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Outpatient Rehabilitation Among Stroke Survivors --- 21 States and the District of Columbia, 2005

Stroke is a leading cause of severe and long-term disability in the United States (1). Approximately 700,000 persons in the United States have a new or recurrent stroke each year (1); among those who survive, only 10% recover completely, and many of the remaining survivors need rehabilitation because of resulting impairments (2). Long-term disability not only affects functional status and social roles among stroke survivors but also results in substantial costs; the combined direct and indirect costs of stroke are projected to be $62.7 billion in the United States in 2007 (1). Although studies have established that timely and intensive rehabilitation can substantially improve patients' functional outcomes and quality of life after an acute stroke (2--4), few studies have provided population-based estimates of the prevalence of acute stroke rehabilitation (5). To examine the prevalence of outpatient stroke rehabilitation among selected populations, CDC assessed data from the 2005 Behavioral Risk Factor Surveillance System (BRFSS) survey on stroke survivors in 21 states* and the District of Columbia (DC). This report summarizes the results of that assessment, which indicated that 30.7% of the stroke survivors received outpatient rehabilitation and a higher prevalence of outpatient stroke rehabilitation was reported among men, non-Hispanic blacks, unemployed or retired adults, and persons living in the center city of a metropolitan statistical area (MSA) than in comparison groups. The findings indicated that the prevalence of stroke survivors who were receiving outpatient stroke rehabilitation services was lower than would be expected if clinical practice guideline recommendations for all stroke patients had been followed (4,6). Increasing the number of stroke survivors who receive needed outpatient rehabilitation might lead to better functional status and quality of life in this population.

Data were analyzed from the 2005 BRFSS survey, a state-based, random-digit--dialed telephone survey of the noninstitutionalized, U.S. civilian population aged >18 years. All participants were asked, "Has a doctor, nurse, or other health professional ever told you that you had a stroke?" If the answer was "yes," the participants were asked an additional question from the optional cardiovascular health module: "After you left the hospital following your stroke, did you go to any kind of outpatient rehabilitation? This is sometimes called `rehab.'" Stroke or rehabilitation could have occurred at any time in the past; no date restrictions were included. Sociodemographic data collected in the survey included age, sex, race/ethnicity, marital status, education, employment status, income level, insurance coverage, and assigned MSA status. Twenty-one states and DC implemented the optional module; the median response rate, based on Council of American Survey and Research Organizations (CASRO) guidelines, was 51.3% (range: 34.6%--66.7%). CASRO response rates account for both the efficiency of the telephone sampling method and the actual participation rates among respondents. The median cooperation rate, defined as the proportion of all respondents interviewed among all eligible persons who were contacted, was 74.3% (range: 63.2%--85.3%).

Prevalence estimates and 95% confidence intervals (CIs) for a history of stroke and receipt of outpatient stroke rehabilitation among stroke survivors were calculated from aggregated data from all 21 states and DC. Prevalence estimates of outpatient stroke rehabilitation also were obtained for populations defined by age, sex, race/ethnicity, marital status, education level, employment status, income level, insurance coverage, and MSA status. Logistic regression was used to estimate the odds of receiving outpatient stroke rehabilitation in subpopulations compared with a referent group, after adjustment for age. Data were weighted to reflect each state's population.

Among 129,761 survey respondents in the 21 states and DC, 4,689 (2.6%, CI = 2.5--2.8) reported ever having a stroke. Of these, 4,420 responded to the question on stroke rehabilitation; 1,297 (30.7%, CI = 28.5--33.1) had received outpatient stroke rehabilitation after leaving the hospital. Stroke survivors in the three age groups had a similar prevalence of outpatient stroke rehabilitation (Table). The age-adjusted prevalence of receipt of outpatient stroke rehabilitation was higher among men than women (adjusted odds ratio [AOR] = 1.31, CI = 1.05--1.63), and non-Hispanic blacks had a higher prevalence of outpatient stroke rehabilitation than non-Hispanic whites (AOR = 1.49, CI = 1.10--2.00). Compared with stroke survivors who were employed at the time of the survey, receipt of stroke rehabilitation was higher among respondents who were unemployed (AOR = 1.59, CI = 1.16--2.18) or retired (AOR = 1.45, CI = 1.01--2.09). Adults living in a non-MSA had a lower prevalence of outpatient stroke rehabilitation than those living in the center city of an MSA (AOR = 0.72, CI = 0.55--0.93). The prevalence of receipt of outpatient stroke rehabilitation did not differ significantly by marital status, education level, income level, or insurance status.

Reported by: J Xie, MD, PhD, MG George, MD, C Ayala, PhD, HF McGruder PhD, CH Denny, PhD, JB Croft, PhD, Div for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion; AL Valderrama, PhD, EIS Officer, CDC.

Editorial Note:

Stroke rehabilitation should begin in the hospital as soon as acute stroke is diagnosed and the patient is medically stable (6). However, short-term benefits from inpatient stroke rehabilitation might not last over the long term, suggesting the need for continuing rehabilitation in an outpatient setting (6,7). Recent clinical practice guidelines recommend outpatient rehabilitation for stroke patients who have been discharged from inpatient rehabilitation and for less severely disabled patients who have been discharged after receiving acute stroke care (4,6); therefore, the majority (i.e., >50%) of stroke survivors would be expected to receive some kind of outpatient rehabilitation if the guidelines were followed. However, the results in this report indicate that less than one third of stroke survivors reported receiving outpatient stroke rehabilitation.

The prevalence of reported outpatient stroke rehabilitation was significantly higher among men than women, among unemployed and retired persons than among employed persons, among adults living in the center city of an MSA than in a non-MSA, and among non-Hispanic blacks than non-Hispanic whites. Based on data in a study on Medicare beneficiaries (8), a potential factor contributing to the higher receipt of outpatient stroke rehabilitation among blacks compared with whites is a higher percentage of motor deficits from stroke among black stroke patients.

The lower than expected prevalence of outpatient stroke rehabilitation among stroke survivors might be caused by a lack of resources, such as too few rehabilitation centers and clinics and inadequate access to rehabilitation staff, especially in non-MSA areas. In addition, support from family and caregivers is essential for ensuring the receipt and continuation of outpatient rehabilitation among stroke survivors. Additional policies that encourage family support, such as the Family and Medical Leave Act (http://www.dol.gov/esa/whd/fmla), could be beneficial.

Outpatient rehabilitation can be provided in a freestanding or hospital outpatient facility or in a day hospital-care setting (6). A multidisciplinary team should be involved and, depending on the disability, can include an occupational therapist; a physician, nurse, physical therapist, kinesiotherapist, speech therapist, psychologist, and recreational therapist; and the family or caregivers (6).

The findings in this report are subject to at least six limitations. First, the BRFSS rehabilitation question asks about receipt of outpatient stroke rehabilitation only. Therefore, the results do not provide information on inpatient rehabilitation services or referral to rehabilitation services. Second, 21 states and DC administered the optional module; no nationwide estimate on the prevalence of outpatient stroke rehabilitation could be calculated. Third, although the receipt of outpatient stroke rehabilitation is highly dependent on disease severity and patient medical status, information on these characteristics was not available. Adjustment for these factors might have changed the associations. Fourth, employment status referred to the respondent's current employment status at the time of the survey, not at the time of stroke. If stroke patients who were employed at the time of stroke but were subsequently unemployed or retired at the time of the survey are more likely to receive outpatient stroke rehabilitation because of greater stroke severity than those who remained employed, the association between stroke rehabilitation and employment status in this study would be biased. Fifth, both stroke and stroke rehabilitation were self-reported and subject to recall bias. Finally, the BRFSS response rate was low, and no studies exist that specifically address the validity of the survey data on receipt of stroke rehabilitation. In addition, persons who reported having had a stroke might have had a transient ischemic attack (TIA). Regardless, the BRFSS estimate for the prevalence of stroke (2.6%) is consistent with the rate in other surveys, which does not include TIAs (1).

Stroke rehabilitation is an integral part of stroke systems of care, which include primary prevention, community education, notification of and prompt response by emergency medical services, acute stroke treatment, subacute stroke treatment and secondary prevention, rehabilitation, and continuous quality-improvement activities (9). Stroke rehabilitation can help stroke survivors reach their physical, psychological, social, and vocational potential (9) through greater independence in activities of daily living, improved psychosocial well-being, better control of risk factors, and reduced risk for medical complications, recurrent stroke, and death (6).

The essential components of the American Stroke Association clinical practice guideline on stroke rehabilitation (6) include rehabilitation assessment, inpatient, outpatient and community-based rehabilitation. Availability of and access to rehabilitation facilities and specialized staff in the community, policies encouraging family support, and physician and patient education might improve rehabilitation rate among stroke survivors. In addition, more research is needed to assess the prevalence of referral and receipt of both inpatient and outpatient stroke rehabilitation at the state and national levels. Public health measures should continue focusing on improving systems of care, from stroke onset through final rehabilitation, to improve overall outcomes among stroke patients.

References

  1. Rosamond W, Flegal K, Friday G, et al. Heart disease and stroke statistics---2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2007;115:e69--e171.
  2. Rosenberg CH, Popelka GM. Post-stroke rehabilitation. A review of the guidelines for patient management. Geriatrics 2000;55:75--81.
  3. Ryan T, Enderby P, Rigby AS. A randomized controlled trial to evaluate intensity of community-based rehabilitation provision following stroke or hip fracture in old age. Clin Rehabil 2006;20:123--31.
  4. Heart and Stroke Foundation of Ontario. Stroke rehabilitation consensus panel report; 2000. Available at http://209.5.25.171/Page.Asp?PageID=122&ContentID=432.
  5. Lee JA, Huber J, Stason WB. Poststroke rehabilitation in older Americans: the Medicare experience. Med Care 1996;34:81--25.
  6. Duncan PW, Zorowitz R, Bates B, et al. Management of adult stroke rehabilitation care: a clinical practice guideline. Stroke 2005;36: e100--43.
  7. Hopman WM, Verner J. Quality of life during and after inpatient stroke rehabilitation. Stroke 2003;34:801--5.
  8. Horner RD, Hoenig H, Sloane R, Rubenstein LV, Kahn KL. Racial differences in the utilization of inpatient rehabilitation services among elderly stroke patients. Stroke 1997; 28:19--25.
  9. Schwamm LH, Pancioli A, Acker JE, et al. Recommendations for the establishment of stroke systems of care---recommendations from the American Stroke Association's Task Force on the Development of Stroke Systems. Stroke 2005;36:690--703.

* Alabama, Arkansas, Connecticut, Georgia, Kansas, Kentucky, Louisiana, Maine, Minnesota, Mississippi, Montana, Nebraska, New Jersey, New York, North Dakota, Ohio, Oklahoma, South Carolina, Utah, Virginia, and West Virginia.

Table

Table 1
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