Significant racial and ethnic disparities in stroke risk factors, occurrence, and outcomes persist in the USA. This article examines socio-economic and health disparities in a diverse, hypertensive sample of 495 post-stroke Black, non-Hispanic and Hispanic home health patients at risk of a recurrent stroke due to elevated systolic blood pressure (SBP), defined as SBP > 140 mmHg. The article, which analyzes cross-sectional data, focuses on correlates of patients’ SBP—the leading modifiable cause of stroke—and physical function—a key stroke sequela and indicator of post-stroke quality of life. Of the 495 participants, 69.7% were Black, non-Hispanic, and 30.3% Hispanic. Black participants had significantly higher mean SBP than Hispanics. After controlling for multiple potential confounders/predictors, being Black was associated with a 3.55 mmHg elevation in SBP relative to being Hispanic. There were no significant Black/Hispanic differences in physical function measures. Seven independent variables significantly predicted better physical function: being male, younger, having fewer comorbidities, lower BMI, fewer depressive symptoms, higher health literacy, and current alcohol drinking (vs. abstinence). Our data provide a unique comparison of homebound Black and Hispanic stroke survivors at heightened risk of recurrent stroke absent targeted intervention. The finding of a significant Black/Hispanic disparity in SBP is striking in this narrowly defined home health care population all of whom are at risk for recurrent stroke. Priority should be given to culturally tailored interventions designed to link vulnerable home care patients to continuous, responsive hypertension care.
Stroke Racial/ethnic disparities Home health care Outcomes
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This study was supported by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health under Award Number U54NS081765.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
Research Involving Human Participants
All procedures performed in this study were in accordance with the ethical standards of the institution and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, et al. Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation. 2017;135(10):e146–603.CrossRefPubMedPubMedCentralGoogle Scholar
Qian F, Fonarow GC, Smith EE, Xian Y, Pan W, Hannan EL, et al. Racial and ethnic differences in outcomes in older patients with acute ischemic stroke. Circ Cardiovasc Qual Outcomes. 2013;6(3):284–92.CrossRefPubMedGoogle Scholar
Bravata DM, Wells CK, Gulanski B, Kernan WN, Brass LM, Long J, et al. Racial disparities in stroke risk factors: the impact of socioeconomic status. Stroke. 2005;36(7):1507–11.CrossRefPubMedGoogle Scholar
George MG, Fischer L, Koroshetz W, Bushnell C, Frankel M, Foltz J, et al. CDC grand rounds: public health strategies to prevent and treat strokes. MMWR Morb Mortal Wkly Rep. 2017;66(18):479–81.CrossRefPubMedPubMedCentralGoogle Scholar
Yang Q, Tong X, Schieb L, Vaughan A, Gillespie C, Wiltz JL, et al. Vital signs: recent trends in stroke death rates - United States, 2000-2015. MMWR Morb Mortal Wkly Rep. 2017;66(35):933–9.CrossRefPubMedPubMedCentralGoogle Scholar
Lisabeth LD, Smith MA, Brown DL, Moye LA, Risser JMH, Morgenstern LB. Ethnic differences in stroke recurrence. Ann Neurol. 2006;60(4):469–75.CrossRefPubMedGoogle Scholar
Skolarus LE, Feng C, Burke JF. No racial difference in rehabilitation therapy across all post-acute care settings in the year following a stroke. Stroke. 2017;48(12):3329–35.CrossRefPubMedPubMedCentralGoogle Scholar
Burke JF, Freedman VA, Lisabeth LD, Brown DL, Haggins A, Skolarus LE. Racial differences in disability after stroke: results from a nationwide study. Neurology. 2014;83(5):390–7.CrossRefPubMedPubMedCentralGoogle Scholar
Burke JF, Skolarus LE, Freedman VA. Racial disparities in poststroke activity limitations are not due to differences in prestroke activity limitation. J Stroke Cerebrovasc Dis. 2015;24(7):1636–9.CrossRefPubMedPubMedCentralGoogle Scholar
Stansbury JP, Jia H, Williams LS, Vogel WB, Duncan PW. Ethnic disparities in stroke: epidemiology, acute care, and postacute outcomes. Stroke. 2005;36(2):374–86.CrossRefPubMedGoogle Scholar
Ellis C, Hyacinth HI, Beckett J, Feng W, Chimowitz M, Ovbiagele B, et al. Racial/ethnic differences in poststroke rehabilitation outcomes. Stroke Res Treat. 2014;2014:950746.PubMedPubMedCentralGoogle Scholar
Sacco RL, Boden-Albala B, Abel G, Lin IF, Elkind M, Hauser WA, et al. Race-ethnic disparities in the impact of stroke risk factors: the northern Manhattan stroke study. Stroke. 2001;32(8):1725–31.CrossRefPubMedGoogle Scholar
Boutin-Foster C, Ogedegbe G, Ravenell JE, Robbins L, Charlson ME. Ascribing meaning to hypertension: a qualitative study among African Americans with uncontrolled hypertension. Ethn Dis. 2007;17(1):29–34.PubMedGoogle Scholar
Cruz-Flores S, Rabinstein A, Biller J, Elkind MS, Griffith P, Gorelick PB, et al. Racial-ethnic disparities in stroke care: the American experience: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42(7):2091–116.CrossRefPubMedGoogle Scholar
Levine DA, Neidecker MV, Kiefe CI, Karve S, Williams LS, Allison JJ. Racial/ethnic disparities in access to physician care and medications among US stroke survivors. Neurology. 2011;76(1):53–61.CrossRefPubMedGoogle Scholar
Josiah Willock R, Miller JB, Mohyi M, Abuzaanona A, Muminovic M, Levy PD. Therapeutic inertia and treatment intensification. Curr Hypertens Rep. 2018;20(1):4.CrossRefPubMedGoogle Scholar
Okonofua EC, Cutler NE, Lackland DT, Egan BM. Ethnic differences in older Americans: awareness, knowledge, and beliefs about hypertension. Am J Hypertens. 2005;18(7):972–9.CrossRefPubMedGoogle Scholar
Addo J, Ayerbe L, Mohan KM, Crichton S, Sheldenkar A, Chen R, et al. Socioeconomic status and stroke: an updated review. Stroke. 2012;43(4):1186–91.CrossRefPubMedGoogle Scholar
Andersen R, Newman JF. Societal and individual determinants of medical care utilization in the United States. Milbank Mem Fund Q Health Soc. 1973;51(1):95–124.CrossRefPubMedGoogle Scholar
Feldman PH, McDonald MV, Trachtenberg MA, Schoenthaler A, Coyne N, Teresi J. Center for stroke disparities solutions community- based care transition interventions: study protocol of a randomized controlled trial. Trials. 2015;16:32.CrossRefPubMedPubMedCentralGoogle Scholar
Bennett JA, Riegel B, Bittner V, Nichols J. Validity and reliability of the NYHA classes for measuring research outcomes in patients with cardiac disease. Heart Lung. 2002;31(4):262–70.CrossRefPubMedGoogle Scholar
Callahan CM, Unverzagt FW, Hui SL, Perkins AJ, Hendrie HC. Six-item screener to identify cognitive impairment among potential subjects for clinical research. Med Care. 2002;40(9):771–81.CrossRefPubMedGoogle Scholar
Kelly MA, Morse JQ, Stover A, Hofkens T, Huisman E, Shulman S, et al. Describing depression: congruence between patient experiences and clinical assessments. Br J Clin Psychol. 2011;50(1):46–66.CrossRefPubMedPubMedCentralGoogle Scholar
Choi SW, Reise SP, Pilkonis PA, Hays RD, Cella D. Efficiency of static and computer adaptive short forms compared to full-length measures of depressive symptoms. Qual Life Res. 2010;19(1):125–36.CrossRefPubMedGoogle Scholar
Teresi JA, Ocepek-Welikson K, Kleinman M, Eimicke JP, Crane PK, Jones RN, et al. Analysis of differential item functioning in the depression item bank from the patient reported outcome measurement information system (PROMIS): an item response theory approach. Psychol Sci Q. 2009;51(2):148–80.PubMedPubMedCentralGoogle Scholar
Reeve BB, Hays RD, Bjorner JB, Cook KF, Crane PK, Teresi JA, et al. Psychometric evaluation and calibration of health-related quality of life item banks: plans for the patient-reported outcomes measurement information system (PROMIS). Med Care. 2007;45(5 Suppl 1):S22–31.CrossRefPubMedGoogle Scholar
Reeve BB. Special issues for building computerized-adaptive tests for measuring patient-reported outcomes: the National Institute of Health’s investment in new technology. Med Care. 2006;44(11 Suppl 3):S198–204.CrossRefPubMedGoogle Scholar
Bruce B, Fries JF, Ambrosini D, Lingala B, Gandek B, Rose M, et al. Better assessment of physical function: item improvement is neglected but essential. Arthritis Res Ther. 2009;11(6):R191.CrossRefPubMedPubMedCentralGoogle Scholar
Mahoney FI, Barthel DW. Functional evaluation: the Barthel index. Md State Med J. 1965;14:61–5.PubMedGoogle Scholar
Ohura T, Hase K, Nakajima Y, Nakayama T. Validity and reliability of a performance evaluation tool based on the modified Barthel index for stroke patients. BMC Med Res Methodol. 2017;17(1):131.CrossRefPubMedPubMedCentralGoogle Scholar
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83.CrossRefGoogle Scholar
Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med. 2004;36(8):588–94.PubMedGoogle Scholar
Lorig KR, Sobel DS, Ritter PL, Laurent D, Hobbs M. Effect of a self-management program on patients with chronic disease. Eff Clin Pract. 2001;4(6):256–62.PubMedGoogle Scholar
Gatti ME, Jacobson KL, Gazmararian JA, Schmotzer B, Kripalani S. Relationships between beliefs about medications and adherence. Am J Health Syst Pharm. 2009;66(7):657–64.CrossRefPubMedGoogle Scholar
Horne RWJ, Hankins M. The beliefs about medicines questionnaire: the development and evaluation of a new method for assessing the cognitive representation of medication. Psychol Health. 1999;14(1):1–24.CrossRefGoogle Scholar
Glasgow RE, Wagner EH, Schaefer J, Mahoney LD, Reid RJ, Greene SM. Development and validation of the patient assessment of chronic illness care (PACIC). Med Care. 2005;43(5):436–44.CrossRefPubMedGoogle Scholar
Revelle W. psych: procedures for personality and psychogical research. (R package version 15.1d). 2015.Google Scholar
Williams O, Leighton-Herrmann Quinn E, Teresi J, Eimicke JP, Kong J, Ogedegbe G, et al. Improving community stroke preparedness in the HHS (hip-hop stroke) randomized clinical trial. Stroke. 2018;49(4):972–9.CrossRefPubMedPubMedCentralGoogle Scholar
Palmer AJ, Bulpitt CJ, Fletcher AE, Beevers DG, Coles EC, Ledingham JG, et al. Relation between blood pressure and stroke mortality. Hypertension. 1992;20(5):601–5.CrossRefPubMedGoogle Scholar
Howard G, Lackland DT, Kleindorfer DO, Kissela BM, Moy CS, Judd SE, et al. Racial differences in the impact of elevated systolic blood pressure on stroke risk. JAMA Intern Med. 2013;173(1):46–51.CrossRefPubMedPubMedCentralGoogle Scholar
Dong C, Della-Morte D, Rundek T, Wright CB, Elkind MS, Sacco RL. Evidence to maintain the systolic blood pressure treatment threshold at 140 mm hg for stroke prevention: the northern Manhattan study. Hypertension. 2016;67(3):520–6.CrossRefPubMedPubMedCentralGoogle Scholar
Thilarajah S, Mentiplay BF, Bower KJ, Tan D, Pua YH, Williams G, et al. Factors associated with post-stroke physical activity: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2017.Google Scholar
Hergenroeder AL, Wert DM, Hile ES, Studenski SA, Brach JS. Association of body mass index with self-report and performance-based measures of balance and mobility. Phys Ther. 2011;91(8):1223–34.CrossRefPubMedPubMedCentralGoogle Scholar
Goldmann E, Roberts ET, Parikh NS, Lord AS, Boden-Albala B. Race/ethnic differences in post-stroke depression (PSD): findings from the stroke warning information and faster treatment (SWIFT) study. Ethn Dis. 2016;26(1):1–8.CrossRefPubMedPubMedCentralGoogle Scholar