Original article| Volume 91, ISSUE 11, P1722-1730, November 2010

Black-White Disparities in Motor Function Outcomes Taking Into Account Patient Characteristics, Nontherapy Ancillaries, Therapy Activities, and Therapy Interventions


      Deutscher D, Horn SD, Smout RJ, DeJong G, Putman K. Black-white disparities in motor function outcomes taking into account patient characteristics, nontherapy ancillaries, therapy activities, and therapy interventions.


      To assess black-white differences in functional outcomes, controlling for patient characteristics, use of nontherapy ancillaries (NTAs), and use of physical (PT) and occupational therapy (OT) activities and interventions.


      Multicenter prospective observational cohort study of poststroke rehabilitation.


      Six U.S. inpatient rehabilitation facilities.


      Patients (N=732) subdivided into case-mix subgroups (CMGs; CMGs 104–107 for moderate strokes [n=397], CMGs 108–114 for severe strokes [n=335]).


      Not applicable.

      Main Outcome Measure

      Discharge Motor FIM.


      Taking into account patient characteristics, NTAs, and therapy activities, multivariate regressions explained (R2) 54% and 69% of variation in outcomes between patients with moderate and severe stroke, respectively. Black race was associated with lower outcomes than white race in the severe group. However, race was no longer associated with outcomes after including interventions used within PT and OT activities. Including interventions within therapy activities increased R2 to 64% and 74% for moderate and severe strokes, respectively. Some PT and OT activities were provided more to blacks than whites and vice versa. Greater intensity sometimes was associated with better and sometimes with poorer functional outcomes.


      After controlling for interventions within activities, no racial differences were found in functional outcomes at discharge despite racial differences in rehabilitation care, possibly because each racial group received a mixture of interventions that were negatively and positively associated with outcome. Clinicians should provide therapies associated with better outcomes with high and similar intensities for black and white patients poststroke.

      Key Words

      List of Abbreviations:

      CMG (case-mix group), NTA (nontherapy ancillary), OT (occupational therapy), PSROP (Post-Stroke Rehabilitation Outcomes Project), PT (physical therapy)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Rosamond W.
        • Flegal K.
        • Furie K.
        • et al.
        Heart disease and stroke statistics—2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.
        Circulation. 2008; 117: e25-e146
        • Lloyd-Jones D.
        • Adams R.
        • Carnethon M.
        • et al.
        Heart disease and stroke statistics—2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.
        Circulation. 2009; 119: e21-e181
        • Brown D.L.
        • Boden-Albala B.
        • Langa K.M.
        • et al.
        Projected costs of ischemic stroke in the United States.
        Neurology. 2006; 67: 1390-1395
        • Bays C.L.
        Quality of life of stroke survivors: a research synthesis.
        J Neurosci Nurs. 2001; 33: 310-316
        • de Haan R.J.
        • Limburg M.
        • Van der Meulen J.H.
        • Jacobs H.M.
        • Aaronson N.K.
        Quality of life after stroke.
        Stroke. 1995; 26: 402-408
        • Nichols-Larsen D.S.
        • Clark P.C.
        • Zeringue A.
        • Greenspan A.
        • Blanton S.
        Factors influencing stroke survivors' quality of life during subacute recovery.
        Stroke. 2005; 36: 1480-1484
        • Sneeuw K.C.
        • Aaronson N.K.
        • de Haan R.J.
        • Limburg M.
        Assessing quality of life after stroke.
        Stroke. 1997; 28: 1541-1549
        • Xie J.
        • Wu E.Q.
        • Zheng Z.J.
        • et al.
        Impact of stroke on health-related quality of life in the noninstitutionalized population in the United States.
        Stroke. 2006; 37: 2567-2572
        • Horner R.D.
        • Matchar D.B.
        • Divine G.W.
        • Feussner J.R.
        Racial variations in ischemic stroke-related physical and functional impairments.
        Stroke. 1991; 22: 1497-1501
        • Shen J.J.
        • Washington E.L.
        • Aponte-Soto L.
        Racial disparities in the pathogenesis and outcomes for patients with ischemic stroke.
        Manag Care Interface. 2004; 17: 28-34
        • Sands L.P.
        • Landefeld C.S.
        • Ayers S.M.
        • et al.
        Disparities between black and white patients in functional improvement after hospitalization for an acute illness.
        J Am Geriatr Soc. 2005; 53: 1811-1816
        • Ellis C.
        • Breland H.L.
        • Egede L.E.
        Racial/ethnic differences in utilization of post-stroke rehabilitation services: a systematic review.
        Ethn Dis. 2008; 18: 365-372
        • Ellis C.
        • Egede L.E.
        Racial/ethnic differences in poststroke rehabilitation utilization in the USA.
        Expert Rev Cardiovasc Ther. 2009; 7: 405-410
        • Cook C.
        • Stickley L.
        • Ramey K.
        • Knotts V.J.
        Variables associated with occupational and physical therapy stroke rehabilitation utilization and outcomes.
        J Allied Health. 2005; 34: 3-10
      1. Weech-Maldonado R. Raciel-ethnic differences in nursing home rehabilitation care. Presented at the 6th Annual Medicaid Policy and Research Conference; State Health Care Innovation: Cost Quality and Access, September 11-12, 2008, Tallahassee-Leon Civic Center, Tallahassee, Florida; 2007.

        • Horn D.
        • Deutscher D.
        • Smout R.J.
        • DeJong G.
        • Putman K.
        Black-white differences in patient characteristics, treatments, and outcomes in inpatient stroke rehabilitation.
        Arch Phys Med Rehabil. 2010; 91: 1712-1721
        • Adler N.E.
        • Rehkopf D.H.U.S.
        disparities in health: descriptions, causes, and mechanisms.
        Annu Rev Public Health. 2008; 29: 235-252
        • Gornick M.E.
        • Eggers P.W.
        • Reilly T.W.
        • et al.
        Effects of race and income on mortality and use of services among Medicare beneficiaries.
        N Engl J Med. 1996; 335: 791-799
        • Oddone E.Z.
        • Petersen L.A.
        • Weinberger M.
        • Freedman J.
        • Kressin N.R.
        Contribution of the Veterans Health Administration in understanding racial disparities in access and utilization of health care: a spirit of inquiry.
        Med Care. 2002; 40: I3-I13
        • Schneider E.C.
        • Zaslavsky A.M.
        • Epstein A.M.
        Racial disparities in the quality of care for enrollees in Medicare managed care.
        JAMA. 2002; 287: 1288-1294
        • Smedley B.D.
        • Stith A.Y.
        • Nelson A.R.
        • Institute of Medicine (U.S.) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care
        Unequal treatment: confronting racial and ethnic disparities in health care.
        National Academy Pr, Washington (DC)2003
        • Bhandari V.K.
        • Kushel M.
        • Price L.
        • Schillinger D.
        Racial disparities in outcomes of inpatient stroke rehabilitation.
        Arch Phys Med Rehabil. 2005; 86: 2081-2086
        • Goldstein L.B.
        • Matchar D.B.
        • Hoff-Lindquist J.
        • Samsa G.P.
        • Horner R.D.
        Veterans Administration Acute Stroke (VASt) Study: lack of race/ethnic-based differences in utilization of stroke-related procedures or services.
        Stroke. 2003; 34: 999-1004
        • Mayer-Oakes S.A.
        • Hoenig H.
        • Atchison K.A.
        • Lubben J.E.
        • De Jong F.
        • Schweitzer S.O.
        Patient-related predictors of rehabilitation use for community-dwelling older Americans.
        J Am Geriatr Soc. 1992; 40: 336-342
        • Ottenbacher K.J.
        • Campbell J.
        • Kuo Y.F.
        • Deutsch A.
        • Ostir G.V.
        • Granger C.V.
        Racial and ethnic differences in postacute rehabilitation outcomes after stroke in the United States.
        Stroke. 2008; 39: 1514-1519
        • Ross J.S.
        • Halm E.A.
        • Bravata D.M.
        Use of stroke secondary prevention services: are there disparities in care?.
        Stroke. 2009; 40: 1811-1819
        • Stansbury J.P.
        • Jia H.
        • Williams L.S.
        • Vogel W.B.
        • Duncan P.W.
        Ethnic disparities in stroke: epidemiology, acute care, and postacute outcomes.
        Stroke. 2005; 36: 374-386
        • De Wit L.
        • Kamsteegt H.
        • Yadav B.
        • Verheyden G.
        • Feys H.
        • De Weerdt W.
        Defining the content of individual physiotherapy and occupational therapy sessions for stroke patients in an inpatient rehabilitation setting.
        Clin Rehabil. 2007; 21: 450-459
        • Pomeroy V.M.
        • Cooke E.
        • Hamilton S.
        • Whittet A.
        • Tallis R.C.
        Development of a schedule of current physiotherapy treatment used to improve movement control and functional use of the lower limb after stroke: a precursor to a clinical trial.
        Neurorehabil Neural Repair. 2005; 19: 350-359
        • Tyson S.F.
        • Selley A.
        The development of the Stroke Physiotherapy Intervention Recording Tool (SPIRIT).
        Disabil Rehabil. 2004; 26: 1184-1188
        • Wade D.T.
        Barriers to rehabilitation research, and overcoming them.
        Clin Rehabil. 2003; 17: 1-4
        • Wittwer J.E.
        • Goldie P.A.
        • Matyas T.A.
        • Galea M.P.
        Quantification of physiotherapy treatment time in stroke rehabilitation—criterion-related validity.
        Aust J Physiother. 2000; 46: 291-298
        • Gassaway J.
        • Horn S.D.
        • DeJong G.
        • Smout R.J.
        • Clark C.
        • James R.
        Applying the clinical practice improvement approach to stroke rehabilitation: methods used and baseline results.
        Arch Phys Med Rehabil. 2005; 86: S16-S33
        • Horn S.D.
        • DeJong G.
        • Smout R.J.
        • Gassaway J.
        • James R.
        • Conroy B.
        Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better?.
        Arch Phys Med Rehabil. 2005; 86: S101-S114
        • Centers for Medicare & Medicaid Services
        Medicare program; prospective payment system for inpatient rehabilitation facilities; final rule.
        Fed Regist. 2001; 68: 45704
        • DeJong G.
        • Horn S.D.
        • Smout R.J.
        • Ryser D.K.
        The early impact of the inpatient rehabilitation facility prospective payment system on stroke rehabilitation case mix, practice patterns, and outcomes.
        Arch Phys Med Rehabil. 2005; 86: S93-S100
        • Horn S.D.
        • Gassaway J.
        Practice-based evidence study design for comparative effectiveness research.
        Med Care. 2007; 45: S50-S57
        • Granger C.V.
        • Hamilton B.B.
        • Linacre J.M.
        • Heinemann A.W.
        • Wright B.D.
        Performance profiles of the functional independence measure.
        Am J Phys Med Rehabil. 1993; 72: 84-89
        • Keith R.A.
        • Granger C.V.
        • Hamilton B.B.
        • Sherwin F.S.
        The Functional Independence Measure: a new tool for rehabilitation.
        Adv Clin Rehabil. 1987; 1: 6-18
        • Babyak M.A.
        What you see may not be what you get: a brief, nontechnical introduction to overfitting in regression-type models.
        Psychosom Med. 2004; 66: 411-421
        • Harrell Jr, F.E.
        • Lee K.L.
        • Mark D.B.
        Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors.
        Stat Med. 1996; 15: 361-387
        • Chan L.
        • Wang H.
        • Terdiman J.
        • et al.
        Disparities in outpatient and home health service utilization following stroke: results of a 9-year cohort study in Northern California.
        PM R. 2009; 1: 997-1003
        • Sandel M.E.
        • Wang H.
        • Terdiman J.
        • et al.
        Disparities in stroke rehabilitation: results of a study in an integrated health system in northern California.
        PM R. 2009; 1: 29-40

      Linked Article