Accessing Young Black Stroke Survivors for Secondary Prevention

19 Accessing Young Black Stroke Survivors for Secondary Prevention Springer, et al. Journal of Health Disparities Research and Practice Volume 12, Issue 6, Winter 2019, pp. 19-25 © 2011 Center for Health Disparities Research School of Community Health Sciences University of Nevada, Las Vegas Accessing Young Black Stroke Survivors for Secondary Prevention Mellanie V. Springer, University of Michigan James F. Burke, University of Michigan Devin L. Brown, University of Michigan Lesli E. Skolarus, University of Michigan Corresponding Author: Mellanie V. Springer, ABSTRACT Background: Stroke rates and risk factors may be increasing in young adults aged 18-64, especially black individuals. We sought to identify whether young high risk stroke survivors could be found at community health centers. Methods: This was a cross-sectional analysis of the National Ambulatory Medical Care Survey from 2006-2011. We used chi-square analyses, t-tests, and proportions to compare and describe stroke survivor visits at community health centers and private offices. Results: Young stroke survivor visits comprise 48% of stroke survivor visits at community health centers compared to 31% of stroke survivor visits at the private office setting. Among young stroke survivors cared for at community health centers, 47% were black individuals compared to 14% at a private office setting. The prevalence of hypertension and cigarette smoking was higher in young stroke survivors at the community health center. Conclusions: The community health center is a setting to access young black stroke survivors. Stroke prevention and preparedness interventions should be considered at community health centers. Keywords: community health centers; stroke; young adult INTRODUCTION Stroke hospitalization rates are increasing in young adults (George, Tong, & Bowman, 2017; Kissela et al., 2012) resulting in years of dependence, loss of work productivity and high health care costs. Black people are disproportionately represented in the young stroke population (Howard et al., 2016). Higher incidence of strokes in black people has been partly attributed to a greater prevalence of risk factors, such as hypertension and diabetes (Howard et al., 2011). Risk factor control is fundamental to preventing incident and recurrent strokes in young stroke patients, particularly young black people. Yet, reaching young black people to optimize risk factors is a major challenge. Journal of Health Disparities Research and Practice Volume 12, Issue 6, Winter 2019 http://digitalscholarship.unlv.edu/jhdrp/ Follow on Facebook: Health.Disparities.Journal Follow on Twitter: @jhdrp 20 Accessing Young Black Stroke Survivors for Secondary Prevention Springer, et al. Secondary stroke interventions reaching young black stroke survivors are few in number and success. Prior interventions have targeted stroke survivors in general, without focusing specifically on the young stroke population, and have had mixed results. Specifically, systolic blood pressure reduction did not differ between stroke survivors who received group and individualized sessions on stroke risk factor reduction compared to those who received a stroke educational pamphlet (Cheng et al., 2018). By contrast, a program for stroke survivors implemented at hospital discharge led to high rates of medication adherence and behavioral risk factor modification at 3 months compared to what has been observed in historical controls (Ovbiagele et al., 2004). In black patients across the adult age spectrum, healthy lifestyle modification may be limited by economic hardship, low health literacy, and unsafe environments (Carnethon et al., 2017). The specific barriers to behavioral change in young black stroke survivors are understudied, but limited data suggest that some barriers include poor health literacy and difficulty implementing behavior change (Blixen et al., 2014). Designing interventions that overcome these challenges is imperative. One strategy is to bring stroke interventions to the primary care setting. Community health centers (CHCs) are community-based organizations serving populations with limited access to health care. Patients are mostly under the age of 65, more likely to be Hispanic or black, and have a high prevalence of cardiovascular (CV) risk factors (Hing, Hooker, & Ashman, 2011; Shi, Lebrun, Tsai, & Zhu, 2010). We sought to quantify the CV risk of stroke survivors in CHCs and the prevalence of young stroke survivor visits at CHCs compared to the private clinic setting. Our overarching goal is to understand the extent to which interventions targeting CHCs may improve care both in high risk stroke survivors, generally, and young black people, more specifically. METHODS Data Source We used data from the National Ambulatory Medical Care survey (NAMCS) from 2006 to 2011, a national survey of office-based medical providers about characteristics of medical visits. The NAMCS three-stage, stratified sampling design enables nationally and regionally representative characterizations of ambulatory medical care. We used NAMCS data from CHCs and private practice settings (private practices, non-federal government clinics, health maintenance organizations), the locations at which the population receives primary care. Other practice locations surveyed in NAMCS were excluded. Patient Characteristics Young stroke survivors were defined as adult patients 18 to 64 years old identified by the provider as currently having cerebrovascular disease. Specifically, the provider is asked “regardless of the diagnoses written in 5a (the visit diagnoses), does the patient now have cerebrovascular disease?”. Older stroke survivors were 65 years and older. Patient age was categorized as above and also analyzed as a continuous variable. The patient’s race/ethnicity was provided by the clinician completing the survey. CV risk factors including diabetes, hyperlipidemia, hypertension, obesity, and current smoking were identified by the provider based on the patient’s current medical problems as binary variables. We explored using a measured systolic blood pressure ≥ 140 mmHg during the index clinic visit to define patients with hypertension. However 27% of values were missing and the data was differentially missing by Journal of Health Disparities Research and Practice Volume 12, Issue 6, Winter 2019 http://digitalscholarship.unlv.edu/jhdrp/ Follow on Facebook: Health.Disparities.Journal Follow on Twitter: @jhdrp 21 Accessing Young Black Stroke Survivors for Secondary Prevention Springer, et al. setting (i.e. CHC, 4.5% vs private, 29%), thus we used provider-reported hypertension in all analyses. Statistical Analysis The continuous variable age was normally distributed and analyzed using a t-test. Chisquare tests were used to evaluate the association between categorical variables and practice location (CHC vs private). All analyses accounted for the weighted survey design. STATA 14 was used to analyze t (...truncated)