Study finds that uninsured Hispanic people are less likely to be referred to care after stroke

Insurance coverage, ethnicity and location may all play a role in a person's ability to receive care after a stroke, according to a study published in the July 17, 2024, online issue of Neurology Clinical Practice.

"Receiving the right care after a stroke is crucial to recovery and minimizing disability," said study author Shumei Man, MD, Ph.D., of the Cleveland Clinic in Ohio and a member of the American Academy of Neurology. "Unfortunately, decisions about care may be influenced by factors such as race, insurance, and geographic location. Our study found a distinct pattern of disparities in care after stroke in the U.S. for uninsured people, especially for uninsured Hispanic people, who had the lowest chance of receiving additional care after a stroke."

For the study, researchers looked at 1.1 million people who had a stroke. Of the total, over one million hospital admissions were due to ischemic stroke. Race/ethnicity for people with ischemic stroke was 67% white, 18% Black, 9.5% Hispanic, 3% Asian-American/Pacific Islander and 0.4% Native American.

Outcomes after hospitalization were: discharged to a facility, such as a rehabilitation facility or nursing home; discharged to home with home health care; or discharged to home with no services.

Overall, 3% of people died in the hospital after ischemic stroke, 36% were discharged to a facility, 15% to home health care, 43% to home with no services and 1% left the hospital against medical advice.

Researchers then looked at race, ethnicity and insurance, comparing each racial and ethnic group within each insurance coverage level. They also looked at geographic regions.

Researchers found that 49% of Hispanic people were discharged to home without home health care, compared to 42% of white people. They also found that only 29% of Hispanic people were discharged to a rehabilitation facility or skilled nursing facility, compared to 37% of both white and Black people.

Researchers found disparities in service access were affected by insurance status even after adjusting for other factors that could affect care, such as age, the severity of stroke, and other health conditions.

Compared with people with private insurance, people with no insurance were 56% less likely to be discharged to a health care facility over home and 21% less likely to be discharged to home health care services over home with no service.

Among those with Medicare or Medicaid insurance, Hispanic people were 20% less likely to be discharged to a facility over home than white people with the same insurance.

Among those who were uninsured, Hispanic people were 26% less likely to receive home health care than white people. These disparities were not seen among people with private insurance or Black people. Man said, "In fact, compared with white people, Black people were 33% more likely to be discharged to a rehabilitation facility over home, and 42% more likely to be discharged to home health care over home without service."

When looking at geographic regions, researchers found that hospitals in the New England area were the most likely to discharge a person with a stroke to a facility over home discharge, as well as home health care over home with no health care. A person with stroke would be twice as likely to be discharged to a facility over home if they were hospitalized in New England versus the Pacific region—which includes Alaska, Washington, Oregon, California, and Hawaii—which had the lowest odds of referring people to a facility.

"These findings indicate that targeted efforts are needed to improve access to care after stroke for people without insurance, especially Hispanic people, as well as those in specific regions to ensure optimal recovery and successful community transition for all people across the country," Man said.

A limitation of the study was that for discharge to a facility, the study was unable to separate rehabilitation facilities from skilled nursing facilities. Another limitation was that not all social factors that could affect a person's access to care were considered, including the presence of other caregivers at home or whether they were married or had a partner.