Xi, Romi

Background: It is known that there are discrepancies between insurance status and access to care for a variety of health conditions. In addition, differences have been shown in initial in-hospital management of stroke as well as outcomes in the acute setting. We sought to examine the relationship between insurance status and risk of recurrent stroke, major bleeding or death following an incident cryptogenic stroke. Methods: Patients with cryptogenic stroke included in a multicenter (n=27 sites) retrospective observational cohort and complete insurance status were evaluated for a primary composite outcome of recurrent stroke, major bleeding, or death. Insurance providers were categorized by Private/Veterans Administration, Medicare, Other, and Medicaid/pending/None, with the primary carrier ranked in that order when multiple insurance carriers applied. Descriptive statistics and an adjusted Cox proportional hazards regression were used to associate the primary insurance provider with the composite outcome, and with each unique secondary outcome, adjusting for age, stroke severity, pre-stroke disability, atherosclerotic risk factors, and potential embolic sources (e.g., patent foramen ovale). Results: Of the 2201 patients, 2006 (91.1%) had reported insurance information and were followed for a median of 1.50 years (interquartile range [IQR 0.41 - 2.99y]). The majority of patients were primary Medicare beneficiaries (42.3%), followed by private insurance (36.7%), Medicaid/none (18.1%) and Other (2.9%). Although there were important differences in demographic and neurodiagnostic results across insurance groups, compared to Private/VA beneficiaries, beneficiaries for Medicaid/pending/none had a higher rate of the composite outcome in adjusted regression (adjusted hazard ratio [HR] 1.35, 95% confidence interval [CI], 1.07-1.69) which was driven largely by the higher rate of recurrent stroke (adjusted HR 1.33, 95%CI, 1.02-1.73) with no significant difference in rate of major bleeding or death (p>0.05 for both). Conclusions: Independent of age, race, pre-existing disability, and atherosclerotic risk factors, insurance status was independently predictive of recurrent stroke in this diverse cohort of cryptogenic stroke.

AbstractBackgroundScreening for cognitive impairment is required at Medicare Annual Wellness Visits (AWV). Subjective or objective methods are suggested, but there is no one screening tool specified by Centers for Medicare and Medicaid Services (CMS). We assessed screening methods, its outcomes, and potential disparities in cognitive screening at AWV.MethodRetrospective chart reviews were done for 1,493 adults 55+ who had initial AWV at a single academic medical center ambulatory site between January 2011 and March 2017. Demographics, assessment type, and positive screens noted by provider were collected. Subjective assessments were by history/direct observation alone. Objective assessments are noted in Table 1. Multiple logistic regression with stepwise variable selection via AIC were done.ResultsMean age was 73.6 years (SD=7.9); 828 (55.5%) were female; 1191 (79.8%) were white (Table 2). 1,311 were screened for cognitive impairment, 120 were not screened, and 62 had an established diagnosis. Of those screened, 87.5% were screened using objective methods; greater age (p<0.001), African American race as compared to white race (p<0.001), and non‐English primary language (p=0.03) were associated with increased probability of positive screens. In subjective screening (n=163), speaking a non‐English primary language was associated with higher probability of positive screening (p = 0.04). In patients with positive screens through any method, 41 had no further cognitive assessment planned, 19 had plans for follow‐up, 15 were referred to neurology.ConclusionAWV are an opportunity to screen for underdiagnosed cognitive impairment. Clinicians in our study used a myriad of tests, despite each test’s unique limitations. Greater age, African American race, non‐English primary language being associated with increased probability of positive objective screening is consistent with the literature. In subjective screenings, patients with non‐English primary language were more likely to screen positive, suggesting that in AWV, non‐English speaking patients may be at a disadvantage for standard cognitive screening. Despite positive cognitive screening, the majority had no further cognitive assessment planned during the visit. Our study suggests that more research should focus on a standardized cognitive screening and decision making after a positive cognitive screening at AWV.