Too Few Stroke Survivors Use Outpatient Rehabilitation, 2013 and 2015

Stroke is a leading cause of death and disability in the United States. About 800,000 American adults have a stroke each year, and about 6 million stroke survivors are living in the country. Stroke rehabilitation — in the hospital, in post-acute care and in outpatient settings — lowers the risk of another stroke and improves function and quality of life. Yet despite long-standing national guidelines, rehab remains underused, especially after patients go home.

A CDC analysis in MMWR updated earlier estimates — 30.7% participation in 21 states and D.C. in 2005 — using the Behavioral Risk Factor Surveillance System, a state telephone survey. In 2013, 20 states and the District of Columbia asked stroke survivors, "Following your stroke, did you go to any kind of outpatient rehabilitation?"; four states asked in both 2013 and 2015.

What it found

• 3.3% of survey respondents had had a stroke, in both 2013 and 2015.
• In 2013, 31.2% of stroke survivors reported taking part in outpatient rehab.
• In the four states that asked in both years, participation rose significantly, reaching 35.5% in 2015 — but remained suboptimal.

Who was less likely to take part: younger adults, women, Hispanic people, non-Hispanic people of races other than Black or White, and people without a high school education. Men, non-Hispanic Black survivors and college graduates were more likely to participate.

By state, adjusted participation in 2013 ranged from 23.1% in Oregon to 43.6% in Minnesota — almost twice as high. In 2015, Maine was lowest (31.3% adjusted) and Iowa highest (49.8%). No group reached 40% participation, and no state reached 50%.

Why so low?

Rehab can be a long and complex process, involving physical, occupational, communication and cognitive therapy in inpatient rehab facilities, skilled nursing facilities and outpatient clinics. Its benefits include better function, survival, heart risk profiles and quality of life, and lower risks of another stroke and of psychological and stress disorders.

Healthy People 2020 aimed to increase the share of stroke survivors assessed and referred for rehab, and assessment and referral rates are high — about 90% during 2008–2011 — but referral isn't participation. Possible reasons for low use include:

• limited access to outpatient facilities;
• ineffective referrals from health care providers;
• high out-of-pocket costs or lack of insurance coverage;
• not knowing about the benefits of outpatient rehab.

CDC's Paul Coverdell National Acute Stroke Program works to understand the care stroke patients receive, identify disparities and improve assessment for, referral to and delivery of rehab.

What could help

• more insurance coverage for outpatient rehab and lower copayments;
• longer clinic hours;
• standardized assessments at hospital discharge to guide referrals;
• teaching survivors about community options that ease transportation and time barriers, such as telehealth, mobile health and home-based care.

Limitations

Answers were self-reported, and people may misremember which type of rehab they had. The survey didn't capture stroke severity, rehab needs or reasons for not taking part; only some states used the module, so results aren't nationally representative; small numbers of stroke survivors in some states made their estimates less certain; and only outpatient rehab was asked about.

Sources

• Ayala C, Fang J, Luncheon C, et al. "Use of Outpatient Rehabilitation Among Adult Stroke Survivors — 20 States and the District of Columbia, 2013, and Four States, 2015," MMWR Vol. 67, No. 20, CDC; a work of the United States government in the public domain. The report gives the four states' 2013 rate as 27.7% in its summary and 27.2% in its results, so the 2013 figure for those states is not stated here.