ORIGINAL ARTICLE Black-White Differences in Patient Characteristics, Treatments, and Outcomes in Inpatient Stroke Rehabilitation Susan D. Horn, PhD, Daniel Deutscher, MSc, PT, Randall J. Smout, MS, Gerben DeJong, PhD, Koen Putman, PT, PhD ABSTRACT. Horn SD, Deutscher D, Smout RJ, DeJong G, Putman K. Black-white differences in patient characteristics, treatments, and outcomes in inpatient stroke rehabilitation. Arch Phys Med Rehabil 2010;91:1712-21. Objective: To describe racial differences in patient charac- teristics, nontherapy ancillaries, physical therapy (PT), occu- pational therapy (OT), and functional outcomes at discharge in stroke rehabilitation. Design: Multicenter prospective observational cohort study of poststroke rehabilitation. Setting: Six U.S. inpatient rehabilitation facilities. Participants: Black and white patients (n=732), subdivided in case-mix subgroups (CMGs): CMGs 104 to 107 for moder- ate strokes (n=397), and CMGs 108 to 114 for severe strokes (n= 335). Interventions: Not applicable. Main Outcome Measure: FIM. Results: Significant black-white differences in multiple pa- tient characteristics and intensity of rehabilitation care were identified. White subjects took longer from stroke onset to rehabilitation admission and were more ambulatory prior to stroke. Black subjects had more diabetes. For patients with moderate stroke, black subjects were younger, were more likely to be women, and had more hypertension and obesity with body mass index greater than or equal to 30. For patients with severe stroke, black subjects were less sick and had higher admission FIM scores. White subjects received more minutes a day of OT, although black subjects had significantly longer median PT and OT session duration. No black-white differ- ences in unadjusted stroke rehabilitation outcomes were found. Conclusions: Reasons for differences in rehabilitation care between black and white subjects should be investigated to understand clinicians’ choice of treatments by race. However, we did not find black-white differences in unadjusted stroke rehabilitation outcomes. Key Words: African Americans; European continental an- cestry group; Occupational therapy; Physical therapy modali- ties; Rehabilitation; Rehabilitation centers; Stroke. © 2010 by the American Congress of Rehabilitation Medicine R ACIAL AND ETHNIC disparities in health care in the United States have been a major focus of biomedical and health services research in recent years, and with good reason. Evidence over several decades has found that black subjects in particular and ethnic minorities in general have disparities across numerous health conditions in severity of disease and quality of care. Black subjects compared with white subjects are more likely to be in poor health, less likely to receive a range of services and procedures, and more likely to receive discriminatory treatment in care settings. Disparities in care frequently are associated with subsequent outcomes. 1-5 We make a distinction between differences and disparities among black and white subjects in patient characteristics, pro- vision of care, and outcomes. Thus, we use the term “differ- ence” to describe variations in patient characteristics or provi- sion of care not necessarily associated with difference in quality of care or in outcomes, and the term “disparity” to describe differences in health status at intake and in quality of care or outcomes favoring black or white subjects. Disparities in Stroke Rehabilitation and Outcomes Despite unambiguous evidence for racial disparities in se- verity of diseases, evidence for racial disparities between black and white subjects in rehabilitation use and outcomes has been both limited and contradictory. 5,6 A recent study suggested that racial/ethnic differences may exist in use of poststroke reha- bilitation services, 7 while others found no consistent racial disparities in rehabilitation care. 8,9 In a prospective study of over 800 elders in California, race appeared as the most sig- nificant single predictor of PT and OT use. Being white was the most significant predictor of rehabilitation use (odds ratio= 4.25) with clear findings: “Minority groups, less-well educated individuals, and the oldest old were significantly less likely to have PT or OT services, even when disability and rehabilitation diagnosis were controlled for.” 10 Evidence for racial disparities in rehabilitation outcomes also is mixed. Some recent reports suggest racial disparities exist in postacute care outcomes for persons with stroke, 11,12 with inconclusive findings reported by others. 9,13 Challenges to Understanding Racial Disparities in Rehabilitation As stroke mortality declines, duration of survival increases, and costs of long-term care increase, we need more high- quality evidence about potential racial disparities in stroke rehabilitation processes and outcomes. Three challenges to understanding racial disparities in rehabilitation treatments and From the Institute for Clinical Outcomes Research, International Severity Infor- mation Systems, Salt Lake City, UT (Horn, Smout); Physical Therapy Department, Maccabi Healthcare Services—Health Maintenance Organization, Tel-Aviv, Israel (Deutscher); Center for Post-acute Studies, National Rehabilitation Hospital, Wash- ington, DC (DeJong, Putman); Department of Medical Sociology and Health Sci- ences, Vrije Universiteit Brussel, Brussels, Belgium (Putman). Supported by the National Institute for Disability and Rehabilitation Research, Department of Education (grant no. H133G050153). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organi- zation with which the authors are associated. Reprint requests to Susan D. Horn, PhD, ISIS, Inc, 699 E South Temple, Ste 300, Salt Lake City, UT 84102, e-mail: shorn@isisicor.com. 0003-9993/10/9111-00338$36.00/0 doi:10.1016/j.apmr.2010.04.013 List of Abbreviations CSI Comprehensive Severity Index OT occupational therapy PSROP Post-Stroke Rehabilitation Outcomes Project PT physical therapy 1712 Arch Phys Med Rehabil Vol 91, November 2010