Stroke remains the third leading cause of death among Americans and the leading cause of nursing home placement. Unfortunately, two-thirds (67 percent) of stroke survivors in nursing homes do not receive anticoagulant or antiplatelet drug therapy to prevent further strokes, according to the findings of a recent study that was supported in part by the Agency for Healthcare Research and Quality (HS11256).
Those over 85 years of age were 14 percent less likely to be treated than those 65 to 74 years of age (odds ratio, OR 0.86). Black residents were 20 percent less likely to be treated than whites (OR 0.80), even though blacks have a greater risk of stroke. Residents with severe cognitive or physical impairment were about one-third less likely (OR 0.63 and 0.69, respectively) to receive treatment than those without impairments.
Patient contraindications to blood-thinning drugs, such as gastrointestinal bleeding and peptic ulcer disease, contributed to physicians' decisions not to treat them. However, they did not fully account for the large gap between recommended and observed levels of treatment, note Brown University researchers, Brian J. Quilliam, Ph.D., and Kate L. Lapane, Ph.D. Using the SAGE (Systematic Assessment of Geriatric drug use via Epidemiology) database, they obtained information on all residents diagnosed with stroke from 1992 to 1995 at Medicare/Medicaid-certified nursing homes in five States. They used logistic regression modeling to identify independent predictors of stroke prevention drug treatment, including aspirin, dipyridamole, ticlopidine, and warfarin alone or in combination with another drug.
Among those treated, most received aspirin alone (16 percent) or warfarin alone (10 percent). The prevalence of atrial fibrillation, which markedly elevates stroke risk, increased with age in these patients, but the use of warfarin decreased with advancing age. Perhaps doctors fear the increased risk of bleeding from warfarin among the elderly or feel they cannot adequately monitor high-risk patients, note the researchers. They suggest that pharmacist-run anticoagulant clinics might alleviate some of these concerns.
In conclusion, Drs. Quilliam and Lapane draw attention to their findings which indicate differential treatment along racial/ethnic lines. Because they did not have any information on educational level, income, or occupation, it was not possible for them to evaluate the effect of race/ethnicity within the context of socioeconomic position. They note that they are unaware of any physiological reasons justifying such differential treatment and voice concern about the underlying reasons for the disparities. The researchers call for further research to explore the effect of race/ethnicity within a social context on the decision to treat or not treat elderly stroke survivors.
See "Clinical correlates and drug treatment of residents with stroke in long-term care," by Drs. Quilliam and Lapane, in the June 2001 Stroke 32, pp. 1385-1393.