Falling Through the Cracks: Middle-Aged Stroke Survivors Not Receiving Care

Recurrent stroke is an important health concern not only from a patient perspective but also from clinical and public health standpoints. Many studies have shown that the risk of a second cerebral infarction is greatest immediately following the primary event. Consequently, clinical management of stroke survivors is focused on preventive therapy to minimize risk.

Currently in the United States, some 5 million persons¹ require access to physicians and medications to modify their risk of having a second stroke, including treatments to modify blood pressure, cholesterol, and diabetes. However, 2 epidemiological studies^2,3 conducted by a team from the Birmingham Veterans Affairs Medical Center in Alabama show that middle-aged persons and those nearing senior citizen status-persons aged 45 to 64 years-have a disproportionately and significantly harder time accessing medications and medical care than more senior stroke survivors-persons 65 years and older. Consequently, the younger group is at a disproportionately higher risk for experiencing a second stroke or cardiovascular event-and the trend is worsening, not improving.

The underlying reason is that persons do not become eligible for Medicare insurance until they are aged 65 years, notwithstanding that they may have suffered a stroke, said Deborah A. Levine, MD, PHP, assistant professor of medicine at the University of Alabama, Birmingham, and lead author of both studies.

Levine and colleagues² examined access to medical care and treatment for stroke survivors in the United States using data from the National Health Interview Survey (NHIS) between 1998 and 2002. The NHIS is an on-going "in-person household survey" of the noninstitutionalized US civilian population. It is undertaken annually by the National Center for Health Statistics using in-person interviews. Levine's findings are consistent with those from studies conducted in Canada⁴ and the United Kingdom⁵ that also highlight inadequate medical care for stroke survivors. Furthermore, Levine's data mirror findings from previous studies done in myocardial infarction (MI) survivors, which show that persons aged 45 to 64 years more frequently had problems with access to care than MI survivors who were aged 65 years or older.

NHIS Data
In reviewing the NHIS, Levine and colleagues identified 3681 stroke survivors from a total of 159,985 respondents aged 45 years or older.² "This represents 4.1 million US stroke survivors, 1.3 million of whom are aged 45 to 64 years," the study authors wrote. The mean age of the younger stroke survivors was 56 years, and the mean age of older stroke survivors was 76 years. Compared with the older cohort, younger stroke survivors were more frequently male (52% vs 47%), African American (19% vs 10%), and lacking health insurance (11% vs 0.4%).

Levine found that a significantly greater number of younger stroke survivors reported no primary care physician visit compared with their older counterparts (4% vs 10%). Similarly, there was a significantly reduced number of visits to a primary care physician or medical specialist in the younger cohort compared with the older group (5% vs 8%). Interestingly, 44% of both cohorts reported not seeing any medical specialist. In addition, fewer younger stroke survivors were able to afford medications compared with their older counterparts (6% vs 15%). Given that 70% of the stroke survivors in this study had hypertension, the inability to afford medications becomes clinically significant as well.

Younger patients with disabilities, not surprisingly, faired even worse, with 16% reporting an inability to afford medications compared with 5% of the older cohort. No visits to a general practitioner were reported by 12% of the younger, disabled cohort compared with just 8% of persons in the older group. Most striking was the percentage of stroke survivors with disabilities who did not have health insurance: 11% in the younger group versus 0.6% in the older group.

To determine what factors were influencing these outcomes, Levine and colleagues used multivariate logistic regression models to analyze a host of covariates, including sex, race, education, annual household income, lack of transportation, delaying care, no usual place of care, neurological disability due to stroke, self-reported health status, and comorbidity.

"In the logistic regression analysis we looked at income and found it was associated with reduced access to physician care and medications. Once we added insurance, however, those associations with physician visits were attenuated," Levine said. "Low income was associated with reduced medication access-regardless of whether insurance was adjusted for or not-in both younger and older stroke survivors," she said. This finding could be related to a lack of prescription drug coverage or competing household costs; however, Levine and her team were unable to directly evaluate those factors in this study.

LACK OF ACCESS
Equally sobering are data from the second study performed by Levine and colleagues, which was reported at the recent annual International Stroke Conference that took place in San Francisco in early February. This study showed that the younger segment of the stroke-survivor population is unable to access medication after the first stroke.³ In this study, Levine and colleagues evaluated regional differences and temporal trends in medication access for US stroke survivors from 1997 to 2004.

"This study paints an alarming picture that medication access has dramatically worsened over the 8-year period," Levine said. "From 1997 to 2004, the number of persons unable to afford medications increased significantly from 8.1% to 12.7% overall," she said.

As in the other study, Levine used data from the NHIS on 6000 white and African American stroke survivors who were aged 45 or older. "We examined inability to afford medications within the past 12 months across the 4 [US] census regions: Northeast, Midwest, West, and South and across time," Levine said.

The results show that in 2004, approximately 76,000 US stroke survivors were unable to afford medications, and lower medication affordability was reported among stroke survivors who were younger (aged < 65 years), African American, and female, and those who had high comorbidity or low health status.

Compared with stroke survivors who were able to afford medications, those who were unable to afford medications also reported other barriers to care more frequently, including lack of transportation (15% vs 3%), health insurance (16% vs 3%), or usual place of care (6% vs 2%); income less than $20,000 per annum (66% vs 40%); and out-of-pocket medical expenses in excess of $2000 (35% vs 25%).

"Basically-once again-there are vulnerable stroke survivor populations that have either reduced access to physician care, to medications, or to both. These people may have inadequate secondary stroke prevention and face an increased risk of other cardiovascular events," Levine said.

COSTS AND IMPLICATIONS
Given that stroke survivors who cannot access care are at greater risk for a secondary event, it would seem logical that not providing access to Medicare insurance might incur greater costs over the longer term. "Previous data have shown that secondary strokes are more costly and more disabling than the initial events," Levine said. Indeed, data from an epidemiological study of recurrent cerebral infarction by Samsa and colleagues⁶ reported that "during months 4 to 24 after stroke, total costs were higher among those with recurrent stroke by approximately $375 per month across all patients, with the difference being greatest for younger patients and least for patients aged 80 years or older." These higher monthly costs resulted from long-term nursing home stays and rehospitalizations. Similarly, survival was noticeably reduced among persons experiencing recurrent stroke: 48.3% versus 56.7% for first stroke survivors at 24 months after initial stroke.

Using multivariate analyses, Samsa and colleagues found a "dose response in that patients with a history of more than 1 previous stroke had [on average] poorer outcomes than patients with a history of exactly 1 previous stroke, who, in turn, had [on average] poorer outcomes than patients with a first stroke." The researchers used data from the Medicare claims database of patients aged 65 or older who were admitted with a primary diagnosis of stroke in 1991. They also used 4-year historical data to differentiate persons who had a first stroke from those who had recurrent stroke.

The implications for public health policy are obviously wide-ranging. "In the United States, secondary stroke prevention primarily is the domain of the primary care physician or primary care providers, although specialist care is important. Access to physician care and medications is essential for optimal secondary stroke prevention," Levine said.

QUALIFYING FOR MEDICARE BENEFITS
For persons younger than 65 years to receive Medicare insurance, certain criteria must be met. "There are some conditions that allow for immediate access to Medicare insurance, such as renal disease, where the person requires dialysis," Levine explained. "That said, if someone has a stroke and is uninsured, he or she can only qualify for Medicare insurance if he receives Social Security or Railroad Retirement Board disability benefits for 2 or more years. Many clinicians falsely believe that when someone has a stroke and lacks health insurance he receives automatic health insurance," she said. "That is actually not the case-that person won't receive health insurance for 2 years and will have to meet certain criteria for disability that have become stricter," she said.

Levine stresses the importance of alerting clinicians to this situation. "One issue is to inform clinicians and policy makers that stroke survivors do lack health insurance. That, in and of itself, is an important issue in thinking about secondary prevention strategies for these vulnerable patients who are at increased risk for recurrent cardiovascular and stroke events," Levine said. She also advocates that uninsured stroke survivors should receive immediate Medicare health insurance with affordable prescription drug coverage and reasonable out-of-pocket copayments so that they have adequate access to physician care and medications.

"Clinicians in general need to incorporate medication access into their decision making regarding secondary stroke prevention therapies and choose appropriately affordable therapeutic modalities," she said. "There are generic medications that can be used in place of trade drugs that are much less costly and as effective," she said.

Levine pointed out that it is equally important to raise awareness within stroke advocacy organizations such as the American Stroke Association. That said, she believes that more evidence will be needed before significant health policy reforms are made.

WHAT IS NEEDED TO AFFECT CHANGE
In an effort to better influence public health policy, Levine plans to conduct additional studies to investigate a possible link between adverse health outcomes and reduced access to care and medications. "To affect policy and create change, myself or others would have to show that stroke survivors with reduced access to physician care and medications have increased health care utilization and increased cardiovascular events compared with stroke survivors who have appropriate access," she said.

Consequently, Levine is planning studies that will use the Medical Expenditure Panel Survey-a subset of the NHIS. In that survey, more than 2 years of health care utilization data, including prescriptions, physicians' visits, emergency department visits, and hospitalizations, are collected for each respondent.

"If the argument could be made or evidence found to show that stroke survivors with reduced access have increased health care utilization, a cost analysis could be done to show that providing uninsured stroke survivors with immediate Medicare insurance-which now includes some prescription drug coverage-would be cheaper and of greater benefit to the population as a whole, than allowing these people to wait for years before being able to access these things. Perhaps then policy would change," she said.

References:

REFERENCES1. American Heart Association. Heart Disease and Stroke Statistics: 2005 Update. Dallas: American Heart Association; 2005.
2. Levine DA, Kiefe CI, Houston TK, et al. Younger stroke survivors have reduced access to physician care and medications: National Health Interview Survey from years 1998 to 2002. Arch Neurol. 2007;64:37-42.
3. Levine DA, Kiefe CI, Howard G, et al. Reduced medication access. A marker for vulnerability in US stroke survivors. Stroke. 2007;38:479.
4. Kapral MK, Wang H, Mamdani M, Tu JV. Effect of socioeconomic status on treatment and mortality after stroke. Stroke. 2002;33:268-273.
5. Redfern J, McKevitt C, Rudd AG, Wolfe CD. Health care follow-up after stroke: opportunities for secondary prevention. Fam Pract. 2002;19:378-382.
6. Samsa GP, Bian J, Lipscombe J, Matchar DB. Epidemiology of recurrent cerebral infarction: a Medicare claims-based comparison of first and recurrent strokes on 2-year survival and costs. Stroke. 1999;30:338-349.