unknown. The objective of this study was to use discharge-level hospital inpatient data to examine the influence of patient residence (rural vs urban) and race-ethnicity on service utilization and cost of care among PWA.

Design

Cross-sectional.

Setting

Administrative data from acute care hospitals in the state of North Carolina.

Participants

Individuals (N=4381) with poststroke aphasia.

Interventions

N/A.

Main Outcome Measures

Length of stay (LOS), speech-language pathology (SLP) service utilization, costs of care.

Methods

The 2011-2012 Healthcare Cost and Utilization Project State Inpatient Database data were analyzed to examine the effect of rural or urban residence on LOS, SLP service utilization, as well as total inpatient and SLP service costs. These outcomes were further analyzed across both residence and racial groups (non-Hispanic white and non-Hispanic black). Outcomes were analyzed using generalized linear model.

Results

Both rural and urban black PWA experienced longer average LOS after controlling for demographics, illness severity, and the hospital where they received care. Rural blacks experienced longer LOS, received greater SLP services, and incurred greater average total hospital costs than their rural white counterparts after adjusting for differences in their demographics and stroke or illness severity. The differences were attenuated after controlling for the hospital where they received care.

Conclusions

For PWA, race-ethnicity has a larger effect on average total medical costs, SLP service utilization, and LOS than residence. It is unclear how and why blacks with aphasia have greater service utilization and costs in acute care, yet their aphasia outcomes are worse. Future studies are required to explore potential factors such as quality of care.

Section snippets

Study Perspective and Approach

The purpose of this study was to examine the influence of rural or urban residence on health care service utilization (general medical and SLP) and costs in hospitalized PWA. Two previous studies have shown that black PWA are more likely to have greater hospital service utilization and at a higher cost than white PWA.10, 11 Yet neither explored the potential for double disadvantage (race-ethnicity and rural/urban residence) in relation to service utilization patterns and costs in PWA.

Methods

This study was reviewed and approved by the East Carolina University Institutional Review Board. Data for this study were obtained from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project (HCUP) State Inpatient Database from the state of North Carolina.¹⁸ The HCUP database includes discharge data from all acute care licensed hospitals located in North Carolina. This analysis used 2011 and 2012 discharge data for PWA.

To identify PWA with ischemic stroke,

Results

There were 4381 individuals identified with poststroke aphasia in North Carolina between 2011 and 2012. Seventy percent were age 65 or older, 55% were women, and Medicare was the primary insurance type in almost two-thirds of the sample. Approximately 50% of the sample experienced a stroke that was considered mild, and ∼40% experienced a stroke that was considered severe. Rural PWA were more likely to have Medicare, less likely to have private insurance, and more likely to be transferred to a

Discussion

The findings of this study suggest that in the acute care setting, race-ethnicity is a more salient contributor to overall health care utilization and costs than residence among PWA. Both rural and urban black PWA experienced a longer LOS with higher associated costs than their white counterparts. Similarly, black PWA living in both rural and urban areas used more SLP services than white PWA living in rural and urban areas. Yet, the observed differences in LOS and costs between white and black

Conclusions

The findings reported here suggest that race-ethnicity influences economic outcomes of PWA treatment. Observed differences were not because of traditional explanations regarding greater stroke severity among blacks. The influence of race-ethnicity on outcomes was in part related to which hospital admitted the patient rather than differences in treatment within a hospital. Because aphasia rehabilitation occurs at all stages of poststroke care, future studies should examine rural-urban and

Supplier

a.
Stata, version 14; StataCorp LP.

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To describe the costs of hospital care for acute stroke for patients with aphasia or dysarthria.
Observational study from the Stroke123 project.
Data from patients admitted with stroke (2009-2013) from 22 hospitals in Queensland participating in the Australian Stroke Clinical Registry (AuSCR) were linked to administrative datasets.
Communication impairments were identified using International Classification of Diseases, 10th Revision, Australian Modification codes. Overall, 1043 of 4195 (25%) patients were identified with aphasia (49% were women; median age 78 years; 83% with ischemic stroke), and 1005 (24%) with dysarthria (42% were women; median age 76 years; 85% with ischemic stroke).
Not applicable.
Linked patient-level, hospital clinical costing related to the stroke, were adjusted to 2013/2014 Australian dollars (AU$, US$ conversion x 0.691) using recommended national price indices and multivariable regression analysis with clustering by hospital performed.
Compared with patients without aphasia, the median hospital costs/patient were greater for those with aphasia for medical (aphasia AU$2273 vs AU$1727, P<.001), nursing (aphasia AU$3829 vs AU$2748, P<.001) and allied health services (aphasia AU$1138 vs AU$720, P<.001). Similarly, costs were greater for patients with dysarthria compared with those without dysarthria. Adjusted median total costs were AU$2882 greater for patients with aphasia compared with patients without aphasia (95% confidence interval, AU$1880-3884), and AU$843 greater for patients with dysarthria compared with those without dysarthria (95% confidence interval, AU$–301 to 1987).
People with communication impairment after stroke incur greater hospital costs, in particular for medical, allied health, and nursing resources.
Aphasia severity is modulated by race and lesion size in chronic survivors: A retrospective study
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Citation Excerpt :
Most often a consequence of stroke, aphasia is an acquired language disorder that occurs in 180,000 stroke survivors annually (Aphasia FAQs. January 5, 2022) . Differences in stroke incidence, access to care, and language impairment have been linked to race and SES (captured by income and education) (Arrich et al., 2008; Hardy et al., 2019). Stroke-related costs in the United States are nearly 53 billion dollars, and the burden of stroke is higher in racial/ethnic minorities (CDC, 2022; Trimble & Morgenstern, 2008).
In stroke survivors with aphasia (SWA), differences in behavioral language performance have been observed between Black and White Americans. These racial differences in aphasia outcomes may reflect biological stroke severity, disparities in access to care, potential assessment bias, or interactions between these factors and race. Understanding the origin of disparities in aphasia outcomes is critical to any efforts to promote health equity among SWA. In this study, we explore aphasia outcomes by examining the relationship between race, socioeconomic status, and neurological factors in SWA.
Eighty-five chronic left-hemisphere SWA (31 Black, 54 White) participated in the study. The primary aphasia outcome measure was the Western Aphasia Battery-Revised (WAB-R). Lesion size was measured based on manual lesion segmentations. FLAIR and T2 images were scored for severity of white matter disease. Independent sample t-tests were used to determine differences by race in education, age, income, aphasia severity, white matter disease, and lesion size. A linear regression model was used to explore factors that predicted aphasia severity on the WAB-R.
Level of education and estimated income differed by race in our sample. For predictors of aphasia severity, the regression model revealed a significant effect of lesion size on WAB Aphasia Quotient and an interaction of race x lesion size, such that Black and White participants with small lesions had similar WAB scores, but in individuals with larger lesions, Black participants had lower WAB scores than White participants.
We suggest two explanations for the difference between Black and White SWA in the relationship between lesion size and aphasia severity. First, the impact of disparities in access to rehabilitation after stroke may be more evident when a stroke is larger and causes significant aphasia. Additionally, an assessment bias in aphasia outcome measures may be more evident with increasing severity of aphasia. Future studies should further discern the drivers of observed disparities in aphasia outcomes in order to identify opportunities to improve equity in aphasia care.
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To investigate whether indicators of patient need (comorbidity burden, fall risk) predict acute care rehabilitation utilization, and whether this relation varies across patient characteristics (ie, demographic characteristics, insurance type).
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Occupational therapy (OT) and physical therapy (PT) utilization. Logistic regression models determined whether indicators of patient need predicted OT and PT utilization. Interactions between indicators of need and both demographic factors (eg, minority status, presence of significant other) and insurance type were included to investigate whether the relation between patient need and therapy access varied across patient characteristics.
Greater comorbidity burden was associated with a higher likelihood of receiving OT and PT. Relative to those with low fall risk, those with moderate and high fall risk were more likely to receive OT and PT. The relation between fall risk and therapy utilization differed across patient characteristics. Among patients with higher levels of fall risk, those with a significant other were less likely to receive OT and PT; significant other status did not explain therapy utilization among patients with low fall risk. Among those with high fall risk, patients with VA insurance and minority patients were more likely to receive PT than those with private insurance and nonminority patients, respectively. Insurance type and minority status did not appear to explain PT utilization among those with lower fall risk.
Patients with greater comorbidity burden and fall risk were more likely to receive acute care rehabilitation. However, the relation between fall risk and utilization was moderated by insurance type, having a significant other, and race/ethnicity. Understanding the implications of these utilization patterns requires further research.
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: Disclosures: none.

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Original researchUrban-Rural Differences in Service Utilization and Costs of Care for Racial-Ethnic Groups Hospitalized With Poststroke Aphasia

Abstract

Objective

Design

Setting

Participants

Interventions

Main Outcome Measures

Methods

Results

Conclusions

Section snippets

Study Perspective and Approach

Methods

Results

Discussion

Conclusions

Supplier

Arch Phys Med Rehabil

Arch Phys Med Rehabil

J Neurol Sci

Arch Phys Med Rehabil

J Health Econ

Arch Phys Med Rehabil

Aphasia

Aphasia in North America 2018

Rate of aphasia among stroke patients discharged from hospitals in the United States

Aphasiology

Aphasia as a predictor of stroke outcome

Curr Neurol Neurosci Rep

Effect of aphasia on acute stroke outcomes

Neurology

Rebuilding the unity of health and the environment in rural America: workshop summary

Rural residence and Hispanic ethnicity: doubly disadvantaged for diabetes?

J Rural Health

The one-year attributable cost of poststroke aphasia

Stroke

Measuring racial/ethnic disparities in health care: methods and practical issues

Health Serv Res

Health services research: scope and significance

The geography of stroke mortality in the United States and the concept of a stroke belt

Stroke

Factors explaining excess stroke prevalence in the US Stroke Belt

Stroke

Original research
Urban-Rural Differences in Service Utilization and Costs of Care for Racial-Ethnic Groups Hospitalized With Poststroke Aphasia