WalkerC Becker, G Howard, KR McLeroy, FM Yatsu, JF Toole, B Coull, J Feibel and MD

York. II: Description of study populationCommunity Hospital-based Stroke Programs: North Carolina, Oregon, and New

1524-4628 Copyright © 1986 American Heart Association. All rights reserved. Print ISSN: 0039-2499. Online ISSN:

Stroke is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX 725141986, 17:285-293Stroke 

http://stroke.ahajournals.org/content/17/2/285located on the World Wide Web at:

The online version of this article, along with updated information and services, is

http://www.lww.com/reprintsReprints: Information about reprints can be found online at   journalpermissions@lww.com410-528-8550. E-mail: Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Fax: Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters  http://stroke.ahajournals.org//subscriptions/Subscriptions: Information about subscribing to Stroke is online at

by guest on July 10, 2011http://stroke.ahajournals.org/Downloaded from

Community Hospital-Based Stroke Programs:North Carolina, Oregon, and New York*

II: Description of Study Population

285

CAROLINE BECKER M.D. , GEORGE HOWARD, M.S. , KENNETH R. MCLEROY, P H . D . ,

FRANK M. YATSU, M.D. , JAMES F. TOOLE, M.D. , BRUCE COULL, M.D. , JOHN FEIBEL, M.D. ,

AND MICHAEL D. WALKER, M.D.

SUMMARY The three Community Hospital-based Stroke Programs collected data on 4132 stroke pa-tients admitted to acute care hospitals during 1979 and 1980. White female stroke patients were older thanthe white male, nonwhite female and nonwhite male stroke patients. Nearly one-fourth (23%) of strokepatients were employed at the time of the event. Most (77%) of the patients were hospitalized for first strokeepisodes. Eighty-three percent of the patients had at least one of the four major risk factors for stroke,namely, hypertension, diabetes, transient Ischemic attacks and cardiac disease. Half (49%) of the patientswere alert at the time of admission. The three diagnostic categories included infarction (60%), stroke nototherwise specified (30%) and hemorrhage (10%). Fourteen days was the median length of hospitalization;50% of the stroke patients were discharged to a home setting, 31% were institutionalized and 19% diedwhile in the hospital. The mean Barthel Index score for 2400 patients at the time of discharge was 61.8(normal is 100). Of those patients who were working at the tune of the stroke, 22% returned to work.

In comparison to the patients in the National Survey of Stroke, patients in this Study were less severe atthe time of admission (49% of patients in the National Survey of Stroke were stuporous or comatosecompared to 21% of the patients hi the current Study). The inhospital fatality was 30.7% in the NationalSurvey of Stroke, and 19.7% hi the current Study.

Stroke Vol 17, No 2, 1986

MAJOR PROBLEMS in the study of stroke trendshave been reviewed.1^1 These previous reviews haveidentified a number of issues that continue to plaguethe studies of stroke mortality, particularly the limita-tions of using the underlying cause of death as reportedon death certificates, the broad range of clinical mani-festations of stroke and the absence of widely useddiagnostic procedures to determine definitive diag-noses.2 Despite these definitional problems, stroke re-mains the third leading cause of death, as determinedby the underlying cause on death certificates, and amajor cause of disability.4

The three Community Hospital-based Stroke Pro-grams (CHSPs) were originally designed to obtainmore information concerning the impact of health care

From the Department of Epidemiology, University of North CarolinaSchool of Public Health; Department of Neurology, Bowman GraySchool of Medicine, Wake Forest University Medical Center; ResearchTriangle Institute, Research Triangle Park, North Carolina; Departmentof Neurology, Oregon Health Sciences University; Department of Neu-rology, University of Rochester, National Institute of Neurological andCommunicative Disorders and Stroke.

'North Carolina (NC) refers to data collected from all acute carehospitals in a 15 county rural area "in eastern North Carolina. Oregon(OR) refers to data collected in one university hospital and thirty com-munity hospitals with approximately one-half of the acute care hospitalbeds in Oregon. New York (NY) refers to data collected in all of thecommunity hospitals in Monroe County, New York.

This study was supported in part by Contract Nos NOI-NS-2385,NOI-NS-2386 and NOI-NS-2387 from the National Institute of Neuro-logical and Communicative Disorders and Stroke, NTH, Bethesda,Maryland.

Address correspondence to: Dr. Frank M. Yatsu, Department ofNeurology, The University of Texas Health Science Center at Houston,6431 Fannin, Rm. 7-044, Houston, Texas 77225

Received July 18, 1984; revision #2 accepted June 12, 1985.

facilities and coordinated services on the outcomes ofhospitalized stroke patients.5 The three programs werestarted in 1978, and while each retained features par-ticularly applicable to the area served, common fea-tures allowed merging of selected portions of the datacollected. This merging of the data across the threeprograms permits a systematic review of geographicdifferences, and the larger number of stroke patientsincreases the ability to examine and compare out-comes.

This paper describes in detail the specific features ofthe combined study population, namely, the demo-graphic features, employment status, whether theevent was a first or recurrent stroke, history of riskfactors, stroke severity, diagnostic categories, lengthof hospital stay, discharge destination and assessmentof activity levels by the Barthel Index Score and otherselected activity scales.

Study Populations and Eligibility CriteriaIn the North Carolina CHSP, all patients with a

diagnosis of stroke admitted into any of the ^commu-nity hospitals in 15 contiguous rural counties of easternNorth Carolina from January 1979 through December1980 were eligible to enter the study (including deathsfrom cerebrovascular disease that occurred in the hos-pital). However, for patient information to be includedin the analytic file, two additional criteria were im-posed: the patient's record must contain the dischargediagnosis indicating a completed stroke and the patienthad to reside in the 15 county area (in order to facilitatefollow-up). For those patients from whom permissionof the attending physician and signed consent of the

by guest on July 10, 2011http://stroke.ahajournals.org/Downloaded from

286 STROKE VOL 17, No 2, MARCH-APRIL 1986

patient or significant family member could not be ob-tained for the interview, information was abstractedfrom the medical record.

In the Oregon CHSP, discharges from one Universi-ty hospital and 30 community hospitals (representingabout 50% of the hospital beds in Oregon) werescreened for codes 430-438 of the International Classi-fication of Disease, 9th edition, as the primary or sec-ondary discharge diagnosis. Only admissions duringthe calendar year of 1979 were considered eligible. Allrecords of the patients in the study contained objectiveevidence of a neurologic deficit lasting more than 24hours. All patients who died in the hospital from cere-brovascular disease were considered eligible.

In the New York CHSP, those eligible for the studywere residents who lived within Monroe County(which includes Rochester, NY), or within 30 miles ofthe county boundaries, and who were admitted with adiagnosis of stroke to one of the eight hospitals locatedin the county; all patients who died in the hospital fromcerebrovascular disease were included. If both physi-cian permission and patient consent were obtained, thepatient was eligible for followup after discharge. Thestudy included all stroke admissions occurring be-tween May 1979 and October 1980.

Other descriptive details of the three CHSPs aredescribed in the preceding paper.10

Statistical tests of significance are not reported in thetables. The large number of cases in the data set sug-gests that relatively small differences may be statisti-cally significant without having substantive mean-ing." In calculating the percentages, we did not

include missing values in the numerator or denomina-tor. The number of patients included in each categoryis indicated in the tables; variation in the number re-ported from each geographic site is a reflection of thenumber of live patients with completed interviews in agiven time period.

Results and DiscussionThe Community Hospital-Based Stroke Programs

were performed in three sites and used either the ad-mission or discharge diagnoses to access patients withstrokes. A sample of the records was reviewed by ateam of neurologists who formed a consensus as to thefinal diagnoses. In view of the fact that not all hospitalshad CT, the most frequent diagnosis was Stroke nototherwise specified.

The results of the study will be compared to othercommunity based stroke studies as appropriate. In theCHSPs more than 95% of the non-white patients wereblack patients.

Differences in Age at Onset of StrokeAs indicated in table 1, white females were the old-

est group at the onset of an acute stroke event in allthree Programs. The rank order of mean age and medi-an age in years from oldest to youngest is white fe-males, white males, non-white females, and non-whitemales in the combined population. The values for themean ages were: 73.5 years for white females, 69.6years for white males, 68.3 years for non-white fe-males and 66.5 for non-white males (table 1). Thevalues for the median ages were: 75.0 years for white

TABLE 1 Age in Years by Program and Race-sex Groups: Mean, Median and % Less than 65 Years

WM WF NWM NWF Total

NC

mean

median

% < 65 years

n

OR

mean

median

% < 65 years

n

NY

mean

median

% < 65 years

n

Total

mean

median

% < 65 years

n

WM = white npatients.

67.7

69.0

35

449

70.3

71.0

27

743

70.3

72.0

28

421

69.6

71.0

29

1613

males; NWM

72.9

74.0

20

460

73.5

75.0

22

889

74.2

77.0

19

482

73.5

75.0

21

1831

= non-white males:

67.7

67.0

37

254

63.3

63.5

50

22

58.9

61.0

66

29

66.5

66.0

41

304

NWF =

69.0

70.0

33

274

70.4

73.0

23

35

60.0

61.0

58

33

68.3

70.0

35

324

non-white females: n =

69.6

71.0

30

1445

71.9

73.0

25

1699

71.6

74.0

26

965

71.0

72.0

27

4109

number of

by guest on July 10, 2011http://stroke.ahajournals.org/Downloaded from

COMMUNITY HOSPITAL-BASED STROKE PROGRAMS/flecter et al 287

TABLE 2 Cell Percent* of Stroke Patients Employed at Time of Stroke by Program and Race-sex Groups

NC

OR

NY

Total

%

31

18

29

23

WM

N

(187)

(703)

(421)

(1311)

%

8

35

13

24

WF

N

(199)

(817)

(479)

(1495)

%

24

24

28

25

NWM

N

(109)

(21)

(29)

(159)

%

17

28

16

19

NWF

N

(135)

(32)

(32)

(199)

%

19

27

21

23

Total

N

(633)

(1581)

(%1)

(3175)

*Cell percent is the % in each subgroup. For example, 31 % of 187 white males in NC were employed at the time of thestroke.

WM = white males; WF = white females; NWM = non-white males; NWF = non-white females; N = number ofpatients.

females, 71.0 years for white males, 70.0 years fornon-white females and 66.0 years for non-whitemales. With few exceptions the rank order for race-sexgroups is the same for each program.

The percentage of hospitalized patients under theage of 65 years in CHSPs (27%) is very similar to thepercentage in the National Stroke Survey (NSS)13,namely 29.6%.

EmploymentAt the time of the stroke event, approximately one-

fourth (23%) of the stroke patients were employedoutside the home. The percentage employed varied byregion; North Carolina had a lower percentage of em-ployed non-white and white female patients than theother two programs. Only 18% of white male patientsin the Oregon Program were employed compared to31 % in North Carolina and 29% in New York (table 2).

First Stroke EpisodesSeventy-seven percent of the patients in the study

were experiencing an episode of stroke for the firsttime (first stroke episode or initial stroke). The per-centage of first stroke episodes was higher in NewYork (81%) and in non-white males in Oregon (95%),as shown in table 3. This high percentage was expect-ed, and is probably based on hospitalization practices.Because the CHSPs accessed patients through admis-sion to or discharge from acute care hospitals, recur-rent stroke episodes may be underrepresented in thisstudy, since recurrent strokes may be less likely to betransferred from chronic care facilities into acute carehospitals.

The percentage of first stroke episodes was between

76 and 78% for each of the race-sex groups, one indi-cation that hospitalization practices were similar forthe four race-sex groups.

The National Stroke Survey13 reported that 73.5% ofthe total stroke patients discharged annually were ini-tial strokes during the four survey years of 1971, 1973,1975 and 1976. In the current CHSP study 77% of thepatients were experiencing initial strokes. The de-crease in the percentage of recurrent strokes in thehospital probably reflects a trend in hospitalizationpractices. The patients who were institutionalized afterthe initial stroke, either in nursing homes, long-termcare hospitals or in psychiatric or mental institutions,were not admitted to acute care hospitals in the event ofa subsequent stroke.

History of Risk FactorsHistory of hypertension, the strongest risk factor for

stroke, was more frequent in non-white females (78%)and least frequent in white males (51%). Sixty-threepercent of white females and 67% of non-white maleshad a history of hypertension.

History of diabetes was most frequent in non-whitefemales (43%) and ranged from 20-25% in the otherrace-sex groups.

History of transient ischemic attacks (TIA) wasmore frequent in whites (22% in white males, 23% inwhite females) than in non-whites (8% in non-whitemales, 9% in non-white females).

History of cardiac disease was similar in white andnon-white patients (except for non-white females inOregon), being 62 and 63% in white males and fe-males and 57 and 58% in non-white males and females(table 4), respectively. Eight-three percent of the total

TABLE 3 Cell Percent* of First Stroke Episodes by Program and Race-sex Groups

NC

OR

NY

Total

%

75

75

80

76

WM

N

(427)

(681)

(419)

(1526)

%

76

75

80

77

WF

N

(429)

(815)

(467)

(1711)

%

74

95

86

76

NWM

N

(242)

(20)

(29)

(291)

%

77

75

90

78

NWF

N

(264)

(32)

(32)

(328)

%

76

75

81

77

Total

N

(1369)

(1555)

(948)

(3872)

"Cell percent is the % in each subgroup. For example, 75% of 427 white males in NC had not had a previous stroke andthis current event represents a "first stroke episode."

WM = white males; WF = white females; NWM = non-white males; NWF = non-white females; N = number ofpatients.

by guest on July 10, 2011http://stroke.ahajournals.org/Downloaded from

288 STROKE VOL 17, No 2, MARCH-APRIL 1986

study population had at least one of these four majorrisk factors for stroke; 17% did not have a history ofany of these risk factors.

Comparisons with the National Stroke Survey(NSS) indicate little change from the percentages ofstroke patients with known risk factors over the yearsfrom 1971 to 1979. Hypertension was present by his-tory in 58.6% of stroke patients admitted to acute carehospitals in the NSS, 59% in CHSP; only white malesin the three CHSP sites had lower percentages of his-tory of hypertension (ranging from 46 to 57%). Dia-betes was present in 22.1% of acute strokes reportedby NSS, 25% in CHSP. The presence of a history of

cardiac disease was similar in the two studies: 64.1%in NSS and 62% in CHSP.

Admission Consciousness Level

Approximately one-half of the stroke patients inCHSP (49%) were described as alert upon admission tothe hospital. The percentage alert on admission rangedfrom 43% in white females in Oregon to 66% of non-white males in Oregon. However, for the combinedpopulation, the race-sex groups ranged from 45% ofwhite females admitted alert to 54% of white males(table 5). Those admitted stuporous or comatoseranged from 17% of the white males to 28% of the

TABLE 4 Cell Percent* for History of Specific Risk Factors by Program and Race-sex Groups

NC

OR

NY

Total

NC

OR

NYTotal

NC

OR

NY

Total

NC

OR

NY

Total

NC

OR

NY

Total

%

54

46

57

51

%

27

22

22

23

%

14

26

23

22

%

60

67

57

62

%

74

84

86

82

WM

N

(241)

(715)

(414)

(1370)

WM

N

(225)

(699)

(421)

(1345)

WM

N

(225)

(554)

(403)

(1182)

WM

N

(427)

(724)

(420)

(1571)

WM

N

(427)

(735)

(421)

(1583)

%

67

61

63

63

%

29

24

24

25

%

13

27

23

23

%

58

65

6663

%

77

87

90

85

WF

N

(259)

(874)

(475)

(1608)

WF

N

(239)

(849)

(481)

(1569)

Previous

WF

N

(239)

(671)

(444)

(1354)

WF

N

(452)

(866)

(480)

(1798)

Any one

WF

N

(452)

(895)

(481)

(1828)

Hypertension

%

66

70

72

67

I

%

17

32

29

20

NWM

N

(140)

(20)

(29)

(189)

diabetes

NWM

N

(125)

(19)

(28)

(172)

transient ischemic

%

6

11

15

8

NWM

N

(125)

(18)(27)

(170)

Cardiac disease

%

58

60

45

57

of the

%

77

91

86

79

NWM

N

(241)

(20)

(29)

(290)

four above

NWM

N

(241)

(21)

(29)

(291)

%

78

79

76

78

%

40

57

42

43

NWF

N

(166)

(33)

(33)

(232)

NWF

N

(152)

(35)

(33)

(220)

attack (T1A)

%

7

14

13

9

%

56

74

55

58

NWF

N

(152)

(28)

(30)

(210)

NWF

N

(269)

(34)

(33)

(336)

risk factors

%

81

89

85

82

NWF

N

(269)

(35)

(33)

(337)

%

65

55

61

59

%

29

24

24

25

%

11

26

22

21

%

58

66

61

62

%

77

86

88

83

Total

N

(810)

(1652)

(951)

(3412)

Total

N

(745)

(1610)

(963)

(3318)

Total

N

(745)

(1275)

(904)

(2924)

Total

N

(1397)

(1652)

(962)

(4011)

Total

N

(1397)

(1695)

(964)

(4056)

*Cell percent is the % in each subtgroup. For example, 54% of 241 white males inNC had a history of hypertension.WM = white males; WF = white females; NWM = non-white males; NWF = non-white females; N = number of

patients.

by guest on July 10, 2011http://stroke.ahajournals.org/Downloaded from

COMMUNITY HOSPITAL-BASED STROKE PROGRAMS/Bfcter et al 289

TABLE 5 Consciousness Level at Admission by Program and Race-sex Groups

White malerow percents*

White femalerow percents

Non-white malerow percents

Non-white femalerow percents

All race-sexrow percents

NCOR

NY

Total

A

59

49

65

54

D/L

19

36

27

30

S/C

24

15

8

17

N

410

745

132

1287

A

47

43

47

45

D/L

22

39

27

33

S/C

30

17

25

22

N

420

897

155

1472

A

46

66

64

49

D/L

24

24

21

24

S/C

31

10

14

28

N

233

21

14

268

A

49

51

60

50

D/L

21

43

33

24

S/C

30

6

7

26

N

257

35

15

307

A

51

46

56

49

D/L

21

38

27

30

S/C

28

16

17

21

N

132

1708

316

3351

A = alert; D/L = disoriented or lethargic; S/C = stuporous or comatose; N = number of patients; WM = white males; WF = whitefemales; NWM = non-white males; NWF = non-white females; N = number of patients.

•Row percent is the % of each race-sex group by center in each of 3 levels of consciousness. For example, 59% of 410 white males in NCwere alert at the time of admission.

black males; of white females, 22% were stuporous orcomatose; black females, 26%.

Table 5 presents the data on the consciousness levelat admission in the three CHSPs according to race andsex groups. Several programmatic, racial and genderobservations can be made. For the aggregate total,nearly one-half of the stroke patients are admittedalert, while almost one-third are disoriented or lethar-gic and one-fifth are stuporous or comatose. It is note-worthy that the total percentages for each race-sexgroup is similar to the total averages although the non-white males and nonwhite females have increased pro-portions admitted stuporous or comatose.

In the North Carolina CHSP from 24-31% of thestroke patients were admitted stuporous or comatose inthe four race-sex groups. The percentage of stuporousor comatose patients is substantially higher than in theOregon or New York CHSPs.

Forty-nine percent of patients in the National StrokeSurvey13 were reported as stuporous or comatose uponadmission, as compared to 21% of CHSP patients.Unfortunately the percentage of patients alert on ad-mission was not reported in the NSS. However, thedifference may reflect a decrease in severity at the timeof hospitalization of stroke patients.

Diagnostic CategoriesStroke patients in North Carolina were categorized ashaving had an infarction (42%), a hemorrhage (8%), ora stroke not otherwise specified (NOS) (50%). Hemor-rhage (table 6) was more frequent in the non-whitegroups (11% in non-white males, 10% in non-whitefemales) than in the white groups (6% in both whitemales and white females).

Because of frequent utilization of diagnostic proce-dures, the categories of stroke in Oregon and NewYork were essentially similar and consisted predomi-nantly of infarctions (72% and 65%, respectively),hemorrhage (10 and 14%, respectively) and stroke,NOS (18 and 21%, respectively). Embolism, intra-cerebral hemorrhage and subarachnoid hemorrhage(categories not identified in North Carolina) were iden-tified in the NY and OR Programs. Embolism account-ed for 24% of the infarctions in each of the NY and ORPrograms; subarachnoid hemorrhages were 30% of allhemorrhages in each of the two programs and intra-

cerebral hemorrhages were 70% and 64% in the ORand NY programs, respectively, of all hemorrhages.

As indicated in table 6, the specific stroke diagnosesfrom the three CHSPs, excluding unspecified strokes,are: 65% thrombotic, 22% embolic, 10% intracerebralhemorrhage and 4% subarachnoid hamorrhage. Thepercentages observed in the CHSPs are remarkablysimilar to other recent stroke studies, namely, the Har-vard Stroke Registry,12 the National Stroke Survey13

and the Framingham Study.14 The dominance ofthrombotic strokes is a consistent finding and reflectsthe continuing impact of atherosclerotic disease as theprimary underlying pathology. The percentage of em-bolic strokes in CHSP was similar to the percentagereported in the Framingham Study (18%); the low(6%) percentage in the National Stroke Survey and thehigh (31%) percentage in the Harvard Registry areunexplained. The combining of both extracranial vas-cular disease with cardiac sources for emboli in theHarvard Registry accounts in part for the high percent-age. Collectively these data reinforce the concern thatcardiac disease is becoming a more prominent causefor strokes. In contrast, the unchanging incidence ofsubarachnoid hemorrhage has been reported in a popu-lation-based study.15

Length of Hospital StayOf patients who were discharged alive, white fe-

males tended to be hospitalized longer than whitemales particularly in the New York Program; non-white males were hospitalized longer than non-whitefemales. In the combined population of patients whowere discharged alive, the median number of dayshospitalized ranged from 10.0 days (white males inNew York) to 32.0 days (non-white males in Oregon).

Of patients who died in hospital, both the mean andthe median number of days of hospitalization wereshorter than the length of hospitalization of patientswho were discharged alive; the one exception was non-white females in New York.

The mean number of hospital days in the total groupfor those patients who were discharged alive was 20.8days; the median, 14 days. For those patients who diedin hospital the mean number of days of hospitalizationwas 16.4; the median, 8.0 days (table 7).

Data from the NSS for 1975-1976 reported that the

by guest on July 10, 2011http://stroke.ahajournals.org/Downloaded from

290 STROKE VOL 17, No 2, MARCH-APRIL 1986

TABLE 6 Percent of Diagnostic Groups by Program and Race-sex Groups

NC

Total

WM

WF

NWM

NWF

OR

Total

WM

WF

NWM

NWF

NY

Total

WM

WF

NWM

NWF

Total

Total

WM

WF

NWM

NWF

N

1447

449

460

254

276

1714

746

900

22

35

964

421

481

29

33

4125

1616

1841

305

344

%oftotal

42

43

45

39

36

72

73

70

68

80

65

67

64

69

58

60

63

62

44

43

Infarction

%ofTH

*

—

—

—

—

71

71

71

67

79

76

84

67

90

84

55

61

57

21

26

INFEM

—

—

—

—

—

24

24

23

27

18

24

16

33

10

16

18

17

22

4

5

%ofNOS

100

100

100

100

100

5

5

6

7

4

—

—

—

—

—

27

22

21

75

69

%ofTotal

8

6

6

11

10

10

9

11

14

9

14

12

14

21

27

10

9

10

12

12

Hemorrhage

%ofICH

—

—

—

—

—

70

73

68

100

33

64

63

65

67

67

49

56

56

18

18

HEMSAH

—

—

—

—

—

30

27

32

—

67

30

29

31

17

33

22

22

27

3

13

%ofNOS

100

100

100

100

100

—

—

—

—

—

—

8

5

17

—

30

22

17

79

70

Strokenos

%oftotal

50

51

49

49

54

18

18

19

18

11

21

20

23

10

15

30

28

27

43

46

WM = white males; WF = white females; NWM = non-white males; NWF = non-white females; N = number ofpatients; INF = infarction; TH = thrombosis; EM = embolus; NOS = not otherwise specified; HEM = hemorrhage;ICH = intracranial hemorrhage; SAH = subarachnoid hemorrhage.

*A (—) designates no diagnosis made in that category.

mean days of hospitalization for those patients whodied in hospital was 13.2 days as compared to 16.4days for patients in the CHSPs. The length of stay forthose patients discharged alive was a mean of 19.3days in the NSS, and 20.8 days in CHSPs.

The most marked difference between the NSS andthe CHSP was the inhospital fatality; in the NSS, in-hospital fatality was 30.7% and in the CHSPs, 19.7%.

Discharge LocationWhite women were discharged to home settings

(44%) less frequently than the other race-sex groups(table 8); the other three race-sex groups were remark-ably similar in that 53-56% returned to home settings,either the individual's own home or the home of asignificant other person (a relative or a friend). Womenof both races were more frequently discharged to insti-tutions (34% for each group) than men (27% of whitemales, 29% of non-white males).

In the combined population, non-white females hadthe lowest percentage of inhospital deaths (13%). Non-white males had 17% deaths, white males had 18%

deaths, and white females had the highest percentageof inhospital deaths (22%).

Barthel Index ScoresAll three centers used the Barthel Index to determine

the ability of stroke patients to care for themselves andto be mobile within the home or care setting. Scoreswere obtained for 2400 patients at the time of dis-charge (table 9) and ranged from a mean of 53.4 to65.3 points in the three studies for the combined race-sex groups. The mean score was 61.8 and the medianwas 65.0 in the total discharged population.

At six months after the stroke episode, repeatBarthel Index Scores on 778 patients indicated aggre-gate improvement to a score of 75.0. At twelvemonths, 940 patients were examined; the Barthel In-dex Score was 78.3 out of a possible 100 points fornormal activity. Across all three CHSPs, the averageamount of improvement from hospital discharge to the12-month followup was 16 points on the Barthel scale.

A variety of measures have been used to assess theimpact of stroke on affected individuals, as well as the

by guest on July 10, 2011http://stroke.ahajournals.org/Downloaded from

COMMUNITY HOSPITAL-BASED STROKE PROGRAMS/flecter et al 291

TABLE 7 Length of Hospital Stay in Days by Program and Race-sex Groups (Mean and Median)

NC

disch alive

mean

median

n

died in hosp

mean

median

n

OR

disch alive

mean

median

n

died in hosp

mean

median

n

NY

disch alive

mean

median

n

died in hosp

mean

median

n

Total

disch alive

mean

median

n

died in hosp

mean

median

n

WM

18.4

13.0

376

16.2

10.0

66

17.0

10.0

556

11.9

6.0

123

24.4

15.0

337

18.6

7.0

83

19.4

12.0

1269

15.0

70.0

272

WF

19.7

16.0

380

14.3

10.0

75

17.9

12.0

627

13.0

6.0

169

29.1

17.0

337

21.4

7.0

143

21.2

15.0

1344

16.4

7.0

387

NWM

21.7

15.0

201

15.4

10.0

48

32.6

32.0

15

—

—

0

40.4

13.0

26

3.3

3.0

3

24.4

15.0

242

14.7

9 0

51

NWF

21.1

16.0

232

19.3

15.0

37

22.9

18.0

29

18.0

18.0

1

34.8

17.0

27

74.8

23.0

6

22.6

16.0

288

26.8

17.0

44

Total

19.9

15.0

1196

15.8

11.0

111

17.9

12.0

1233

12.6

6.0

293

27.5

15.0

111

21.6

7.0

235

20.8

14.0

3156

16.4

8.0

755

Disch alive = discharged alive; died in hosp = died in hospital;WM = white males; WF = white females; NWM = non-whitemales; NWF = non-white females; n = number of patients.

relative effectiveness of different treatment modali-ties.16 Measures include instruments designed to assessphysical functioning;17 social functioning;18 living ar-rangements post discharge;19 employment status attime of stroke;20 communication, sensation, perceptionand motor skills;21 intellectual functioning;22 usual roleactivities;23 and psychologic adjustment to disability.24

Among the most widely used measures are those de-signed to assess the individual's ability to performroutine self care activities, such as the Barthel, Kenny,Katz and PULSES scales.M-26 Of these scales, the

Barthel has certain advantages25 and was the measureof activities of daily living (ADL) used by the threeCHSPs.

Comparisons of the cross-sectional Barthel scores atdischarge, and at 6 months and 12 months post-dis-charge (table 9) indicate remarkable similarities infunctional status across the three programs during thetwo followup time periods. However, North Carolinastroke patients are 8-10 points lower in averageBarthel scores at the time of discharge from the hospi-tal. These initially lower Barthel scores in North Caro-lina (at discharge) may be due to the larger proportionof stuporous or comatose stroke patients at the time ofadmission to the hospital (table 5). A publication inprogress using this data set will address factors affect-ing Barthel scores at 12 months, and will use multivar-iate techniques to control for initial differences acrossthe three populations.

Since the Barthel scores in table 9 are based on crosssections of the study populations, and therefore do notnecessarily represent the same individuals, it is notpossible to draw conclusions from the data presented intable 9 about changes in Barthel scores across the threetime periods. An analysis of cases that were measuredat both discharge and at 12 months suggests that theaverage amount of change in Barthel scores for the 883cases was +7.5 between discharge and 12 monthspost-discharge. However, the average Barthel score atdischarge for the 883 cases was 70.6. This suggeststhat those patients who were still alive, and who werefollowed at 12 months had higher Barthel scores on theaverage than those who died or were lost to followupduring the 12 month period.

The average Barthel scores from the patients understudy in the three CHSPs (table 9) are similar to thosein previous studies. Granger et al27 in a study of reha-bilitation outcomes of 307 general rehabilitation pa-tients (134 of whom were stroke patients), reportedmean Barthel scores of 71 and 72 at discharge from 10rehabilitation facilities and at two years respectively.Granger had previously reported an average dischargeBarthel score of 72 for 124 patients at Hussey Hospitalfollowing an average length of stay of approximately 6weeks.

Selected Activity Scales

Table 10 gives the percentage of stroke patients byProgram who could perform the specified activity attwelve months after the stroke event. The data regard-ing each activity were collected only on patients whocould perform the activity prior to the stroke event;therefore, the number of study participants providinginformation is given for each activity.

The activities that were studied need a brief explana-tion. The cue words used in table 10 are underlined.

One step command referred to the proper motor re-sponse to an oral request.

Make change was tested by asking about the abilityof the patient to make or calculate change for moneycorrectly.

If the study participant could perform complex arith-

by guest on July 10, 2011http://stroke.ahajournals.org/Downloaded from

292 STROKE VOL. 17, No 2, MARCH-APRIL 1986

TABLE 8 Discharge Location by Program and Race-sex Group

White malerow percents*

White femalerow percents

Non-white malerow percents

Non-white femalerow percents

All race-sexrow percents

NC

OR

NY

Total

H

51

58

57

56

I

34

24

23

27

D

15

18

20

18

N

447

685

420

1552

H

40

49

38

44

I

43

30

32

34

D

17

21

30

22

N

458

808

480

1746

H

50

88

66

54

1

30

13

24

29

D

19

0

10

17

N

253

16

29

298

H

49

80

61

53

I

37

17

21

34

D

14

3

18

13

N

274

30

33

337

H

47

54

48

50

I

37

27

28

31

D

16

19

24

19

N

1440

1547

962

3949

H = home; I = institution; D = died in hospital; WM = white males; WF = white females; NWM = non-white males; NWF = non-whitefemales; N = number of patients.

*Row percent is the % of each race-sex group by center with discharge location of home (H), institution (I), or death (D) in hospital. Forexample, 51% of 447 white males in NC were discharged home.

metic, he or she could balance a checkbook or com-plete income tax forms.

Those patients who could perform ordinaryhousework before the stroke event were asked if theycould perform housekeeping chores currently.

The question regarding use of the telephone includ-ed answering the telephone and dialing a number cor-rectly.

Those patients who could use transportation, eitherpublic or private, were graded as to whether this usewas performed independently or with assistance.

The questions on general outside activity referred toactivities such as walking, working in the yard, sittingon the porch or riding in a car.

Those patients who had informal interaction, eitherindependently or with assistance, participated ingames with other people, family gatherings, visits tofriends, dining at a restaurant and other similar activi-ties.

The questions on return to work were asked only forthe study participants who were working outside of thehome at the time of the stroke event.

TABLE 9 Barthel Index Scores by Program at Discharge and atSix and Twelve Months (Mean and Median)

Discharge 6 Months 12 Months

NC

mean

median

n

OR

mean

median

n

NY

mean •

median

n

Total

mean

median

n

53.447.0

552

65.3

75.0

1372

61.2

66.0

491

61.8

65.0

2400

74.789.0

328

72.9

85.0

159

76.5

94.0

291

75.0

90.0

778

77.3

94.0

229

78.6

90.0

393

78.9

100.0

248

78.3

94.0

940

The percentages given in table 10 were the percent-ages in each subgroup. Figures are only for patientswho could perform the particular activity prior to thestroke episode.

TABLE 10 Cell Percent* by Program Capable of Performing Se-lected Activities at Twelve Monthst

NC NY OR Total

One step command% yes

n

Make change

% yes

n

Complex arithmetic

% yes

n

Housework

% yes

n

Telephone

% yes

n

Transportation

% independent

% with assistance

n

General outside activities

% independently

% with assistance

n

Informal interaction

% independently

% with assistance

n

Return to work

% yes

n

92

302

69

293

50

241

52

260

67

2%

28

52

294

66

15

296

60

25

295

21

57

99

207

90

195

——

——

78

209

38

38

248

——

—

——

—

13

246

99

363

85

295

74

257

64

316

73

348

50

31

351

62

25

360

66

23

357

45

105

96

872

80

783

62

498

59

576

72

853

39

40

893

64

20

656

63

24

652

22

408

WM = white males; WF = white females; NWM = non-whitemales; NWF = non-white females; N = number of patients.

•Cell percent is the % in each subgroup.tRgures are based only on cases who could perform activity

prior to stroke.WM = white males; WF = white females; NWM = non-white

males; NWF = non-white females; n = number of patients.

by guest on July 10, 2011http://stroke.ahajournals.org/Downloaded from

COMMUNITY HOSPITAL-BASED STROKE PROGRAMS/£«*er et al 293

At the end of 12 months after the stroke event, 96%could follow one-step commands; 80% could makechange, and 62% of 498 patients could perform com-plex arithmetic. 59% of 576 patients could dohousework, and 72% could use the telephone. Of 893patients, 39% could use transportation independentlyplus an additional 40% who could use transportationwith assistance. Of 408 patients who were working atthe time of a stroke event, 22% had returned to work atthe twelve-month follow-up (table 10).

References1. Kuller LH: Epidemiology of stroke Advances in Neurology 19:

281-311, 1978.2. Ostfeld AM: A review of stroke epidemiology. Epid Reviews 2:

136-152, 1980.3. Evans JG: The epidemiology of stroke Age and Aging 8: 50-56,

1979.4. Robins M, Baum HM: the National Survey of Stroke: Incidence

Stroke 12 (suppl 1): 45-55, 1981.5. Garraway WM, Whisnant JP, Furlan AJ, Phillips LH, Kurland LT,

O'Fallon WM: The declining incidence of stroke. N Engl J Med300: 449-452, 1979.

6. Soltero 1, Liu K, Cooper R, Stamler J, Garside D: Trends inmortality from cerebrovascular diseases in the United States, 1960to 1975. Stroke 9: 549-555, 1978.

7. Anderson GL, Whisnant JP- A comparison of trends in mortalityfrom stroke in the United States and Rochester, Minnesota. Stroke13: 804-809, 1982.

8. HDFP cooperative group: Five-year findings of the HDFP III,reduction in stroke incidence among persons with high blood pres-sure. JAMA 247: 633-638, 1982.

9. Baum HM Stroke prevalence: an analysis of data from the 1977national health interview survey. Pub Health Rep 34-30, 1982.

10. Yatsu FM, Becker C, McLeroy KR, Coull B, Feibel J, Howard G,et al: Community Hospital-based Stroke Programs: North Carolina,Oregon and New York: I. Goals, Objectives and Data CollectionProcedures. Stroke 17: 276-284, 1986

11 Miller RG: Simultaneous Statistical Inference, McGraw-Hill, 1stedition, 1966.

12 Mohr Caplan LR, Melski JW, Goldstein RJ, Duncan GW, Kistler

JP et al: The Harvard cooperative stroke registry: a prospectiveregistry. Neural 28: 754-762, 1978.

13. National Survey of Stroke, Supplement No. 1 to Stroke, Vol. 12,No. 2, March/April 1981.

14. Wolf PA, Kannel WB, DawberTR: Prospective investigations: theFramingham study and the epidemiology of stroke Adv in Neural:107-120, 1978.

15 Phillips LH, Whisnant JP, O'Fallon WM, Sundt TM: The unchang-ing pattern of subarachnoid hemorrhage in a community Neural30: 1034-1040, 1980.

16. Smits SJ: Variables related to success in a medical rehabilitationsetting. Arch of Physical Medicine and Rehabilitation, Vol 55:449-454, October 1974.

17. Jette AM: Functional capacity evaluation: an empirical approach.Arch of Physical Medicine and Rehabilitation. Vol. 61: 85-89,February 1974.

18 Labi LCM, Phillips TF, Gresham GE. Psychosocial disability inphysically restored long-term stroke survivors. Arch of PhysicalMed and Rehab 61: 561-565, 1980.

19 Anderson E, Anderson T, Kottke F: Stroke rehabilitation, mainte-nance of achieved gains Arch of Physical Med and Rehab 58:345-352, 1977.

20. Goldberg RT, Bemad M, Granger CV: Vocational status- predic-tion by the Barthel Index and PULSES profile. Arch of PhysicalMed and Rehab 61: 580-583, 1980.

21. Jimenez J, Keltz MC, Stein MC, White MME: Evaluation of strokedisability. Can Med J 114: 615-617, 1976.

22 Hertzog C, Schaie KW, Gribbin K: Cardiovascular disease andchanges in intellectual functioning from middle to old age J ofGeront 33: 872-883, 1978.

23. Jette AM: Functional status index: reliability of a chronic diseaseevaluation instrument. Arch of Physical Med and Rehab 61:395-401, 1980.

24. Albrecht GL, Higgins PC: Rehabilitation success: the interrelation-ships of multiple criteria. J of Health and Behav 18: 36-45, 1977

25. Gresham GE, Phillips TF, Labi MLC: ADL status in stroke: rela-tive merits of three standard indexes. Arch of Physical Med andRehab 61: 355-358, 1980

26 Freed MM, Wainapel SF: Predictors of stroke outcome. Am FamPhysician: 119-123, 1983

27. Granger CV, Albrecht GL, Hamilton B Outcome of comprehen-sive medical rehabilitation: measurement by PULSES profile andthe Barthel Index Arch of Phy Med and Rehab 60: 1979.

28. Granger CV, Greer DS: Functional status measurement and medi-cal rehabilitation outcomes. Arch of Phy Med and Rehab 57:103-109, 1976

by guest on July 10, 2011http://stroke.ahajournals.org/Downloaded from