Copyright 1997 by
The Cerontological Society of America
The Cerontologist
Vol. 37, No. 4, 483-489
This study is based on data for individuals with a history of stroke taken from the NIAsponsored Longitudinal Study of Aging (LSOA), 1984-1990. It provides information on the
factors predicting survival and changes in disability and activity limitations in this cohort
with stroke or cerebrovascular accident over the period of two years, 1984 to 1986. The
results indicate that individuals who were less than 80 years old had higher chances of
survival and were likely to show reduced activity limitations and disabilities. It was also
observed that the individuals who were in excellent health were more likely to survive
despite a history of stroke. Individuals with severe activity limitations had a very low
incidence of survival over the two-year period. Further, the results of this study support
the contention that the increased use of health care resources in the form of visits to
physicians, hospitals, and nursing homes results in improved survival and lower disability
and activity limitations among the elderly.
Key Words: Longitudinal Study of Aging, Health-related quality of life, Geriatric care
Factors Predicting Survival, Changes
in Activity Limitations, and Disability
in a Geriatric Post-Stroke Population
Manoj S. Dighe, BPharm, PhD,1 Rajender R. Aparasu, BPharm, PhD,2
and Harvey M. Rappaport, PhD1
Arthritis, high blood pressure, diabetes, ischemic
heart disease, cancer, and stroke or cerebrovascular
accident are the most common chronic conditions
seen in the geriatric population (Verbrugge, Lepkowski, & Imanaka, 1989). Older people often have
several chronic conditions simultaneously (comorbidity). Stroke is one of the most prevalent chronic
conditions and is the main reason for hospitalization in people aged 65 years and above (National
Center for Health Statistics, 1992a, 1992b). Stroke
mortality has declined steadily since the 1920s, and
the United States now has one of the lowest stroke
mortality rates in the world (Bonita, Stewart, & Beaglehole, 1990). Each year approximately 500,000
Americans suffer a new or recurrent stroke. Of this
number, 350,000 will survive (American Heart Association, 1992). Although the incidence of stroke is
decreasing, its prevalence in the population appears to be increasing because of enhanced stroke
survival and a growing elderly population (American Heart Association, 1992). Nonetheless, stroke is
the third leading cause of death (Sacco, 1995).
Since the 1950s, completed strokes and severe
strokes have decreased, whereas milder strokes with
'Address correspondence to Manoj S. Dighe, BPharm, PhD, School of
Pharmacy, Division of Pharmacy Administration, Northeast Louisiana University, Monroe, LA 71209.
'South Dakota State University, School of Pharmacy, Division of Pharmacy Administration, Brook ings, SD.
Vol. 37, No. 4,1997
minimal and moderate deficits have increased (Wolf
et al., 1992). Improvements in post-stroke survival
have been reported among several populations in
the United States. Improvement in survival at 28 to 30
days after a stroke has been observed in hospitalbased studies in Minnesota (1970-1985) and in community-based stroke registries in Rochester, Minnesota (1945-1984) (Broderick, Phillips, Whisnant,
O'Fallon, & Bergstralh, 1989; McGovern et al., 1992).
May, Casper, Croft, and Giles (1994), using a nationally representative sample of Medicare beneficiaries,
showed a modest improvement in post-stroke survival from 1985 to 1989. It was further reported in this
study that the trends for improvement in patients
with hemorrhagic stroke were greater than for persons with ischemic stroke. Improvement was also
greater among persons without known prior hospitalization for stroke and during periods of follow-up
shorter than 2 years.
In studies using Medicare data sets, the absence
of information on cause of death prevents the identification of the actual cause of death among stroke
patients. However, according to published studies,
stroke is the underlying cause of death in approximately 80 to 90% of deaths that occur within one
month of a stroke (Bamford, Dennis, Sandercock,
Burn, & Warlow, 1990; Dennis et al., 1993; Howard et
al., 1989; Von Arbin, Britton, & Faire, 1992), in 70 to
80% of the deaths that occur 3 to 6 months after a
stroke (Dennis et al., 1993; Howard et al., 1989; Von
Arbin et al., 1992), and in approximately 50% of the
483
deaths that occur within several years of a stroke
(Von Arbin et al., 1992; Health Care Financing Administration, 1989).
With improved survival rates after stroke, as well as
the increasing number of elderly people and individuals with treatment disability post-stroke, identifying
those whose quality of life can be enhanced through
appropriate means becomes increasingly important
(Kelly-Hayes & Paige, 1995). Systematic assessment of
impairment and disability after stroke is valuable for
describing the impact of the event, monitoring the
recovery process, evaluating response to specific interventions, and determining long-term benefit. Although many are available, the use of assessment
measures varies, and no single measure or group of
measures is widely accepted (Kelly-Hayes & Paige,
1995). Exact estimates of disability following stroke
are difficult to obtain because patients selected for
study may be population-based or referral-based
(acute hospitals or rehabilitation facilities), outcome
measures may be inconsistent, and assessments may
have been taken at different times during the recovery period (Duncan, 1994).
A literature review of the studies evaluating quality of life in individuals who have had a stroke or a
cerebrovascular event identifies several factors associated with improvement or decline in quality of
life. In the Framingham cohort, Gresham, Phillips,
and Wolf (1979) compared stroke survivors with
age-matched controls and found that 90% of the
stroke survivors demonstrated one or more disabilities, compared with 58% of the matched controls. In
another study, using the Sickness Impact Profile,
Schuling, Greidanus, and Meyboom-de Jong, (1993)
found that stroke affected household management,
leisure activities, and mobility. Christie (1982) reported an "imperfect correlation" between residual
physical impairment and disability. In a review of 33
articles, Jongbloed (1986) identified older age and
history of prior stroke as prognosticators of poor recovery. A broader perspective is therefore needed
to understand the nature of stroke-related disablement in the population.
Johnson and Wolinsky (1994) utilized the Nagi
"functional limitations" model (1969) to examine the
differences in perceived health status across gender
and race. The results of this study, based on crosssectional data used from the Longitudinal Study of
Aging (1984-90), confirmed the construct validity of
separate dimensions of disability and functional limitation. They further recommended developing exploratory models to track the longitudinal course of
recovery or decline in health and its relationship to
the use of health services. Such research would allow
estimates of the stability of varying dimensions of
health status over time. They would also allow for estimates of lagged and time-limited effects of certain
diseases on changes in disability or functional limitations. Stroke is one such chronic disease in which the
longitudinal evaluation of the functional limitations
and disabilities can provide important information for
future medical and nursing needs in these populations. Given the high probability of patient disability
after a nonfatal stroke, studies are needed to address
the impact of improved survival on the quality of life
of stroke survivors (May et al., 1994). Studies in the
past on the assessment of changes in functional status, activity limitations, and quality of life were based
on small samples which were not nationally representative. Therefore, using a data set such as the Longitudinal Study of Aging (LSOA), which includes individuals over the age of 65 years representing all the
regions of this country, can provide significant insights into the longitudinal trends in mortality and activity limitations and disability. The purpose of this
study was therefore to identify factors predicting survival and changes in disability and activity limitations
in a large nationally representative data set.
Methods
The LSOA, a data set provided by the National
Center for Health Statistics and National Institute on
Aging for individuals over the age of 65 years, was
used for this study. The details of these data are provided by Fitti and Kovar (1987). The first objective of
this study was to identify the factors predicting survival over a two-year period in individuals who had a
stroke before the first interview of the LSOA in 1984.
The second objective of this study was based on the
recommendations of Johnson and Wolinsky to assess any changes in disability and functional limitations in those individuals who survived until the second interview of the LSOA. Individuals w h o
reported having a stroke or cerebrovascular accident before the first interview were selected for the
purpose of this study. This extraction criterion resulted in data for 372 individuals. These 372 cases
represented those stroke victims who were not lost
to follow-up or nonselection for reinterview in 1986
and were, therefore, used in the subsequent statistical analysis.
The first objective of this study aimed at assessing
the survival estimates in these stroke victims. For
the first objective, the measure of survival was obtained from the National Death Index (NDI). The
NDI provided the exact dates of death of these
LSOA participants. Based on the presence or absence of the date of death, the survival function,
"yes" or " n o " were defined. The factors predicting
survival included:
•
•
•
•
Demographic factor
Comorbid conditions factor
Health status factor, and
Health care utilization factor
The variables under each of these factors, except
the health care utilization factor, were obtained in
1984 at the time of the first interview. Health care
utilization in the form of visits to the physician, hospital, or nursing home varied by the individuals' survival time. Out of these 372 cases, 278 survived until
the second interview in 1986. Therefore, for cases
alive in 1986, the health care utilization was for both
1984 and 1986, while the health care utilization for
those who died before 1986 was only for 1984.
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The Gerontologist
The Nagi "functional limitations" model was used
to test the second objective of this study using the
data for 278 stroke victims. The model for the purpose of this study was modified in a number of important ways. These include using different terminology in some instances, deleting the impaired
physiology construct, and adding the constructs of
demographic and health care utilization information. The modified model is shown in Figure 1.
In this model, pathology or disease refers to the
disease condition for which information was obtained from the data. The disease or comorbid conditions included hypertension, coronary heart disease, angina, myocardial infarction, other heart
conditions, diabetes, arthritis, and cancer.
Demographic information refers to individual
age, sex, race, marital status, geographic location,
poverty status, and veteran status.
Health care utilization information refers to physician visits and admissions to hospitals or nursing
homes during 1984 and 1986. Information on the
use of community services such as use of a health
aid, use of a senior center, and the use of a visiting
nurse service were also obtained.
The measures of activity limitations, defined as
activities of daily living (ADLs), include difficulties in
bathing, dressing, eating, getting in and out of bed
or a chair, walking, getting outside, and toileting.
Other measures of activity limitations, defined as instrumental activities of daily living (lADLs), include
difficulties in meal preparation, shopping, managing money, using the telephone, doing heavy
housework, and doing light housework. These were
measured on a dichotomous scale in which a value
of "one" reflected a "yes" answer to having difficulty in that activity and a value of "zero" indicated
a "no" response for that activity.
The measure of disability included inabilities to
walk a quarter of a mile or walk up ten steps, being
on one's feet for 2 hours (stand), sitting for 2 hours
(sit), stooping, crouching, kneeling (stoop), lifting 25
pounds, lifting 10 pounds, and inabilities to reach
over head, reach out, and grasp objects with one's
fingers. The scores on each of these items were
summed up to give the index of disability or functional limitations (FLs).
In addition, the measures of disability and activity
limitations were summed up to provide an index of
health-related quality of life. The data on disability assessment and activity limitations were collected not
only for individuals with a history of stroke but for a
general population of elderly people, representative
of the national population. Thus, information on depression and social and psychological functioning in
these individuals is not available. The operational
definition of quality of life is therefore restricted only
to physical functioning, labeled as health-related
quality of life (physical function) or HRQOLP.
Pathology
or Disease
or Comorbid
Conditions
Factor
Disability
(Functional
Limitations or FLs)
Health
Care
Utilization
Factor
\j
/
/
/
Activity
Limitations
(ADL, & IADL)
^Health-related Quality of Life
(Physical Limitations)
HRQOLp = (FLs + ADL + IADL)
Figure 1. Modified Nagi "functional limitations" model.
across the different variables are shown in Table 1.
The table provides information for all the stroke victims in 1984 and those who survived over the twoyear period, 1984-86. As shown in the table, a majority of the victims were female, White, widowed, and
living in the southern part of the United States. Very
few individuals were veterans, although equal proportions of individuals were below and above the
National Health Interview Survey poverty threshold.
Arthritis and hypertension were the two major comorbid conditions present in these victims. About
50% of the individuals indicated an activity limitation status in 1984, while 32% indicated poor health
status. With regard to health care utilization, Table 1
provides information on the physician, hospital, and
nursing home services utilization by all the 372
cases in 1984. It is observed that very few individuals
utilized nursing home care in the 12 months before
their interview in 1984. Table 2 provides information
on the health care utilization for 1984 as well as for
1986 by the 278 stroke victims who survived until
1986.
A similar pattern was seen across physician visits,
hospitalization, and nursing home care, with no significant differences in the extent of services utilized
in either 1984 or 1986. The summary statistics for the
disability, activity limitations, and HRQOLP indices
are shown in Table 3. Each index indicates a statistically significant reduction in the number of limitations over the two-year period. We chose not to use
the weights necessary to make the estimates from
the sample representative of the United States population of people aged 70 and older. The aim of this
study was to examine the association between
stroke and survival and recovery over a two-year period (Fitti & Kovar, 1987).
Data Analysis and Results
All the data were analyzed using PC SAS version
6.04 (1989). The characteristics of the individuals
Vol. 37, No. 4, 1997
Demographic
Factor
485
Outcome Prediction
In the first analysis for the first objective, a logistic
regression model was built to predict the incidence
of survival over the study period. Out of the 372 individuals, 278 (74.73%) survived until 1986. The limited or discrete time intervals for which the survival
Table 2. Summary Table of the Health Care Utilization
Characteristics of the 278 Stroke Victims who Survived Until 1986
Table 1. Summary Table of the Characteristics of the Stroke
Victims, LSOA 1984-1986
1984
372 (100%)
Demographic Factor
Sex
Male
Female
Age
Race
Black
White
Other
Region
Northeast
North central
South
West
Veteran status
Marital status
Married
Widowed
Other
Povery status
Below poverty threshold
Above poverty threshold
Comorbid Conditions Factor
Coronary heart condition
Angina
Other heart condition
Cancer
Arthritis
Diabetes
Myocardial infarction
Hypertension
137 (36.82%)
235 (63.17)
77.67 yrs
101 (36.33%)
177 (63.67)
81.43 yrs
44 (11.83)
315 (84.68)
13 (03.50)
33 (11.87)
237 (85.25)
8 (02.88)
80
87
135
70
37
59
65
102
52
30
(21.22)
(23.38)
(36.70)
(18.71)
(10.79)
163 (43.82)
184 (49.46)
25 (06.72)
124 (44.60)
137 (49.28)
11 (03.96)
115 (30.91)
257 (69.09)
82 (29.50)
196 (70.50)
43
56
67
61
245
75
17
290
Health Status Factor
Activity limitation status in 1984
Unable to perform major
activity
99
Limited in kind/amount
103
of major activity
67
Limited in other activities
Not limited
103
Health status in 1984
20
Excellent
Very good
36
Good
83
Fair
112
Poor
121
Health Care Utilization Factor3
Physician visits in 1984
0 visits
1-2 visits
2-5 visits
Hospitalization in 1984
0 times
1-4 times
Nursing home care in 1984
0 times
At least once
Use of a health aid
Use of a senior center
Use visiting nurse service
(21.50)
(23.39)
(36.29)
(18.82)
(09.95)
(11.56)
(15.05)
(18.01)
(16.40)
(65.86)
(20.16)
(04.57)
(77.96)
28
40
45
39
186
48
9
189
(26.61)
59 (21.22)
(27.69)
(18.01)
(27.69)
75 (26.99)
59 (21.22)
85 (30.58)
(05.38)
(09.68)
(22.31)
(30.11)
(32.53)
14
29
64
89
82
(93.55)
(06.45)
(10.75)
(18.55)
(14.25)
26 (09.35)
49 (17.63)
28 (10.07)
"Health care utilization in the last 12 months before the interview. Data for victims who survived till 1986 are shown in Table 2
with the appropriate distribution in 1984 and 1986 for physician
visits, hospitalizations, and nursing home care.
155 (55.76)
123 (44.24)
177 (63.67)
101 (3633)
213 (76.62)
65 (23.38)
0 times
266 (95.68)
12 (04.31)
268 (96.40)
10 (03.60)
* Indicates that there was no significant difference in the health
care utilization between 1984 and 1986.
Table 3. Summary Statistics of the Four Indices Used To Measure
Disability, Activity Limitations, and Health-Related Quality
of Life (Physical Limitations) HRQOL, in the 278 Stroke Victims,
LSOA, 1984-86
Activities of daily living
(ADLs), (0-7)a
Instrumental activities of daily
living (lADLs), (0-6)'
Functional limitations (FLMs),
(0-10)a
Health-related quality of life
(physical limitations),
(HRQOU), (0-23)1
(05.04)
(10.43)
(23.02)
(32.01)
(29.50)
189 (50.81)
183 (49.19)
174 (62.59)
104 (37.41)
At least once
In 1986
0 times
1-5 times
(10.07)
(14.39)
(16.19)
(14.03)
(66.91)
(17.27)
(03.24)
(67.99)
10 (02.69)
259 (69.62)
103 (27.69)
348
24
40
69
53
Physician Visits*
In 1984
< 6 visits
> 6 visits
In 1986
< 2 visits
> 2 visits
Hospitalization*
In 1984
0 times
1-4 times
In 1986
0 times
1-5 times
Nursing Home Care*
In 1984
1986
278 (100%)
Mean
for
1984
Mean
for
1986
1.863
1.640
0.223
1.795
1.496
0.299
4.651
3.309
1.342
8.309
6.478
1.831'
Mean
Difference
a
The measurement for each item of all the indices was done on
a nominal scale of " 1 " if there was a limitation, and " 0 " if there
was no limitation. These scores were summed up to provide the
score for each index.
*p < .05.
data are available prevent the use of life-table analysis or a proportional hazards model, which require
multiple survival data observations for each individual (Hosmer & Lemeshow, 1994). These results of
survival, however, are not based on stroke as a
cause of death.
As shown in Table 4, individuals who were less
than 80 years of age had a higher incidence of survival following a stroke, in comparison to those
over 80 years of age. Individuals who had the highest activity limitations in performing major activities
were less likely to survive over the two-year period
than those who were not limited in any activities.
These results strongly support the literature on
486
The Gerontologist
Table 4. Summary Table of the Logistic Regression-Based Survival Analysis in the Cohort of Stroke Victims
Who Survived Over the Two-year Period, LSOA 1984-86
Coefficient
Relative Odds
of Survival
95% Confidence
Interval
P-value
1.414
4.11
(2.00-8.45)
0.0001
0.931
2.54
(1.04-6.21)
0.0413
-1.284
0.28
(0.09-0.81)
0.0197
2.278
9.76
(1.64-57.98)
0.0122
Age
(< 80 years)
Health status in 1984
Fair
Activity limitations in 1984
Severely restricted in major activities
Physician visits in 1986
2-5 visits
Table 5. Summary Regression Table for the Four Models Developed to Identify the Variables Under Each Factor
Significantly Affecting Activity Limitations and Disability in the Cohort of Stroke Victims, LSOA 1984-86
Factors
Demographic
Age < 80 years
Health status
Health status in 1984
Excellent
Comorbid conditions
Other heart condition
Health care utilization
Physician visits in 1984
Physician visits in 1986
Hospitalization in 1984
Hospitalization in 1986
Baseline disability
ADU
IADU
FLMM
HRQOLPM
Adjusted R2
Regression
Model I
(ADU
Regression
Model II
(IADU)
Regression
Model III
(FLMJ
Regression
Model IV
(HRQOU)
-0.679
-0.744
-1.351
-2.857
1.650
1.227
1.873
5.063
1.912
0.884
-0.170
1.583
-0.472
1.003
.725
0.820
-0.728
3.167
-0.612
1.744
6.483
-1.483
3.475
0.445
0.256
0.351
0.395
0.473
0.589
0.441
0.554
All variables are significant at p < .05.
stroke-related limitations and survival (Duncan,
1994). The results further indicate that those individuals who had at least a fair health status had a
higher incidence of survival than those who were in
a poor health status. Individuals who had a greater
number of visits to the physician over the last 12
months had higher odds of survival than those who
did not use any physician services. None of the comorbid conditions present in these individuals significantly affected survival.
In the second analysis, ordinary least squares or
multiple linear regression models were developed
to predict variations in functional status. Four regression models were built using the ADL, IADL, FLs
and HRQOLp indices. The results for these four regression models, shown in Table 5, indicate that individuals less than 80 years of age showed significant improvements on all the four indices of activity
limitations and disability. Similar results were observed for individuals with a reported excellent
Vol. 37, No. 4,1997
health status at the time of the first interview in
1984. Among the comorbid conditions/ individuals
with heart conditions other than coronary heart disease, angina, and myocardial infarction showed improvements on IADL and HRQOLP indices.
Further, results of this study, shown in Table 5,
strongly stress the importance of health care utilization in reducing long-term disability and activity
limitations. The results indicate that lower physician
services utilization in 1984 but higher physician services utilization in 1986 resulted in decreased limitations in the activities measured under the IADL and
FLs indices over the two-year period. Increased visits to a physician in 1986 also significantly reduced
the limitations in the activities measured under the
ADL and HRQOLp indices.
Hospital services utilization showed similar results with no use in 1984 and higher use in 1986 significantly reducing the limitations on all the indices
but ADL. However, higher hospital services utiliza-
487
tion in 1986 did reduce the limitations in the activities measured under ADL. As very few individuals
utilized nursing home services in either 1984 or
1986, the data for nursing home care were not included in the regression models. All the four regression models explained a significantly high proportion of variance based on the variables included
under each factor.
Discussion
The results of this study are consistent with what
is observed in the literature surveyed. A majority of
the individuals had arthritis and/or hypertension. In
addition, some had diabetes as a comorbid condition. However, the presence of any of these conditions did not result in mortality or decline in functional status. As is seen from the results of this
study, stroke at a lower age in this cohort of individuals may not result in mortality. In addition, it was
observed that individuals who had stroke at a lower
age were likely to survive longer and also to show
improvement in physical functional status. This may
be due to the greater use of health care services in
the form of physician visits, hospitalizations, and
nursing home care. The results of this study are limited by the absence of the exact year of occurrence
of stroke. Therefore, only the prevalence and not
the incidence of stroke for these individuals can be
ascertained. Also not ascertained was whether the
reason for death could have been due to a condition other than stroke. However, a mortality rate of
about 25% over the two-year period in these individuals is fairly low, considering that their average
age in 1986 was 81.43 years. They probably had had a
mild stroke, or sufficient time had elapsed since
they had had a stroke or a cerebrovascular accident.
Furthermore, there was no information on any of
the clinical manifestations associated with stroke
within this LSOA data set. This greatly limited the
methodological analysis of this study in the absence
of severity of illness information. There also was no
information on the costs associated with the health
care services utilized by these individuals in reducing their disability or functional status. This prevents the assessment of cost per unit of reduced
disability or functional status in this cohort. The
measurement of functional status or disability on
the measures of ADL, IADL, or functional limitations
is done on a scale of 0 to 1. This creates a "ceiling
effect" on the indices, which further reduces the
variability in the assessment of disability or functional status in these individuals.
Despite these limitations, this study has important geriatric health policy implications. The study
supports the use of the LSOA and other such national data bases to identify the factors associated
with survival and changes in disability or functional
status. The majority of the information available in
such national data bases is nonclinical, which differentiates them from the studies done using randomized trials or hospital-based studies.
Studies done using data from the Manitoba Lon-
gitudinal Study of Aging (MLSA) and Colorado
Medicare Study (CMS) identified longitudinal patterns of health care utilization by communitydwelling elderly (Mossey & Shapiro, 1985; Nelda &
Wai, 1983). Stump, Johnson, and Wolinsky (1995) reported higher utilization of health services in elderly persons with greater functional limitations.
Their results are supported in this study, which
showed reduced disabilities and improved activities
as a result of greater health care utilization in the
form of physician and hospital visits. These results
are consonant with prior analyses of both physician
and hospital resource consumption among the
LSOA respondents (Wolinsky, Culler, Callahan, &
Johnson, 1994; Stump et al., 1995), and provide further evidence to support the claim of Roos, Shapiro,
and Tate (1989) of the "small group, high usage"
phenomenon.
Health care utilization may have been the most
important reason for reducing the disability or activity limitations in these stroke victims. It is also
possible that this health care utilization activity may
apply to any of the comorbid conditions present in
these individuals, especially to the heart conditions,
which may be responsible for improvement or decline in some individuals. However, this is in contrast to support in the literature in which Ahlsio,
Britton, Murray, and Theorell (1984) reported no effect of any heart condition on health care utilization
and subsequent improvement in disability or functional status.
The results of this study are based on the measures of central tendency. Individual changes on all
the measures of disability or functional limitations
may vary across this cohort of stroke victims. It is
also difficult to identify the exact items that showed
improvements in the four indices used in this study.
While controlling for all other factors, those who
had lower scores on these summated indices had
fewer limitations and utilized a higher number of
health care services. The modified Nagi "functional
limitations" model was a good fit to these data
based on the variance explained by each of the four
models. However, a majority of the variance associated with the functional status or disability was explained by the health care utilization factor. The
index of health-related quality of life (physical disability), HRQOLp, was a valid measure to assess the
global physical limitations in these individuals. The
results on assessment of HRQOLP showed similar
findings.
Future surveys in the form of LSOA should utilize
health status assessment instruments that will provide information on psychological and social activities of the participants in addition to their physical
limitations. Although the data are for the individuals
who were stroke victims before 1984, they are the
only data which provide information on a nationally
representative sample of community-dwelling individuals over the age of 70 years. Additionally, these
are the only nationally representative data in which
individuals can be tracked for a period of seven years.
Although no major technological improvements in
488
The Gerontologist
the treatment of stroke patients have occurred, improvements in routine care (such as use of aspirin to
prevent recurrent stroke, attention to acute control of
blood pressure, emphasis on physical rehabilitation,
and admissions to nursing homes, where stroke patients may receive better care than at home) have occurred (Langhorne, Williams, Gilchrist, & Howie,
1993). The lack of routine care at the time these data
were collected may have been the reason for higher
utilization of physician services and hospitalizations.
It is also possible that the visits may have been to
avoid any further deterioration in health due to
stroke or to treat other comorbid conditions. It is important to identify if physician services and hospitalbased care can be substitutes rather than complements, as shown by the results of this study. In this
regard, the role of managed care has to be evaluated
in future studies to determine the impact of early
physician-based care on health status, on the utilization of physician services and hospitalizations, and,
ultimately, on activity limitations and disability.
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Received June 21, 1996
Accepted December 6,1996
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