Informing hospital patients and their relatives about stroke

Seventy-three episodes of stroke leading to hospital admission were followed up over the first two weeks. Patients and their relatives were assessed shortly after admission to hospital for their knowledge about the predisposing causes of stroke, the nature of the patients' illness and the treatment that was being given, their prognoses and the nature of financial and other help that would be available to them when they returned home. After one week, half the patients and relatives received an informative leaflet about stroke. When their knowledge of these factors was later assessed, only 7% of the patients who had not received the leaflet and 30% of their relatives could recall having received any information about stroke since admission. The corresponding figures for those who had received the leaflet were 65% and 62% respectively. Those who had received a leaflet knew significantly more about the aetiology of stroke and the treatment they were receiving than those who had not, but the leaflet made no difference to the level of knowledge about the patient's specific prognosis, nor about the range of benefits that would be available at the time the patient returned home. It is suggested that ward staff underestimate the amount of information that can usefully be absorbed by patients and their relatives and in this way are failing to establish the optimal conditions for their rehabilitation.

The geographic variation in stroke incidence in two areas of the southeastern stroke belt: the Anderson and Pee Dee Stroke Study

BACKGROUND AND PURPOSE

South Carolina and the southeastern United States have maintained the highest stroke mortality in the country. The Anderson and Pee Dee Stroke Study is an assessment of cerebrovascular disease incidence in 2 geographically defined communities in the stroke belt.

METHODS

Strokes were identified in the Anderson and Pee Dee areas of South Carolina. All hospitalized and out-of-hospital deaths occurring during 1990 among the residents of these 2 areas were included. Strokes were classified by an independent panel of neurologists using a standard protocol that included specific criteria for stroke and subtypes.

RESULTS

The overall age-adjusted stroke incidence rates (per 100 000 population) were significantly higher in the Pee Dee population (293.1) compared with Anderson (211.2). The geographic differences were more dramatic in the younger age groups of 35 to 64 years. Likewise, incidence rates for blacks were nearly twice the rates for whites. The rates in the Pee Dee were higher than the rates from other studies in the United States and other parts of the world. Although the stroke subtypes did not vary between the 2 regions, race-sex differences were identified.

CONCLUSIONS

High stroke incidence and disease rates persist for all 4 race-sex groups in the Southeast and reflect similar risks as mortality rates. However, geographic variability in stroke rates suggests that the pattern of disease in the region is not so much a "belt" of increased stroke in contiguous areas but rather more a "necklace" of different levels of risk. These results should be useful in the identification of factors associated with this geographic enigma.

Racial differences in the utilization of inpatient rehabilitation services among elderly stroke patients

BACKGROUND AND PURPOSE

We undertook this study to ascertain whether elderly black and white patients who are hospitalized for stroke utilize inpatient physical and occupational therapy (PT/OT) services differently, adjusting for characteristics associated with use of these services.

METHODS

We retrospectively reviewed medical records regarding the care received by a nationally representative sample of 2497 black and white Medicare patients, aged 65 years of older, who were hospitalized at any of 297 acute-care hospitals located in 30 communities within five states.

RESULTS

Compared with whites, black stroke patients were younger and more likely to have Medicaid coverage, have an ischemic stroke, and have a motor deficit noted at the time of admission. There was no difference in either sex or level of consciousness on admission. Overall, a larger proportion of black stroke patients used inpatient PT/OT at some point during the hospitalization (66.3% versus 55.8%; P < .01). However, after adjustment for characteristics associated with use of PT/OT, there was no racial difference in either the likelihood of inpatient PT/OT use (adjusted relative risk, 1.06; 95% confidence limits, 0.89 to 1.27; P = .42) or time to initial contact (median: blacks, 6.6 days; whites, 7.4 days; P = .42). Adjusted analyses also indicated a similarity between the racial groups in the number of inpatient PT/OT days overall or as a proportion of the hospital stay.

CONCLUSIONS

Elderly black and white stroke patients who have Medicare coverage have similar patterns of use of inpatient PT/OT services.

Racial variations in ischemic stroke-related physical and functional impairments

BACKGROUND AND PURPOSE

We sought to determine whether there are racial differences in physical and functional impairments resulting from an initial ischemic stroke.

METHODS

We conducted a prospective, county-wide, multisite cohort study including a university hospital, a community hospital, and a Veterans Affairs hospital. The study population was an inception cohort of 145 patients hospitalized for ischemic stroke. Physical and functional impairments were measured using a modified form of the Fugl-Meyer test and the Barthel Index, respectively. Nurses trained to use these tests made assessments at admission and 5, 30, 90, and 180 days after admission. Patient and disease-specific data along with treatment data and vital status were collected.

RESULTS

Forty-one patients (28%) were black. Compared with whites, black stroke patients were more likely to be widowed (51% versus 26%) and hypertensive (83% versus 63%) but less likely to be male (42% versus 69%) and alert on admission (66% versus 76%). There were no racial differences in mortality. Physical impairment was significantly more severe in black than in white patients at admission, and although physical impairment improved, it remained significantly worse in blacks. Functional impairment was also greater in black patients initially but was similar to that in white patients 90 days after the event. Multivariable analyses confirmed these findings.

CONCLUSIONS

These results indicate that blacks may have greater residual physical deficits from stroke than whites.

Stroke in blacks

In an attempt to answer unresolved questions and to suggest directions for future research concerning stroke in black populations, data from the National Center for Health Statistics were examined and published studies were reviewed. Stroke was the third leading cause of death among U.S. blacks in 1982, accounting for 18,698 deaths, 8.25% of the total. Black men aged 35-74 years were 2.5 times and black women 2.4 times as likely as whites to die of stroke. A long-term decline in stroke mortality rates continued through 1982, with the declines since 1968 probably due to improved hypertension control. Data on morbidity trends are lacking. About 7% of black men and 11% of black women in the U.S. noninstitutionalized population aged 65 and over reported having had a stroke in 1977, black women having the highest prevalence of any group. In several studies, black women had higher incidence rates of stroke than white women in each age group. Black men had higher incidence rates than whites up to age 75 years. Survivorship and outcome following stroke may have been poorer in blacks than in whites. Advanced age and elevated blood pressure were the only putative risk factors for stroke for which published data were adequate to firmly establish the association in blacks. Thus, data are needed to examine trends in stroke incidence and survivorship in blacks and to assess the relation of many variables to the risk of stroke.

Cerebrovascular disease morbidity in the United States, 1970-1983. Age, sex, region, and vascular surgery

Data from the National Hospital Discharge Survey were reviewed to assess trends in hospital discharge rates for cerebrovascular disease in the United States between 1970 and 1983. Hospital discharge rates showed little consistent change during the 1970's but increased after 1979. Hospital case fatality declined during the same period. Cerebrovascular disease discharge rates were higher among older persons, men, and blacks. Hospital case fatality was higher in older persons and blacks. Rates of cerebral arteriography and endarterectomy of vessels of the head and neck increased between 1979 and 1983. Methodologic problems in monitoring cerebrovascular disease trends are reviewed and recommendations for future research presented.

The epidemiology of stroke in an urban black population

Hospital admissions for acute stroke were monitored over a twelve month period. Only patients age 20 and over were studied. Out of a population at risk of 114931 there were 116 cases, giving an overall incidence of 1.01 admissions per 1000 population per year over age 20. Cerebral hemorrhages were present in 32.8%, large artery thromboses in 31.9%, cerebral embolism in 13.8% and lacunar infarctions in 20.7% of cases. Atrial fibrillation was the presumed cause of cerebral embolism in 6.9% of patients. Hypertension was present in 69.8% of patients. Further studies are needed to establish the characteristics of stroke in the Third World.

Stroke in south Alabama: incidence and diagnostic features--a population based study

This study has attempted to identify all persons from an area of southern Alabama who had a stroke in 1980 and were hospitalized. Data were gathered on disease onset, clinical course, laboratory results, history of risk factors, and outcome. The age-adjusted incidence rates for initial stroke were 109 per 100,000 for whites and 208 per 100,000 for blacks. Age-specific rates were higher in blacks than whites, and highest for black females. The distribution of cases by type of stroke was: atherothrombotic (6%), embolic (26%), lacunar (13%), infarction of unspecified origin (40%), parenchymatous hemorrhage (8%), subarachnoid hemorrhage (6%), and unidentified type (1%). Blacks had higher incidence rates for hemorrhages, and black females had the highest incidence rate for lacunar stroke. The overall stroke incidence rates in this series were not significantly higher than those from prior population studies, suggesting that southern Alabama is not part of the so-called "Stroke Belt" area of the southeastern United States.

A collaborative study of stroke incidence in Japan: 1975-1979

A Japan Collaborative Study of Stroke covering 20 regional and occupational population groups was conducted with the support of the Ministry of Health and Welfare. In this study 17,423 males and 16,856 females, aged 40 to 69, were followed up prospectively from 1975 to 1979. The average annual incidence of all types of stroke was 3.94 for men and 2.52 for women per 1,000 population. The incidence of cerebral hemorrhage for men and women stood at 1.26 and 0.59 and that of cerebral infarction at 1.87 and 1.10 respectively. The difference in incidence between the sexes was large particularly in the age range of 40-49. The incidence of all types of stroke, cerebral hemorrhage and cerebral infarction increased with age. The incidence of all strokes in Japan during the period 1975-1979 appears to have decreased in comparison with that in 1960-1969, but tended to be still higher than that in Western countries.

Incidence of stroke in Shibata, Japan: 1976-1978

A stroke registry was established in Shibata City, Niigata Prefecture, Japan (population 75,000) in 1976. WHO recommendations for criteria were followed. This paper reports stroke incidence for the initial 3 years of the registry: 1976 through 1978. All living patients were examined clinically by a staff physician. Only patients with a diagnosis of first stroke were included in the study. Sensitivity of the referral system was estimated at 85 + %, comparable to that in American studies. Average annual incidence per 1,000 in resident greater than or equal to 20 years was 2.61 for all strokes (3.42 for males; 1.88 for females), 0.20 for subarachnoid hemorrhage, 0.61 for cerebral hemorrhage, 1.51 for cerebral infarction - rates similar to those reported 10-20 years previously for the United States. The male-female ratio, 2:1, reflected a high rate among males, low among females. Rats among Shibata males were higher than 1972 U.S. rates reported by the Epidemiologic Study Group; rates among Shibata females were lower than corresponding U.S. rates. Incidence of all strokes combined increased with age, the age relationship being strongest for cerebral infarction. No subarachnoid hemorrhage was observed in Shibata residents greater than or equal to 70 years of age.

The incidence and economic costs of cancer, motor vehicle injuries, coronary heart disease, and stroke: a comparative analysis

The economic impact of disease and injury has most often been calculated by examining the costs associated with the prevalence of the impairments in the reference year. An alternative accounting approach is to assign all disease costs to the year of incidence, an approach which entails present-valuing to the year of incidence both health care expenditures and lost productivity. The incidence approach is the more appropriate for gauging the economic gains achievable through prevention, immediate rehabilitation, and arresting progression. Incidence-based costs have been estimated for the United States in 1975 for cancer, coronary heart disease, motor vehicle injuries, and stroke. A noteworthy finding is the relative economic importance of motor vehicle injuries, which frequently have been overlooked in the ordering of public health expenditure priorities. After cancer, which generated approximately $23.1 billion in present-valued costs in 1975 (discounted at 6 per cent), motor vehicle injuries and coronary heart disease constitute the next most expensive conditions--having generated estimated annual costs of $14.4 billion and $13.7 billion, respectively. Stroke, at $6.5 billion, follows in economic importance.

A prospective epidemiological survey of cerebrovascular disease in a Swedish community

A prospective epidemiological study of cerebrovascular diseases and transient ischemic attacks (TIA) is presented. During a three-year period the annual incidence of strokes was 2.90 and of TIA 0.45 per thousand population. This difference in incidence and the disparities in age characteristics favour the hypothesis that TIA precedes only a minority of the strokes. The short-term mortality is high among the stroke patients.

Incidence of stroke in Frederiksberg, Denmark

Since 1971, stroke registers in several countries have been cooperating in a study of stroke epidemiology, initiated by WHO. One of the registers covers the population of Frederiksberg, Copenhagen. During the first two years of registration strokes were recorded in 556 Frederiksberg citizens. A certain diagnosis of cerebral hemorrhage--verified by angiography, spinal fluid examination, or autopsy--was made in 10% of the patients; subarachnoid hemorrhage was demonstrated in only 2%; most of the remaining patients probably had cerebral infarction. The overall annual incidence of stroke, when adjusted for age for the Danish population, was 1.9 per 1,000 for males, and 1.6 per 1,000 for females. For every type of stroke, except subarachnoid hemorrhage, the incidence increased markedly with age. The age-specific stroke incidence rates found in the present investigation are much lower than those demonstrated by Aho in a community-based study in Finland. In view of the strict comparability of the two studies, real differences in the risk of stroke may exist between the two communities.

Incidence and Early Prognosis of Stroke in Espoo-Kauniainen Area, Finland, in 1972

A stroke register has been operating in the Espoo-Kauniainen area, Finland, since January 1, 1972. The study population was 108,000 persons on January 1, 1972. In order to find totally new cases of stroke the following sources were utilized: hospitals and practicing physicians serving the study area were contacted regularly, death certificates were perused every two weeks, and copies of medical certificates or stroke patients applying for sick leave were received from The National Pensions Institute.

During 1972 a total of 153 new stroke cases were registered, giving an incidence of 142/100,000/year. The young age structure of the study population (5.2% were 65 years or older) explains this relatively low incidence. When applied to the total population of Finland and adjusted for age and sex the incidence is 231/100,000/year. The total cases were distributed equally between men and women. Men in age groups 50 to 59 and 60 to 69 years had an incidence twice that of women. The opposite was true in the age group 70 to 79 years. The incidence increased steeply with age.

Case fatality during the acute phase, the first three weeks, was 38% for all stroke cases. In the different clinical entities the case fatality was highest among intracerebral hemorrhages (66%) and lowest among ischemic cerebral infarction (27%).

The results of the first year of registry give an incidence of stroke for Finland which is relatively high compared with many earlier studies from other countries.

Stroke in Jerusalem district 1960 through 1967: an epidemiological study

An epidemiological study was performed in Jerusalem district on the incidence of new stroke patients during the years 1960 through 1967.

On the assumption that the vast majority of patients with a new cerebrovascular event were either hospitalized in one of the three local hospitals or later referred to the Neurological Outpatient Clinic at the Hadassah University Hospital, a retrospective study was performed in order to obtain a close estimation of the incidence of stroke in the district of Jerusalem. In the period of 1960 through 1967, 1,522 new stroke cases were identified and included in this study. On the basis of the history, clinical picture and auxiliary tests, the patients were divided into three groups: (1) ischemic stroke, (2) stroke due to hemorrhage, and (3) stroke of undetermined type. The criteria for differentiation of cerebral ischemia from hemorrhage were rigid, demanding at least a lumbar puncture, angiography, operation, or autopsy for a diagnosis of either one to be made. These rigid criteria account for the high percentage of undetermined cases. Ischemic stroke was diagnosed in 509 (33%), stroke due to hemorrhage in 181 (12%), and stroke of undetermined type in 832 (55%).

The average annual incidence of stroke in the district of Jerusalem was 90/100,000 population.

The age-specific annual incidence rates showed an almost constant increase for both sexes and the various types of stroke, with increasing age. The age-specific and sexspecific annual incidence rates disclosed a male preponderance for all the age groups above 45 in the "ischemic" and "undetermined" types, and for the total series. This preponderance was marked in the 65 to 74 age group. In the "stroke due to hemorrhage" type there was a slight male preponderance in the 65 to 74 age group and a slight female preponderance in the 75+ age group, the ratio being equal for the total hemorrhagic series. Our findings were compared with those reported in other studies and discussed.

The use of medical facilities for cerebrovascular disease patients in a county of Western Pennsylvania

A survey of hospital, nursing home, and death certificate records, and interviews with local physicians were undertaken in a country of 201,000 population. Data from these sources indicate that the incidence of cerebrovascular disease episodes requiring medical care is somewhat higher (particularly among the aged) than the incidence of cerebrovascular disease reported in the United States population. Each year, 385 patients per 100,000 population sought medical care for cerebrovascular disease; 37% of these patients died. One county resident in eight could expect to require care for cerebrovascular disease in the decade after his retirement. To care for the affected patients, one in 20 of the county's hospital beds and one in three of its nursing home beds were required. Including only the most easily identified direct costs, the care of patients with stroke in 1971 required $2,100 per patient and a yearly expenditure of $688,000 per 100,000 population.

Cerebrovascular disease in the bi-racial population of Evans County, Georgia

An epidemiological study was made of cerebrovascular disease in a bi-racial Southern community. The study population comprised about 3,000 men and women aged 15 to 75 years at the time of entry into the study. During the 87-month period between the initial and second examinations, 94 persons developed their first cerebrovascular event.

The incidence of stroke among white men (4.77/1,000/year) was almost four times that in white women and more than twice that reported for white men in other sections of the country. The incidence rates of stroke in Negro men and women were equal (5.8/1,000/year).

The risk factors predisposing to stroke in white men appeared to be severe hypertension, obesity, high hematocrit levels, and antecedent electrocardiographical abnormalities These factors were not as prominent among the other race-sex groups.

The high incidence of cerebrovascular disease found in this semirural population of Georgia supports previous reports of increased mortality rates for stroke in this section of the country and represents a unique situation, the exact cause for which remains to be determined.

The community medicine of cerebrovascular disease

We now know enough about the incidence rates of cerebrovascular disease in different age groups in the U.S.A. to estimate the number of new cases occurring in mainly white communities in the coming years. Our information on nonwhite incidence is less secure, although rough estimates are possible. Prevalence figures are also known, but give less help in planning future programs. Medical care and hospital programs have given figures which show many deficiencies in our current arrangements for care. A tentative list of risk factors should encourage wider efforts to show whether primary prevention is truly possible. More extensive diagnostic examinations, more specific methods of treatment, and earlier and wider attempts at rehabilitation will improve the fate and quality of existence of future stroke patients. Shorter-trained personnel will help extend good care to a greater proportion of all patients, but not without upsetting some cherished beliefs of health professionals. We should resist the temptation to concentrate on collecting more data, and act now to eradicate neglect from this large problem in community medicine.