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(Stroke. 1997;28:19-25.)
© 1997 American Heart Association, Inc.

Articles

Racial Differences in the Utilization of Inpatient Rehabilitation Services Among Elderly Stroke Patients

Ronnie D. Horner, PhD; Helen Hoenig, MD, MPH; Richard Sloane, MPH; Lisa V. Rubenstein, MD, MSPH Katherine L. Kahn, MD

the Center for Health Services Research in Primary Care, Veterans Affairs Medical Center (R.D.H., R.S.), Department of Medicine, Duke University Medical Center (R.D.H., H.H.), and Physical Medicine and Rehabilitation Service, Veterans Affairs Medical Center (H.H.), Durham, NC; the Health Program of RAND (K.L.K.), Santa Monica, Calif, and the Division of General Internal Medicine and Health Services Research, University of California at Los Angeles (K.L.K.); and the Health Services Research and Development Field Program, Veterans Affairs Medical Center, Sepulveda, Calif (L.V.R.).

Correspondence to Ronnie D. Horner, PhD, Center for Health Services Research in Primary Care, HSR&D (152), VA Medical Center, 508 Fulton St, Durham, NC 27705. E-mail horne003@acpub.duke.edu.

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
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 or 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.

Key Words: blacks • elderly • racial differences • rehabilitation

	Introduction

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Blacks experience a greater incidence and mortality from stroke,^{1 2 3 4 5 6 7 8 9} have more severe residual motor impairment,^{10 11} and have worse functional status after stroke than whites.^{10 12} However, it is unclear whether the racial difference in stroke-related functional outcomes is primarily attributable to differences in the severity of stroke, spontaneous recovery, or use of rehabilitation services.^{10 13 14} In two reports, no racial difference was found in either the rate of referral of stroke patients to inpatient rehabilitation or in the level of functioning at either entry or completion of therapy, although neither study adjusted for racial differences in stroke severity.^{13 14} Given the greater severity of stroke-related deficits among blacks, these reports suggest that blacks may be underutilizing stroke rehabilitation services.

There also may be racial differences in either the time to initiation of rehabilitation services or in the amount of these services that, in turn, may affect functional outcomes.¹⁵ A previous study of racial differences in the quality of care delivered to Medicare patients revealed that patients who were either black or poor experienced a worse process of care in general than other types of patients.¹⁶ This association held across five different diseases, one of which was stroke. The study was one of a series of reports on the quality of care received by a nationally representative sample of Medicare patients before and after initiation of the PPS.^{16 17 18 19 20 21 22 23 24 25 26}

We used the data from that quality-of-care study¹⁷ to examine racially based patterns of use of inpatient rehabilitation services among the stroke patients. In this report, we compare the use, timing, and amount of inpatient rehabilitation services among black and white Medicare patients who were hospitalized for stroke.

	Subjects and Methods

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Study Population
This is a secondary analysis of data from a national study of the quality of hospital care provided to a representative sample of Medicare patients in 1981 through 1982 and 1985 through 1986.¹⁷ The study cohort comprised 2497 black and white patients who were hospitalized for stroke at one of the 297 hospitals located in 30 communities within five states. Patients of other races (n=327) were excluded to have more homogeneous racial cohorts; among the excluded patients, there were 22 Asians, 195 Hispanics, 10 patients of other races, and 100 patients whose race was not ascertained. Administrative and clinical data had been obtained by medical record review, including data on patient demographics, health insurance, signs and symptoms at admission, process of care, use of selected inpatient services, status at discharge, and discharge destination. Interrater reliability of the abstracted data was high, with an average of =0.78.

Outcomes
For the present study, the primary outcomes were (1) use of any PT/OT services during the hospital stay and (2) time to initiation of therapy, defined as the day of the hospital stay when the first PT/OT contact occurred. As a secondary outcome, we used the amount or extent of therapy, defined alternatively as (1) the total number of days of inpatient PT/OT therapy and (2) the percentage of the hospital stay involving PT/OT (ie, total number of days of PT/OT divided by the number of days of the hospital stay).

Variables
The independent variable of interest was the patient's race, categorized as either black or white. Covariates were selected to be representative of those clinical and nonclinical factors likely to be associated with use of inpatient rehabilitation services.²⁷ In addition to race, patient sociodemographics included age at admission, sex, whether the patient had Medicaid coverage in addition to Medicare, and whether the patient had been either a resident in a nursing home or had lived alone at home before admission.

Stroke characteristics were described along several dimensions. These included type of stroke (hemorrhagic, lacunar, or other ischemic), level of consciousness on admission as ascertained by a physician (alert, confused, lethargic/stuporous, or comatose), whether the patient was admitted through the hospital emergency department, physician-ascertained presence of a motor deficit at the time of admission, history of a prior stroke, and ability to walk without difficulty before admission.

Comorbid conditions of interest included presence of cardiac arrhythmias (particularly atrial fibrillation), chronic obstructive pulmonary disease, congestive heart failure, dementia, diabetes mellitus, hypertension, incontinence, malnourishment (ie, cachectic, debilitated, or emaciated), morbid obesity, prior myocardial infarction, and substance abuse as represented by use of alcohol or tobacco. Abuse of alcohol was indicated by a history of alcoholism or cirrhosis of the liver; tobacco use was defined as current regular smoking of cigarettes. The patient was considered to have one of these conditions if the medical record contained a physician's note that the condition was present at the time of admission. Characteristics of the admitting hospital included hospital type: rural, urban nonteaching, and urban teaching; hospital ownership: government, for profit, and other; number of beds; and geographic region as indicated by the state within which the hospital was located. To preserve hospital confidentiality, the states are not identified by name.

We used several variables to assess the process or quality of care provided; better process of care has been associated with lower mortality.¹⁸ Overall quality of care was measured by the RAND Corporation process-of-care index. The composition, validity, and reliability of this index is described elsewhere; a higher score reflects higher quality.²¹ Other process measures were whether DNR orders were present in the medical record and whether the data were from the time period before or after initiation of the PPS, when significant reforms were instituted regarding reimbursement for care received by Medicare patients. In addition, in-hospital death was recorded; if the patient was discharged alive, it was recorded whether the patient was discharged to home versus some other setting.

Data Analysis
The patient was the unit of analysis at all stages. All analyses were weighted, with the weights reflecting the probability of the patient being included in the sample. SUDAAN software was used to adjust for the effect of the multistage sampling (ie, clustering) that was part of the study design.²⁸

Unadjusted Analysis
The unadjusted analysis involved bivariate comparisons of race with each outcome and covariate. Categorical variables were summarized by frequencies and percentages; for continuous variables, the mean, the standard error of the mean, and the median were calculated. The association between the patient's race and each of the variables was assessed by the ² statistic for categorical covariates; Student's t test and its nonparametric equivalent (eg, Wilcoxon rank sum test) was used to assess statistical significance between race and the continuous covariates. A proportional hazards model that included only race was used to determine the existence of a racial difference in the relative risk of using inpatient rehabilitation services over the course of a hospital stay; patients who did not use inpatient PT/OT services during the hospital stay were censored at the time of their discharge. For both the number of inpatient PT/OT days (ie, amount of PT/OT) and percentage of the length of stay involving PT/OT (ie, relative amount of inpatient PT/OT), a design-weighted least-squares regression model with only race as the independent variable was used; this analysis was restricted to the subpopulation of patients who had used any inpatient PT/OT.

Adjusted Analysis
Multiple regression analyses were conducted to determine the unique contribution of the patient's race to the use and timing of inpatient PT/OT after adjustment for other relevant factors. Previous investigations have indicated that some racial effects are revealed only after adjustment for covariates.¹⁶ The model specification included the set of covariates that were a priori clinically significant predictors of referral to rehabilitation services; the model also included variables that were potential confounders of the association between race and use of PT/OT.²⁷ On the basis of this model specification strategy, all of the multiple regression models (ie, proportional hazards and linear) included the following set of covariates in addition to the patient's race. For patient sociodemographic characteristics, we included age, which was dichotomized at age 85 years (ie, the age at which our preliminary analyses indicated a clear difference in use of rehabilitation), sex, Medicaid status, and residence before admission. For disease characteristics, we included stroke type, presence of a motor deficit, severity of illness (ie, level of consciousness on admission), history of cerebrovascular disease, and selected comorbid conditions. Process or quality-of-care measures included the RAND Corporation process-of-care index score, presence of DNR orders in the medical record, and whether the admission was before or after institution of the PPS. For hospital characteristics, we included geographic region (ie, state), hospital type, and hospital ownership. Hospital type and number of beds were significantly associated, with rural hospitals having fewer beds than other types of hospitals (Spearman's =0.55; P<.001). Because these variables essentially measured the same hospital characteristic, we did not include number of beds in the model.

As part of the modeling process, two interaction terms were evaluated: (1) patient's race and process of care and (2) patient's race and admission through the emergency department. Previous work using the larger data set has indicated that an interaction between race and process of care was possible.¹⁶ The other interaction term was evaluated because black patients have been shown to delay in presenting to the emergency department for acute myocardial infarction (ie, an emergent life-threatening condition similar to stroke) and that this delay is associated with a worse prognosis.^{29 30 31} Thus, compared with white stroke patients who are admitted through the emergency department, blacks may be presenting later in the acute course of the stroke, having a greater likelihood of a completed stroke with the accompanying fixed and perhaps more severe deficits.

	Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Baseline Characteristics of the Cohort
Blacks and whites differed on several important baseline characteristics that may influence whether a patient receives inpatient rehabilitation (Table 1). Black stroke patients were younger on average than the white stroke patients: the mean±SE age of blacks was 75.6±0.45 years, whereas the mean age of whites was 78.9±0.17 years (P<.001). A larger proportion of blacks than whites had Medicaid coverage in addition to Medicare. No statistically significant racial differences were found for sex, residence before admission, or discharge location.

View this table: [in this window] [in a new window]   Table 1. Baseline Characteristics of Study Cohort*

Clear racial differences existed in clinical factors, particularly in the distribution of type of stroke and the impact of stroke on motor function (Table 1). In this cohort of hospitalized elderly patients, the proportion of black stroke patients with a hemorrhagic stroke was approximately half that of white stroke patients; the proportion of blacks with a lacunar stroke was about twice that of whites; and a similar proportion of each racial group had other types of ischemic strokes. The racial groups were similar in level of consciousness on admission; that is, a similar proportion of blacks and whites were comatose when admitted to the hospital. However, a larger proportion of blacks had a motor deficit associated with their stroke, although a motor deficit was present for almost all patients regardless of race. A larger proportion of blacks also had a notation of alcohol abuse in their medical record (ie, a physician's note of alcoholism or cirrhosis of the liver) and had hypertension. A smaller proportion of blacks than whites, however, had cardiac arrhythmias.

Racial differences were also found in the type of hospital facility to which the stroke patients were admitted (Table 1). A statistically significantly larger proportion of blacks were clinically managed in hospitals that were government-operated (ie, county, state, or federal hospital), large (400 beds), and urban teaching facilities. The geographic region (ie, state) of the admitting hospitals differed by the patient's race as well.

There were few obvious racial differences on several measures of process of care. A statistically significantly smaller proportion of blacks had a DNR order issued during the hospital stay, although a similar proportion of patients from both racial groups died in the hospital and, as previously noted, were discharged to home. Among patients discharged alive, the median length of stay differed between blacks and whites by less than 1 day (12.0 versus 11.1 days, respectively; P=.50). However, among patients dying in the hospital, there was a substantial racial difference, with a median length of stay for blacks of 9.4 days versus 6.7 days for whites (P<.001).

Use of Inpatient PT/OT
Overall, 66.3% of black stroke patients versus 55.8% of white stroke patients received inpatient PT/OT (P<.01). On the basis of proportional hazards modeling, the unadjusted relative risk of receiving inpatient PT/OT for blacks was 1.11 (95% CL, 0.93 to 1.33; P=.22). With adjustment for important indicators for receiving inpatient PT/OT through multivariable proportional hazards modeling, there was a similar likelihood of receiving inpatient PT/OT among patients; as shown in Table 2, the adjusted relative risk of receiving inpatient PT/OT for blacks was 1.06 (95% CL, 0.89 to 1.27; P=.42).

View this table: [in this window] [in a new window]   Table 2. Adjusted Relative Risk of Receiving Inpatient PT/OT Associated With Sociodemographic, Clinical, and Admitting Hospital Characteristics of Black and White Stroke Patients With Medicare, Using Proportional Hazards Modeling

Other characteristics that were significantly associated with a greater likelihood of receiving inpatient PT/OT included having a motor deficit on admission, geographic location of the hospital, and being hospitalized in the post-PPS era. Characteristics that were significantly associated with a lower likelihood of receiving inpatient PT/OT were being comatose on admission, having a hemorrhagic stroke, being malnourished, having a DNR order, and coming from a nursing home. All of these factors were indicative of worse clinical status.

Time to Initiation of Inpatient PT/OT
Without adjustment for relevant factors, the time to initiation of inpatient rehabilitation services was similar for blacks and whites. Among patients who received PT/OT, the unadjusted median time to initiation of inpatient rehabilitation services was 5.6 days for blacks versus 6.6 days for whites (P=.22). After adjustment for relevant clinical and nonclinical factors (ie, the same set of variables shown in Table 2), the median time to initiation of inpatient PT/OT was 6.6 days for blacks versus 7.4 days for whites (Figure; P=.42).

View larger version (11K): [in this window] [in a new window]   Figure 1. Time to initiation of inpatient PT/OT among a nationally representative sample of black and white Medicare patients hospitalized for stroke in 1982-1983 or 1985-1986. Survival estimates are derived from the proportional hazards model as presented in Table 2 and correspond to the sample means of the covariates that are presented in Table 1.

Days of Inpatient PT/OT
Without adjustment for other factors, there was no statistically significant difference in either the total number of days of inpatient PT/OT received by black and white stroke patients or in the percentage of hospital days involving PT/OT. Among patients who received any inpatient PT/OT, blacks received an average±SE of 7.6±0.54 days of inpatient PT/OT, whereas whites received 8.2±0.21 days inpatient PT/OT, a statistically insignificant difference (P=.34). The unadjusted regression parameter estimate for total number of days of inpatient PT/OT for blacks relative to whites was 0.54 (95% CL, -0.51 to 1.70; P=.34). Overall, the mean±SE percentage of the hospital stay involving PT/OT was 46±1.7% for blacks and 49±0.6% for whites (P=.08). From the linear regression model, the unadjusted parameter estimate for blacks for percentage of hospital stay involving PT/OT was 0.03 (SE, 0.02; P=.075).

After adjustment for clinical and nonclinical factors associated with use of rehabilitation services, the patient's race was still not associated with number of inpatient PT/OT days either overall or relative to the length of stay. Blacks received approximately the same number of PT/OT days during the hospital stay as whites (ß=0.04; SE=0.60; P=.90). Similarly, the percentage of hospital stay during which PT/OT was received was virtually identical among blacks and whites (ß=0.08; SE=0.06; P=.20).

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Among a nationally representative sample of Medicare patients who had been hospitalized for stroke, we found that a larger proportion of blacks than whites used inpatient PT/OT. We also found that a larger proportion of these black stroke patients had a motor deficit on admission and received care in large facilities and in urban teaching hospitals. The observed difference in utilization of inpatient PT/OT services among the racial groups was consistent with their differences in the prevalence of a motor deficit (ie, the need for physical therapy) and with the type of hospital to which they were admitted. Others have shown that large urban teaching hospitals score higher on process-of-care measures than other types of hospitals and that better process of care is associated with receiving inpatient PT/OT.^{21 22 23 24 25 26} With adjustment for presence of a motor deficit, process of care, and other covariates associated with use of inpatient rehabilitation services, patients in both racial groups had a similar likelihood of receiving inpatient PT/OT. For other dimensions of inpatient PT/OT utilization, after adjustment for relevant covariates, there was also no indication of a racial difference in either time to first PT/OT contact or in the number of days of inpatient PT/OT, overall or relative to the length of the hospital stay.

No previous studies have directly ascertained whether black stroke patients utilize rehabilitation services differently than stroke patients of other racial groups.^{13 14} Given that a larger proportion of blacks than whites experience more severe strokes and have a higher likelihood of a motor deficit sufficient to necessitate therapy,¹² the utilization rate of inpatient rehabilitation services is anticipated to be higher among black stroke patients. However, Kuhlemeier and Steins¹⁴ reported no racial difference in the rate of referral to an inpatient rehabilitation unit among stroke patients. In addition, although rates of referral were not reported by McElligott et al,¹³ they found no racial difference in initial functional status among patients who used the inpatient rehabilitation service. These reports imply that fewer black than white stroke patients with a need for rehabilitation are receiving this inpatient service. We have now shown that elderly black stroke patients are at least as likely as elderly white stroke patients to use inpatient PT/OT after adjustment for presence of a stroke-related motor deficit and for other factors that are associated with use of stroke rehabilitation services. We have also shown that these black patients are receiving inpatient rehabilitation services at a similar point in the hospital stay as whites and that both racial groups receive a similar number of days of therapy.

Unexplained racial disparities are reported for many aspects of health care, specifically a lower rate of use of various diagnostic and therapeutic procedures for black patients.^{32 33 34 35 36} These observed differences have raised concerns that blacks may be underutilizing medical care because of racial bias among providers. Efforts have only begun to examine the relative importance of plausible explanations other than racial bias, including racial differences in clinical indications for various procedures, ability to pay, and patient preferences or decision-making patterns.³⁷ In a review of the evidence regarding factors influencing the use of carotid endarterectomy among racial groups, the available reports consistently indicated that blacks are less likely to have the constellation of clinical factors, such as high-grade carotid artery lesions, that would make them candidates for the procedure.³⁷ Ability to pay for care appeared to be less important than clinical factors as an explanation of the lower use of carotid endarterectomy. There was insufficient evidence regarding racial differences in patient preferences for the surgery.

Our findings also suggest that factors other than the patient's race are important in explaining the observed racial patterns in use of inpatient rehabilitation services for stroke. Region of hospitalization may be among these more important factors. Regional variation is reported for many procedures and is compatible with the observed regional variations in use of inpatient PT/OT in this study.³⁸ Even with adjustment for factors associated with use, we found clear differences among states in the relative likelihood of use of inpatient PT/OT. One explanation of regional variation in utilization of procedures and services is clinician preference or enthusiasm for the procedure.³⁹ Onsite availability of the technology or personnel and the availability of hospital beds are other likely factors that influence the utilization of services.^{40 41} For example, use of diagnostic CT is strongly associated with both onsite availability and region of the nation, with hospitals located in New York having a higher level of use.⁴⁰ The association between onsite availability of technology and its use has also been reported for cardiovascular disease–related diagnostic and treatment technology, suggesting that the relationship between onsite availability and use of technology is a general phenomenon.⁴¹ Federal mandates regarding Medicare reimbursement also modify the use of services (probably through shorter lengths of stay) as indicated by higher and earlier use of inpatient PT/OT in the post-PPS period.

As an explanation of inpatient PT/OT utilization patterns among blacks and whites, ability to pay appears to be less important than the region and federal healthcare rules. We observed racial variation in the use of inpatient PT/OT in a population of patients having similar insurance coverage for hospital care (ie, Medicare). Equally important, we found in this nationally representative sample of Medicare patients that those who also had Medicaid coverage (ie, a marker for lower socioeconomic status) were as likely to use inpatient PT/OT as stroke patients who did not have Medicaid as a supplement to Medicare.

We recognize, however, that these inferences regarding racial variation in the use of inpatient stroke rehabilitation services may not hold for the utilization of other diagnostic and therapeutic procedures, particularly those that are invasive. We also recognize the need for some caution in the interpretation of our findings. First, we do not have detailed data on the severity of the motor and other stroke-related deficits; only the presence of deficits was recorded. Thus, we cannot draw conclusions regarding the appropriateness of either the proportion of patients using inpatient rehabilitation among the racial groups or the extent of the therapy received as reflected by the number of days of PT/OT. Second, we have no information regarding racial differences in either the mix of services or the quality of the PT/OT therapy received. While it is possible that black stroke patients may receive less intensive therapy or fewer services, an earlier report suggests that this is not occurring, as indicated by an absence of a racial difference in the level of functioning on admission and discharge from an inpatient rehabilitation program.¹³ A third limitation is our lack of data on the use and quality of outpatient stroke rehabilitation services. It is possible that white patients receive either more or higher quality outpatient rehabilitation for their stroke-related deficits because their strokes are less severe or because they may be better able to get to the services (eg, have access to reliable transportation or supplemental insurance that allows greater access to these postdischarge services). Fourth, our study was restricted to older patients, although it is a nationally representative sample of Medicare patients. There may be a racial difference in utilization of inpatient stroke rehabilitation services for relatively younger stroke patients (ie, those 45 to 64 years of age) who do not have sufficient health insurance to pay for services. This is a particularly important consideration for cerebrovascular disease because the incidence of stroke is greater in middle-aged blacks than in middle-aged whites. Fifth, these data are from the 1980s; the observed patterns of stroke rehabilitation may not hold currently. However, there are no compelling reasons to suspect a different racial pattern in use of inpatient rehabilitation in the 1990s. No substantial health policy changes have occurred during the post-PPS period that would have had a differential effect on the use of inpatient rehabilitation among racial groups.⁴²

Despite these limitations in interpretation, we conclude that there is no evidence of either underutilization or delayed utilization of inpatient stroke rehabilitation services among elderly black stroke patients with Medicare. Beyond confirming our findings, further efforts should evaluate the existence of racial differences in several areas of rehabilitation, including utilization of inpatient rehabilitation services among stroke patients who are not covered by Medicare, utilization of outpatient rehabilitation services, and the quality of inpatient and outpatient rehabilitation services received.

	Selected Abbreviations and Acronyms

 

CL = confidence limit DNR = do not resuscitate PPS = prospective payment system PT/OT = physical and occupational therapy

	Acknowledgments

 
This work was sponsored in part by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, as Service Directed Research Project 93-003, and by the National Institutes of Health through the National Institute on Aging, Claude D. Pepper Older Americans Independence Center grant No. 5 P60 AG11268. The data used in this manuscript were collected by RAND investigators supported by the Health Care Financing Administration, US Department of Health and Human Services, Cooperative Agreement 18-C-98853/9-03. The authors thank William E. Wall of the Duke University Center for the Study of Aging and Human Development for assistance in the data analysis. The opinions, conclusions, and recommendations for future research in this manuscript are those of the authors alone and do not necessarily represent the views of either of the organizations with which the authors are affiliated or the organizations that funded this work.

Received May 21, 1996; revision received September 20, 1996; accepted September 20, 1996.

	References

Top Abstract Introduction Subjects and Methods Results Discussion References

 

1. Centers for Disease Control. Cerebrovascular disease mortality and Medicare hospitalization: United States, 1980-1990. MMWR Morb Mortal Wkly Rep. 1992;41:477-480.[Medline] [Order article via Infotrieve]
2. Gillum RF. Stroke in blacks. Stroke. 1988;19:1-9.[Abstract/Free Full Text]
3. Otten MW, Teutsh SM, Williamson DF, Marks JJ. The effect of known risk factors on the excess mortality of black adults in the United States. JAMA. 1990;263:845-850.[Abstract]
4. Eckstrom PT, Brand FR, Edlavitch SA, Parrish HM. Epidemiology of stroke in a rural area. Public Health Rep. 1969;84:878-882.[Medline] [Order article via Infotrieve]
5. Heyman A, Karp HR, Heyden S, Bartel A, Cassel JC, Tyroler HA, Cornoni J, Hames CG, Stuart W. Cerebrovascular disease in the bi-racial population of Evans County, Georgia. Stroke. 1971;2:509-518.[Abstract/Free Full Text]
6. Gross CR, Kase CS, Mohr JP, Cunningham SC, Baker WE. Stroke in south Alabama: incidence and diagnostic features—a population-based study. Stroke. 1984;15:249-255.[Abstract/Free Full Text]
7. Klatsky AL, Armstrong MA, Friedman GD. Racial differences in cerebrovascular disease hospitalizations. Stroke. 1991;22:299-304.[Abstract/Free Full Text]
8. Sacco RL, Hauser WA, Mohr JP. Hospitalized stroke in blacks and Hispanics in Northern Manhattan. Stroke. 1991;22:1491-1496.[Abstract/Free Full Text]
9. Aronow WS. Prevalence of atherothrombotic brain infarction, coronary artery disease and peripheral arterial disease in elderly blacks, Hispanics and whites. Am J Cardiol. 1992;70:1212-1213.[Medline] [Order article via Infotrieve]
10. Horner RD, Matchar DB, Divine GW, Feussner JR. Racial variations in ischemic stroke-related physical and functional impairments. Stroke. 1991;22:1497-1501.[Abstract/Free Full Text]
11. Kuhlemeier KV, Steins SA. Racial disparities in severity of cerebrovascular events. Stroke. 1994;25:2126-2131.[Abstract]
12. Sacco RL, Hauser WA, Mohr J, Foulkes MA. One-year outcome after cerebral infarction in whites, blacks, and Hispanics. Stroke. 1991;22:305-311.[Abstract/Free Full Text]
13. McElligott JM, Dolezal J, Hamilton J. Stroke, racial variations, and effective inpatient rehabilitation in a rural setting. Arch Phys Med Rehabil. 1993;74:1278. Abstract.
14. Kuhlemeier KV, Steins SA. Rehabilitation after stroke: gender and racial disparities? Arch Phys Med Rehabil. 1991;72:840-841. Abstract.
15. Gresham GE, Duncan PW, Stason WB, Adams HP, Adelman AM, Alexander DN, Bishop DS, Diller L, Donaldson NE, Granger CV, Holland AL, Kelly-Hayes M, McDowell FH, Myers L, Phipps MA, Roth EJ, Siebens HC, Tarvin GA, Trombly CA. Post-Stroke Rehabilitation. Clinical Practice Guidelines, No. 16. Rockville, Md: US Department of Health and Human Services; May 1995. Public Health Service, Agency for Health Care Policy and Research. AHCPR publication 95-0662.
16. Kahn KL, Pearson ML, Harrison ER, Desmond KA, Rogers WH, Rubenstein LV, Brook RH, Keeler EB. Health care for black and poor hospitalized Medicare Patients. JAMA. 1994;271:1169-1174.[Abstract]
17. Kahn KL, Draper D, Keeler EB, Rogers WH, Rubenstein LV, Kosecoff J, Sherwood MJ, Reinisch EJ, Carney MF, Kamberg CJ, Bentow SS, Wells KB, Allen H, Reboussin D, Roth CP, Chew C, Brook RH. The Effects of the DRG-Based Prospective Payment System on Quality of Care for Hospitalized Medicare Patients: Final Report. Santa Monica, Calif: RAND; 1992; publication R-3931-HCFA.
18. Kahn KL, Rubenstein LV, Draper D, Kosecoff J, Rogers WH, Keeler EB, Brook RH. The effects of the DRG-based prospective payment system on quality of care for hospitalized Medicare patients: an introduction to the series. JAMA. 1990;264:1953-1955.[Abstract]
19. Draper D, Kahn KL, Reinisch EJ, Sherwood MJ, Carney MF, Kosecoff J, Keeler EB, Rogers WH, Savitt H, Allen H, Wells KB, Reboussin D, Brook RH. Studying the effects of the DRG-based prospective payment system on quality of care: design, sampling and fieldwork. JAMA. 1990;264:1956-1961.[Abstract]
20. Keeler EB, Kahn KL, Draper D, Sherwood MJ, Rubenstein LV, Reinisch EJ, Kosecoff J, Brook RH. Changes in sickness at admission following the introduction of the prospective payment system. JAMA. 1990;264:1962-1968.[Abstract]
21. Kahn KL, Rogers WH, Rubenstein LV, Sherwood MJ, Reinisch EJ, Keeler EM, Draper D, Kosecoff J, Brook RH. Measuring quality of care with explicit process criteria before and after implementation of the DRG-based prospective payment system. JAMA. 1990;264:1969-1973.[Abstract]
22. Rubenstein LV, Kahn KL, Reinisch EJ, Sherwood MJ, Rogers WH, Kamberg C, Draper D, Brook RH. Changes in quality of care for five diseases measured by implicit review, 1981 to 1986. JAMA. 1990;264:1974-1979.[Abstract]
23. Kosecoff J, Kahn KL, Rogers WH, Sherwood MJ, Rubenstein LV, Draper D, Roth CP, Chew C, Brook RH. Prospective payment system and impairment at discharge: the `quicker-and-sicker' story revisited. JAMA. 1990;264:1980-1983.[Abstract]
24. Kahn KL, Keeler EB, Sherwood MJ, Rogers WH, Draper D, Bentow SS, Reinisch EJ, Rubenstein LV, Kosecoff J, Brook RH. Comparing outcomes of care before and after implementation of the DRG-based prospective payment system. JAMA. 1990;264:1984-1989.[Abstract]
25. Rogers WH, Draper D, Kahn KL, Keeler EB, Rubenstein LV, Kosecoff J, Brook RH. Quality of care before and after implementation of the DRG-based prospective payment system. JAMA. 1990;264:1989-1994.[Abstract]
26. Keeler EB, Rubenstein LV, Kahn KL, Draper D, Harrison ER, McGinty MJ, Rogers WH, Brook RH. Hospital characteristics and quality of care. JAMA. 1992;268:1709-1714.[Abstract]
27. Hoenig H, Rubenstein L, Kahn K. Rehabilitation after hip fracture: equal opportunity for all? Arch Phys Med Rehabil. 1996;77:58-63.[Medline] [Order article via Infotrieve]
28. SUDAAN. SUDAAN User's Manual, Release 6.4. Research Triangle Park, NC: Research Triangle Institute; 1994.
29. Cooper RS, Simmons B, Castaner A, Prasad R, Franklin C, Ferlinz J. Survival rates and prehospital delay during myocardial infarction among black persons. Am J Cardiol. 1986;57:208-211.[Medline] [Order article via Infotrieve]
30. Ghali JK, Cooper RS, Kowatly I, Liao Y. Delay between onset of chest pain and arrival to the coronary care unit among minority and disadvantaged patients. J Natl Med Assoc. 1993;85:180-184.[Medline] [Order article via Infotrieve]
31. Johnson PA, Lee TH, Cook EF, Rouan GW, Goldman L. Effect of race on the presentation and management of patients with acute chest pain. Ann Intern Med. 1993;118:593-601.[Abstract/Free Full Text]
32. Elixhauser A, Harris DR, Coffy RM. Trends in Hospital Procedures Performed on Black Patients and White Patients: 1980-87. Provider Studies Research Note 20. Rockville, Md: Agency for Health Care Policy and Research, Public Health Service; 1994. AHCPR publication 94-0003.
33. Oddone EZ, Horner RD, Monger ME, Matchar DB. Racial variation in carotid angiography and endarterectomy among veterans hospitalized for stroke or transient ischemic attack. Arch Intern Med. 1993;153:2781-2786.[Abstract]
34. Escarce JJ, Epstein KR, Colby DC, Schwartz JS. Racial differences in the elderly's use of medical procedures and diagnostic test. Am J Public Health. 1993;83:948-954.[Abstract/Free Full Text]
35. Mort EA, Weissman JS, Epstein AM. Physician discretion and racial variation in the use of surgical procedures. Arch Intern Med. 1994;154:761-767.[Abstract]
36. Brook RH, Park RE, Chassin MR, Solomon DH, Keesey J, Kosecoff J. Predicting the appropriate use of carotid endarterectomy, upper gastrointestinal endoscopy, and coronary angiography. N Engl J Med. 1990;323:1173-1177.[Abstract]
37. Horner RD, Oddone EZ, Matchar DB. Theories explaining racial differences in the utilization of diagnostic and therapeutic procedures for cerebrovascular disease. Milbank Q. 1995;73:443-462.[Medline] [Order article via Infotrieve]
38. Wennberg JE. Dealing with medical practice variations: a proposal for action. Health Aff (Millwood). 1984;3:6-37.[Medline] [Order article via Infotrieve]
39. Chassin MR. Explaining geographic variations: the enthusiasm hypothesis. Med Care. 1993;31(5 suppl):YS37-YS44.
40. Howard G, Brockschmidt JK, Coull BM, Becker C, Feibel J, Walker MD, McLeroy KR, Toole JF, Yatsu FM. The community hospital-based stroke programs in North Carolina, Oregon and New York, V: stroke diagnosis: factors influencing the diagnostic evaluation of patients following acute stroke. J Clin Epidemiol. 1991;44:293-301.[Medline] [Order article via Infotrieve]
41. Every NR, Larson EB, Litwin PE, Maynard C, Fihn SD, Eisenberg MS, Hallstrom AP, Martin JS, Weaver WD, for the Myocardial Infarction Triage and Intervention Project Investigators. The association between on-site cardiac catheterization facilities and the use of coronary angiography after acute myocardial infarction. N Engl J Med. 1993;329:546-551.[Abstract/Free Full Text]
42. Buchanan JL, Rumpel JD, Hoenig H. Charges for outpatient rehabilitation services: growth and differences in outpatient types. Arch Phys Med Rehabil. 1996;77:320-328.[Medline] [Order article via Infotrieve]

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