Nursing home residents, minorities under-treated for recurrent stroke

October 09, 2003

DALLAS, Oct. 10 - Only half of elderly Americans in nursing homes are treated to prevent recurrent strokes, according to a review of nursing home admission records reported in today's rapid access issue of Stroke: Journal of the American Heart Association.

The study also showed racial minorities receive blood thinners for recurrent stroke less often than whites do. Blood thinners help prevent stroke-inducing blood clots.

Recurrent stroke is a major cause of disability and death among stroke survivors. Studies have shown that anticoagulants (blood thinners) like warfarin and antiplatelet drugs such as clopidogrel and aspirin help prevent future strokes. However, little is known about the extent to which such therapies are given to nursing home residents, many of whom are admitted to recuperate after surviving an initial stroke.

Past research suggests that blacks are less likely than whites to receive drug treatment for stroke, and that race often distinguishes who is healthy and who has access to and uses health services, said Jennifer Christian, Pharm.D., MPH, lead author of the study and a postdoctoral fellow in the Center for Gerontology and Health Care Research at Brown University in Providence, R.I. For these reasons, researchers investigated the extent to which racial minorities are less likely to receive necessary drug treatment for stroke while living in a U.S. nursing home.

They used the Systematic Assessment of Geriatric Drug Use Via Epidemiology (SAGE) database. SAGE is an integrated database that includes information from the federal government's Center for Medicare and Medicaid Services. By federal mandate, all Medicaid/Medicare-certified nursing homes complete comprehensive resident assessments when patients are admitted, collecting information on demographics, clinical diagnoses, physical and cognitive functioning, and medication use. The researchers evaluated data from five states - Kansas, Maine, Ohio, New York, and Mississippi - between 1992 and 1996. Researchers identified 19,051 residents who had been hospitalized in the prior six months for ischemic stroke (clot-caused). Of these residents, 7,053 had other health conditions that warranted the use of anticoagulant therapy.

"The current antiplatelet treatments for stroke prevention in the elderly are aspirin/dipyridamole combination, aspirin, and clopidogrel," Christian said. Warfarin is indicated in people who have had an ischemic stroke and are at an increased risk of clotting.

The researchers found that about 61 percent of Asian/Pacific Islanders did not receive any treatment to prevent recurrent stroke. Likewise, 54 percent of Hispanics, 51 percent of blacks, 46 percent of whites and 42 percent of American Indians were not treated.

In general, Asian/Pacific Islanders received less of any secondary prevention treatment and American Indians received more of any preventive treatment compared to whites.

Most residents - 60 percent to 75 percent - whose health status indicated the need for a blood thinner did not receive warfarin. Non-white racial groups were less likely to receive the treatment than whites.

"Clearly, interventions are needed to improve and increase the use of treatments for recurrent stroke in all nursing home residents," Christian said. "Not only were important stroke-preventing drugs underused but also most residents who were eligible for anticoagulant therapy in our study did not receive it," she said. "It appears that minority populations in nursing homes are at greater risk for under treatment, which is only partially explained by patient characteristics such as age, gender, physical and cognitive function, or other diseases."

Christian noted that the data is limited to a "snapshot on admission" to a nursing facility and researchers were unable to evaluate whether the observed differences indicate treatment patterns in the nursing home or are simply a reflection of prescribing standards within the community or the various hospital settings. "We can only speculate on possible reasons, such as structural differences in the facilities in which people of color live and/or racial discrimination. Understanding why differences were observed is beyond the capabilities of the data."
Co-authors are Kate L. Lapane, Ph.D. and Rebecca S. Toppa, Ph.D. This study was partly funded by the National Institute on Aging.

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