Factors associated with the initiation and discontinuation of secondary stroke prevention agents in nursing homes.
OBJECTIVE
Little is known about factors relating to initiation and discontinuation of antiplatelet and anticoagulant therapies among stroke survivors in nursing homes.


METHODS
In 6 states from 1992 to 1996, we followed up stroke survivors admitted to nursing homes for at least 6 months; 9547 were not receiving any secondary stroke prevention treatment at admission, whereas 6244 were receiving therapy. Factors relating to initiation and discontinuation of drug therapy included resident factors (e.g., sociodemographics, clinical factors) and facility factors (e.g., for profit, part of a chain). Generalized estimating equations provided estimates of residents and facility characteristics adjusting for the clustering effects owing to the correlation of residents living within the same home.


RESULTS
In all, 12% initiated drug therapy; 30.3% discontinued. Conditions known to increase the risk of recurrent stroke (e.g., atrial fibrillation) were predictive of initiation. Black residents (odds ratio [OR] 0.62, 95% confidence interval [CI] 0.49-0.78) were less likely than non-Hispanic white residents to initiate therapy. American Indian (OR 1.16, 95% CI 0.80-1.68), black (OR 1.23, 95% CI 1.03-1.47), and Hispanic residents (OR 1.30, 95% CI 0.79-2.13) tended to be more likely than non-Hispanic white residents to discontinue therapy, with facility characteristics completely explaining the observed associations.


CONCLUSIONS
In nursing homes, interventions to improve drug management of recurrent stroke are needed and implementation should occur without regard to a patient's skin color. Intervention studies may have little success in the nursing home setting if the context in which the care is given and financial/structural difficulties are not addressed in the implementation of such interventions.
Hughes
Carmel M
CM
School of Pharmacy, The Queen's University of Belfast, Belfast, Northern Ireland.
Lapane
Kate L
KL