{"@context":{"@language":"en","Affiliation":"http:\/\/vivoweb.org\/ontology\/core#departmentOrSchool","AggregatedSourceRepository":"http:\/\/www.europeana.eu\/schemas\/edm\/dataProvider","Citation":"https:\/\/open.library.ubc.ca\/terms#identifierCitation","Contributor":"http:\/\/purl.org\/dc\/terms\/contributor","CopyrightHolder":"https:\/\/open.library.ubc.ca\/terms#rightsCopyright","Creator":"http:\/\/purl.org\/dc\/terms\/creator","DateAvailable":"http:\/\/purl.org\/dc\/terms\/issued","DateIssued":"http:\/\/purl.org\/dc\/terms\/issued","Description":"http:\/\/purl.org\/dc\/terms\/description","DigitalResourceOriginalRecord":"http:\/\/www.europeana.eu\/schemas\/edm\/aggregatedCHO","FullText":"http:\/\/www.w3.org\/2009\/08\/skos-reference\/skos.html#note","Genre":"http:\/\/www.europeana.eu\/schemas\/edm\/hasType","IsShownAt":"http:\/\/www.europeana.eu\/schemas\/edm\/isShownAt","Language":"http:\/\/purl.org\/dc\/terms\/language","PeerReviewStatus":"https:\/\/open.library.ubc.ca\/terms#peerReviewStatus","Provider":"http:\/\/www.europeana.eu\/schemas\/edm\/provider","Publisher":"http:\/\/purl.org\/dc\/terms\/publisher","PublisherDOI":"https:\/\/open.library.ubc.ca\/terms#publisherDOI","Rights":"http:\/\/purl.org\/dc\/terms\/rights","RightsURI":"https:\/\/open.library.ubc.ca\/terms#rightsURI","ScholarlyLevel":"https:\/\/open.library.ubc.ca\/terms#scholarLevel","Subject":"http:\/\/purl.org\/dc\/terms\/subject","Title":"http:\/\/purl.org\/dc\/terms\/title","Type":"http:\/\/purl.org\/dc\/terms\/type","URI":"https:\/\/open.library.ubc.ca\/terms#identifierURI","SortDate":"http:\/\/purl.org\/dc\/terms\/date"},"Affiliation":[{"@value":"Medicine, Faculty of","@language":"en"},{"@value":"Other UBC","@language":"en"},{"@value":"Non UBC","@language":"en"},{"@value":"Physical Therapy, Department of","@language":"en"}],"AggregatedSourceRepository":[{"@value":"DSpace","@language":"en"}],"Citation":[{"@value":"BMC Health Services Research. 2019 Mar 27;19(1):192","@language":"en"}],"Contributor":[{"@value":"Vancouver Coastal Health Authority. Research Institute","@language":"en"},{"@value":"University of British Columbia. Graduate Programs in Rehabilitation Science","@language":"en"}],"CopyrightHolder":[{"@value":"The Author(s).","@language":"en"}],"Creator":[{"@value":"Obembe, Adebimpe O.","@language":"en"},{"@value":"Simpson, Lisa A.","@language":"en"},{"@value":"Sakakibara, Brodie M.","@language":"en"},{"@value":"Eng, Janice","@language":"en"}],"DateAvailable":[{"@value":"2019-03-27T20:31:10Z","@language":"en"}],"DateIssued":[{"@value":"2019-03-27","@language":"en"}],"Description":[{"@value":"Background:\r\n                More people are surviving stroke but are living with functional limitations that pose increasing demands on their families and the healthcare system. The aim of this study was to determine the extent to which stroke survivors use healthcare services on a population level compared to people without a stroke.\r\n              \r\n              \r\n                Methods:\r\n                This was a cross-sectional population-based survey that collected information related to health status, healthcare utilization and health determinants using the 2014 Canadian Community Health Survey. Healthcare utilization was assessed by a computer-assisted personal interview asking about visits to healthcare professionals in the last 12\u2009months. Negative binomial regression was used to estimate the incidence rate ratios (IRR) and 95% confidence intervals (CI) for the number of health professional visits between stroke survivors and people without a stroke. The regression models were adjusted for demographics, as well as for mobility, mood\/anxiety disorder and cardiometabolic comorbid conditions.\r\n              \r\n              \r\n                Results:\r\n                The study sample included 35,759 respondents (948 stroke, 34,811 non-stroke) and equate to 12,396,641 (286,783 stroke; 12,109,858 non-stroke) when sampling weights were applied. Stroke survivors visited their family doctor the most, and stroke was significantly associated with more visits to most healthcare professionals [e.g., family doctor IRR 1.6 (CI 1.4\u20131.8); nurse IRR 3.0 (CI 1.8\u20134.8); physiotherapist IRR 1.8 (CI 1.1\u20131.9); psychologist IRR 4.0 (CI 1.1\u20135.7)] except the dental practitioner, which was less [IRR 0.7 (CI 0.6\u20130.9)]. Mood\/anxiety condition, but not cardiometabolic comorbid condition increased the probability of visiting a family doctor or social worker\/ counsellor among people with stroke.\r\n              \r\n              \r\n                Conclusion:\r\n                Stroke survivors visited healthcare professionals more often than people without stroke, and were approximately twice as likely to visit with those who manage problems that may arise after a stroke (e.g., family doctor, nurse, psychologist, physiotherapist). The effects of a stroke include mobility impairment and mood\/ anxiety disorders. Therefore, adequate access to stroke-related healthcare services should be provided for stroke survivors, as this may improve functional outcome and reduce future healthcare costs.","@language":"en"}],"DigitalResourceOriginalRecord":[{"@value":"https:\/\/circle.library.ubc.ca\/rest\/handle\/2429\/69312?expand=metadata","@language":"en"}],"FullText":[{"@value":"RESEARCH ARTICLE Open AccessHealthcare utilization after stroke inCanada- a population based studyAdebimpe O. Obembe1,2, Lisa A. Simpson2,3, Brodie M. Sakakibara1,2 and Janice J. Eng1,2*AbstractBackground: More people are surviving stroke but are living with functional limitations that pose increasingdemands on their families and the healthcare system. The aim of this study was to determine the extent to whichstroke survivors use healthcare services on a population level compared to people without a stroke.Methods: This was a cross-sectional population-based survey that collected information related to health status,healthcare utilization and health determinants using the 2014 Canadian Community Health Survey. Healthcareutilization was assessed by a computer-assisted personal interview asking about visits to healthcare professionals inthe last 12 months. Negative binomial regression was used to estimate the incidence rate ratios (IRR) and 95%confidence intervals (CI) for the number of health professional visits between stroke survivors and people without astroke. The regression models were adjusted for demographics, as well as for mobility, mood\/anxiety disorder andcardiometabolic comorbid conditions.Results: The study sample included 35,759 respondents (948 stroke, 34,811 non-stroke) and equate to 12,396,641(286,783 stroke; 12,109,858 non-stroke) when sampling weights were applied. Stroke survivors visited their familydoctor the most, and stroke was significantly associated with more visits to most healthcare professionals [e.g.,family doctor IRR 1.6 (CI 1.4\u20131.8); nurse IRR 3.0 (CI 1.8\u20134.8); physiotherapist IRR 1.8 (CI 1.1\u20131.9); psychologist IRR 4.0(CI 1.1\u20135.7)] except the dental practitioner, which was less [IRR 0.7 (CI 0.6\u20130.9)]. Mood\/anxiety condition, but notcardiometabolic comorbid condition increased the probability of visiting a family doctor or social worker\/ counselloramong people with stroke.Conclusion: Stroke survivors visited healthcare professionals more often than people without stroke, and wereapproximately twice as likely to visit with those who manage problems that may arise after a stroke (e.g., family doctor,nurse, psychologist, physiotherapist). The effects of a stroke include mobility impairment and mood\/ anxiety disorders.Therefore, adequate access to stroke-related healthcare services should be provided for stroke survivors, as this mayimprove functional outcome and reduce future healthcare costs.Keywords: Stroke, Healthcare utilization, Health services, MobilityBackgroundStroke is a leading cause of long-term disability in adultsworldwide [1] and it can be devastating to individuals.After age 55, there is a lifetime risk of stroke of 1 in 5for women and 1 in 6 for men [2]. Stroke can result inloss of independence with immense human and financialburden, which will magnify as the world-wide incidenceof stroke and stroke survivors continue to increase [3].Donabedian [4] defined health utilization as the outcomeof the interaction between health professionals and pa-tients. Health utilization is a multidimensional processthat includes indicators such as quality of care, accessi-bility, efficiency, equity, volume, continuity, comprehen-siveness, productivity of care and healthcare expenses.[5]. Several factors (e.g. demographics, physical, psycho-logical) might influence how stroke survivors use health-care services [6\u20138]. In Canada, about 85 to 90% ofstroke survivors return to their own environment withor without support services [9, 10]. While there are\u00a9 The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http:\/\/creativecommons.org\/licenses\/by\/4.0\/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http:\/\/creativecommons.org\/publicdomain\/zero\/1.0\/) applies to the data made available in this article, unless otherwise stated.* Correspondence: janice.eng@ubc.ca1Department of Physical Therapy, The University of British Columbia,Vancouver, Canada2Rehabilitation Research Program, GF Strong Rehab Centre, VancouverCoastal Health Research Institute, Vancouver, CanadaFull list of author information is available at the end of the articleObembe et al. BMC Health Services Research          (2019) 19:192 https:\/\/doi.org\/10.1186\/s12913-019-4020-6some data that suggest that stroke survivors may utilizegreater healthcare services after their stroke [7, 8, 11,12], studies have not compared this utilization using acontrol group. Impaired functional health, higher finan-cial income, younger age, emotional distress [8],pre-stroke dependency [7], living arrangement, socialcircumstances [7] and access to a physician [6] havebeen associated with the use of healthcare services afterstroke. Stroke survivors living at home have reportedunmet needs in several domains, including mobility,mood, communication, health provision after dischargeand managing stroke-related problems [13, 14]. Thesefactors could plausibly affect healthcare utilization afterstroke but their association has never been established.Two-thirds of patients with a first stroke survive after3 years, and the risk of surviving is lowest in the firstyear [15]. Pre-existing medical conditions, especially car-diometabolic conditions, are common among stroke pa-tients, and can affect functional outcome [16]. Providingcare for stroke survivors can be complex, requiring acontinuum of coordinated health and support serviceswhich may include physicians and other allied healthteam members [17], although the utilization of thesehealthcare services has never been reported in a nation-ally representative population-based study of stroke sur-vivors living in the community. It is widely recognizedthat healthcare systems lack continuity across servicesand are often criticized for shortening hospitallength-of-stay and offering limited community services[18]. Therefore, the purpose of this study was to deter-mine the effect of having a stroke on the annual visit ratesto healthcare professionals using a population-based sam-ple of community-dwelling adults in Canada. Given themultiple physical and cognitive impairments common instroke, in addition to numerous pre-existingco-morbidities, we hypothesized that stroke survivorswould utilize greater healthcare services compared topeople without stroke.MethodsData sourceData were from the 2014 Canadian Community HealthSurvey\u2013 Annual Component (CCHS), a cross-sectionalsurvey that collected information related to health sta-tus, healthcare utilization and health determinants forthe Canadian population. Statistics Canada data did notrequire an ethics review as it is a secondary analysis,however, a proposal on the use of the data was approvedby Statistics Canada. The CCHS covers the population 12years of age and above, and living in private households inthe ten provinces and the three territories, and it reliesupon a large sample of respondents. Persons living on re-serves and other Aboriginal settlements; full-time membersof the Canadian Forces; institutionalized persons, childrenaged 12\u201317 years that are living in foster care, and personsliving in the Quebec health regions of R\u00e9gion du Nunavikand R\u00e9gion des Terres-Cries-de-la-Baie-James, were ex-cluded from the survey. On the whole, these exclusionsrepresent less than 3 % of the Canadian population aged12 years and older. Healthcare utilization was assessed by acomputer-assisted personal interview asking about thenumber of visits to healthcare professionals [19]. Respond-ing to the survey was voluntary. Respondents were askedwhether they had conditions diagnosed by a healthcare pro-fessional that had lasted or was expected to last at least 6months. Detailed descriptions of the survey are availableelsewhere [19, 20].Inclusion and exclusion criteriaOur inclusion criteria required that individuals be atleast 50 years of age at the time of the interview. Health-care utilization rises slowly throughout adult life, and in-creases exponentially after the age of 50 years [21].While the mean age of stroke is 69 years (and decreas-ing) [22], approximately 20% of stroke survivors are be-tween the ages of 50 and 69 years [23].VariablesRespondents were stratified into two groups, stroke andnon-stroke. The stroke group consisted of respondentswho had suffered from the effects of a stroke that wasexpected to last or had already lasted 6months or more[20]. The non-stroke group consisted of respondentswho did not have a stroke and other major medical con-ditions (asthma, arthritis, cancer, chronic obstructivepulmonary disease, chemical sensitivity, scoliosis, backproblem). Respondents were asked to provide informa-tion on age, sex, educational status, total household in-come and healthcare utilization. Respondents wereasked how many times they had seen or talked to thefollowing health professionals for care or advice abouttheir physical, emotional or mental health in the last 12months; family doctor or general practitioner, eye spe-cialist, other medical specialists (e.g., allergist, ortho-paedist, psychiatrist), nurse, dental practitioner (dentist\/dental hygienist\/orthodontist), chiropractor, physiother-apist, psychologist, social worker\/counsellor, and audi-ologist\/speech\/occupational therapist. Respondents werestratified by sociodemographic variables (male\/female;< or \u2265 65 years of age; < or \u2265 $40,000 income) based onthe literature. Individuals who are female, older andhave a lower income have poorer outcomes after stroke[24, 25]. Respondents were also stratified into presenceand absence of the following; mobility (able to walkwith\/without difficulty), mood or anxiety disorder (e.g.,depression, bipolar disorder, mania, dysthymia, phobia,obsessive-compulsive disorder or a panic disorder), andcardiometabolic comorbid conditions (hypertension,Obembe et al. BMC Health Services Research          (2019) 19:192 Page 2 of 8diabetes, heart disease). These variables were selectedbecause these are chronic medical conditions that aremore likely to occur in stroke survivors [16, 26, 27] andit is well established that such physical and mentalhealth impairments, as well as cardiometabolic comor-bidities lead to poorer functioning [16] and quality oflife [24, 25] after stroke.Statistical analysisDescriptive statistics of weighted frequency, percent,mean and standard deviation were used to summarizethe data. To account for survey design effects such asclustering and unequal selection probabilities, and to en-sure that the results were representative of the Canadianpopulation, the set of replicate sampling weights devel-oped for the CCHS 2014 by Statistics Canada was usedfor all analyses. Negative binomial regression with inci-dence rate ratios (IRR) and 95% confidence intervals(CI) were used to investigate the association betweenvariables. This technique is able to handle over-disperseddata as typically found with health provider visits [28].Simple pair-wise associations (IRR and 95% CI) betweenthe number of visits for each health professional and age,sex, education, income, mobility, mood\/anxiety disorderand cardiometabolic comorbid condition explored factorsassociated with health utilization in the stroke group.Models were then built to investigate the relationship be-tween dependent variables (visits to each healthcare pro-fessional) and the independent variable (group \u2013 strokeversus non-stroke) (Crude Model). Adjusted IRR and 95%CI were determined after controlling for sociodemo-graphic covariates - age, sex, education, income (Model1). Three additional models were explored by separatelyadding mobility (Model 1a), mood\/anxiety disorder(Model 1b) or cardiometabolic comorbid condition(Model 1c) to control for physical and mental health con-ditions in stroke survivors.Alpha level was set at 0.05. All analyses were per-formed with the IBM Statistical Package for Social Sci-ences (SPSS) for windows version 24.0 and Stata\/ ICversion 15 software package.ResultsThe study sample consisted of 35,759 respondents (948stroke survivors and 34,811 non-stroke) across Canadaand equate to an estimated 12,396,641 (286,783 strokesurvivors; 12,109,858 non-stroke) when samplingweights were used. The mean age of the sample was63.6 \u00b1 10.0 years and 52.3% were women. The strokegroup (mean = 70.5 \u00b1 10.8 years) was older than thenon-stroke group (mean = 63.4 \u00b1 9.9 years). The strokegroup had 1.5, 1.8 and 2.0 times the proportion ofpeople with a mobility condition, cardiometabolic condi-tion or mood\/anxiety disorder, respectively compared tothe non-stroke group (Table 1).The most common healthcare providers visited werethe same between the stroke\/non-stroke groups: familydoctor (93.2%\/ 84.7%), eye specialist (55.1%\/ 50.2%),other medical specialists (54.0%\/ 36.8%) and dental prac-titioner (43.9%\/ 64.2%). The mean number of visits withTable 1 Characteristics of study sample from the 2014 Canadian Community Health SurveyN (%)a Total12,396,641 (100)Stroke286,783 (2.3)Non-stroke group12,109,858 (97.7)Age (Years) Mean (SD) 63.6 (10.0) 70.5 (10.8) 63.4 (9.9)Age (Years) n(%)< 65 7,328,212 (59.1) 96,554 (33.7) 7,231,659 (59.7)\u2265 65 5,068,429 (40.9) 190,229 (66.3) 4,878,199 (40.3)Sex n(%)Male 5,911,848 (47.7) 153,493 (53.5) 5,758,355 (47.6)Female 6,484,793 (52.3) 133,290 (46.5) 6,351,503 (52.4)Education n(%)< High School 1,455,086 (11.7) 66,868 (23.3) 1,388,218 (11.5)\u2265 High School 10,941,555 (88.3) 219,915 (76.7) 10,721,639 (88.5)Total Household Income (CAD) n(%)< 40,000 3,849,612 (31.1) 140,730 (49.1) 3,708,881 (30.6)\u2265 40,000 8,547,029 (68.9) 146,053 (50.9) 8,400,977 (69.4)Mobility (Able to walk without difficulty) Yes n(%) 11,205,716 (90.4) 171,802 (59.9) 11,033,914 (91.1)Had at least one cardiometabolic comorbid condition (Yes) n(%) 5,350,149 (43.2) 213,043 (74.3) 5,137,106 (42.4)Had a mood\/ anxiety disorder (Yes) n(%) 1,470,019 (11.9) 65,146 (22.7) 1,404,873 (11.6)aWeighted distributionObembe et al. BMC Health Services Research          (2019) 19:192 Page 3 of 8the family doctor was 4.9 visits\/ person\/ year [StandardDeviation (SD) =5.9] for the stroke group, and 3 visits\/person\/ year (SD =4.8) for the non-stroke group. Pro-portion and mean number of visits to healthcare pro-viders are presented in Table 2.From the simple pair-wise associations in the strokegroup (Table 3), higher income was related to visits todental practitioners and psychologists (IRR 1.5\u20138.8), andmood\/anxiety disorder was related to visits to familydoctors, other medical specialists, psychologists and so-cial worker\/counsellors (IRR 1.4\u201322.1). Age (\u2265 65 years),male sex and cardiometabolic comorbid condition wasrelated to visits to eye specialists (IRR 1.7\u20131.9). Strokesurvivors who were able to walk without difficulty (mo-bility) visited the eye specialists and social worker\/coun-sellors less (IRR 0.2\u20130.5).Table 4 shows a summary of IRRs for annual visits tohealthcare professionals, comparing stroke andnon-stroke groups in the regression models. When un-adjusted (Crude Model), stroke survivors visited the familydoctor, other medical specialists, nurse, psychologist, so-cial worker\/counsellor and audiologist\/ speech or occupa-tional therapist significantly more (IRR 1.6\u20133.7) andvisited dental professionals less than people without stroke(IRR 0.7). The stroke survivors had higher visitation ratesto these healthcare professionals (IRR 1.6\u20133.2) than thenon-stroke group. After controlling for sociodemographiccovariates (age, sex, education and income), the healthprofessions that showed greater visits by stroke survivorsin the Crude Model continued to be significant (IRR1.6\u20133.2), in addition to visits to physiotherapists and psy-chologists (Model 1). The models also showed that strokesurvivors have higher visitation rates to these healthcareprofessionals after mobility (IRR 1.3\u20133.0), mood\/anxietydisorder (IRR 1.5\u20133.3) and cardiometabolic comorbidcondition (IRR 1.4\u20135.1) were controlled (Models 1a - 1c).DiscussionThe burden that stroke constitutes for patients, theirfamilies and the healthcare system is substantial [29].Corresponding to our hypothesis, stroke survivors weremore likely to visit most healthcare professionals thanthose without stroke using a large population-basedsample with a comparison control group without stroke,and this suggests that community-dwelling individualswith stroke need more care and may have greater healthneeds because of their health condition. Stroke survivorsvisited the family doctor more than any of the otherhealth professionals. The stroke sample in our study wasmore likely to visit healthcare professionals that typicallymanage problems that may arise after a stroke (e.g., fam-ily doctor, nurse, physiotherapist, audiologist\/speechtherapist, occupational therapist, psychologist).Even after the models were adjusted for sociodemo-graphic variables and the presence of a mobility, mood\/anxiety or cardiometabolic condition, the greater num-ber of health professional visits still remained for thestroke group. It is possible that the severity of these con-ditions may have influenced the number of visits as onlythe presence\/absence of these conditions was consid-ered, and not a finer gradation such as walking speed formobility or actual resting blood pressure for cardiometa-bolic risk. Certainly the mobility impairments of strokesurvivors can be complex and severe with partial muscleparalysis, sensory loss, spasticity and ataxia.There was a much higher prevalence of a mobility im-pairment, mood\/anxiety disorder or cardiometaboliccondition in the stroke group compared to the control,and consequently a higher prevalence of having multipleconditions which may require visits to the family doctor.Thus, it is possible that interactions among these condi-tions may have had impacted the results, for example,mobility problems may contribute to anxiety, while lowTable 2 Mean number of health professional visits reported by samples in the 2014 Canadian Community Health SurveyVariable Total Stroke Non-Stroke groupVisited Healthcare Provider (Yes) N (%) Mean (SD) n (%) Mean (SD) n (%) Mean (SD)Family Doctor 10,521,679 (84.9) 3.0 (4.8) 267,142 (93.2) 4.9 (5.9) 10,254,536 (84.7) 3.0 (4.8)Eye Specialist 6,235,330 (50.3) 1.1 (5.8) 157,994 (55.1) 1.4 (6.9) 6,077,336 (50.2) 1.1 (5.8)Other Medical Specialists 4,611,415 (37.2) 1.1 (3.6) 154,815 (54.0) 2.2 (10.3) 4,456,601 (36.8) 1.1 (3.2)Nurse 1,503,285 (12.1) 0.9 (10.4) 79,446 (27.7) 3.2 (17.6) 1,423,838 (11.8) 0.9 (10.2)Dental Practitioner 7,901,339 (63.7) 1.3 (1.6) 125,892 (43.9) 1.0 (1.8) 7,775,447 (64.2) 1.3 (1.6)Chiropractor 1,485,209 (12.0) 1.1 (5.1) 23,912 (8.3) 1.1 (7.7) 1,461,297 (12.1) 1.1 (5.0)Physiotherapist 1,588,690 (12.8) 1.3 (6.9) 46,142 (16.1) 1.9 (8.1) 1,542,548 (12.7) 1.2 (6.9)Psychologist 272,087 (2.2) 0.2 (1.8) 8792 (3.1) 0.4 (4.2) 263,295 (2.2) 0.2 (1.7)Social Worker\/ Counsellor 429,440 (3.5) 0.2 (2.8) 29,412 (10.3) 0.7 (6.4) 400,028 (3.3) 0.2 (2.1)Audiologist\/ Speech or Occupational Therapist 653,850 (5.3) 0.1 (1.2) 34,038 (11.9) 0.4 (1.9) 619,812 (5.1) 0.1 (1.1)N (%) \u2013 Visited healthcare provider at least once during the last 12 monthsSD Standard deviationObembe et al. BMC Health Services Research          (2019) 19:192 Page 4 of 8Table3Pair-wiseassociationsofhealthcareutilizationofstrokesurvivorsVariableIRR(95%CI)FamilyDoctorEyeSpecialistOtherMedicalSpecialistsNurseDentalPractitionerChiropractorPhysiotherapistPsychologistSocialWorker\/CounsellorAudiologist\/SpeechorOccupationalTherapistAge(Years)<65c\u2265650.8(0.6\u20131.1)1.7(1.0\u20132.9)a0.4(0.2\u20130.7)b1.4(0.5\u20133.7)1.7(0.4\u20131.2)0.4(0.1\u20134.3)0.6(0.2\u20131.5)0.1(0.0\u20131.9)0.4(0.1\u20131.4)0.5(0.2\u20131.3)Sex FemalecMale0.9(0.6\u20131.2)1.7(1.0\u20132.7)a0.7(0.5\u20131.1)1.2(0.5\u20133.1)1.1(0.8\u20131.7)0.3(0.1\u20131.1)1.1(0.4\u20132.8)1.9(0.4\u201310.0)2.3(0.7\u20137.7)0.9(0.4\u20131.7)HighestlevelofEducation<HighSchoolc\u2265HighSchool1.1(0.8\u20131.3)1.1(0.6\u20131.9)1.0(0.5\u20131.8)0.6(0.2\u20131.5)1.0(0.5\u20131.8)2.0(0.4\u201310.3)0.9(0.1\u20137.1)0.2(0.0\u20137.2)1.5(0.4\u20135.3)1.5(0.5\u20134.4)Income(CAD)<$40,000c\u2265$40,0001.0(0.7\u20131.3)0.6(0.3\u20131.1)0.9(0.6\u20131.4)0.7(0.2\u20131.8)1.5(1.0\u20132.2)a2.1(0.4\u20139.6)1.3(0.5\u20133.3)8.8(1.6\u201349.1)a0.7(0.2\u20132.7)1.3(0.6\u20133.0)MobilityCannotwalkcCanwalk0.8(0.6\u20131.1)0.5(0.3\u20130.9)b0.8(0.5\u20131.3)0.6(0.2\u20131.5)1.1(0.7\u20131.7)0.5(0.1\u20131.9)1.2(0.4\u20133.3)0.7(0.1\u20133.8)0.2(0.1\u20130.6)b0.5(0.2\u20131.1)Mood\/AnxietyNocYes1.4(1.1\u20131.8)a1.5(0.7\u20133.0)1.8(1.0\u20133.1)a2.4(0.8\u20136.8)1.1(0.7\u20131.9)1.4(0.3\u20135.5)1.0(0.2\u20135.2)22.1(3.2\u2013149.8)a7.4(2.5\u201321.9)a2.1(0.8\u20135.1)CardiometabolicComorbidConditionNocYes1.1(0.8\u20131.5)1.9(1.2\u20132.8)a1.1(0.6\u20132.2)1.9(0.7\u20135.0)0.9(0.6\u20131.4)0.3(0.1\u20132.2)0.4(0.1\u20131.8)1.6(0.1\u201345.3)0.4(0.1\u20133.6)1.5(0.6\u20134.3)IRR(95%CI)Incidencerateratio(95%confidenceinterval)a SignificantlyassociatedwithhigherhealthcareservicevisitsafterstrokebSignificantlyassociatedwithlowerhealthcareservicevisitsoddsafterstrokec ReferencecategoryObembe et al. BMC Health Services Research          (2019) 19:192 Page 5 of 8mood may deter one from activities that keep one mo-bile. Interestingly, stroke survivors with walking difficul-ties visited a social worker\/counsellor around five timesmore often than stroke survivors without a walking diffi-culty. A number of explanations may account for thisfinding, including the evidence that those with walkingdifficulties have more psychosocial difficulties [30] or therole of social workers in organizing mobility and trans-portation services to address physical impairments [31].In addition, other mediators may be involved as mo-bility ability has been shown to relate to overallstroke severity [32] and social workers\/counsellorslikely prioritize individuals who are more impacted bytheir stroke.The greatest discrepancy in visits was with psycholo-gists where stroke survivors visited four to six times thatof people without stroke. Stroke survivors with mood\/anxiety disorders were far more likely to visit a psych-ologist, but not their family doctor than stroke survivorswithout a mood\/anxiety disorder. Furthermore, while22.7 and 11.6% of the stroke and non-stroke groups re-ported a mood\/anxiety disorder, the proportions visitinga psychologist were very small (2\u20133% in both groups).Stigmas, as well as a lack of knowledge about mentalhealth symptoms and treatments may prevent peoplefrom seeking treatment for depression or anxiety; a USnational study of 21,000 males showed that less than50% sought treatment, despite experiencing depressionor anxiety on a daily basis [33]. Psychological disordershave also been linked to greater dependence in activitiesof daily living, poorer quality of life after stroke [34] andhigher utilisation of healthcare services if untreated [35\u201337]. A barrier to most community-based psychologicalservices is the fact that they are delivered by private ser-vices, making it unaffordable for many people [38]. Also,psychological services are not covered by health insur-ance, making it even more unaffordable. Sixty-five per-cent of Canadians have private health insurance whichpays for the health-care expenditures that go towardsother professionals (dentists, optometrists and physio-therapists, among others) [39]. Private health insurancehas been suggested to be a predictor of improved out-comes after stroke [40].The findings from this study have considerable im-portance and implications as this study was based on alarge sample of adults with or without stroke in Canada.The results suggest that stroke survivors havestroke-related health needs that requires more visits tohealthcare professionals than people without stroke.Stroke survivors with disabilities usually require carethat can be complex due to their multiple needs. Theseindividuals might need to consult several healthcare pro-fessionals for different medical conditions. Their com-plex care requires easy accessibility to healthcareservices professionals. It is essential for the healthcaresystem to be responsive to these needs. Interdisciplinaryhealth services delivery programs, involving healthcareprofessionals crucial to stroke management, should bedeveloped for the care of these patients.There are several limitations that warrant acknowledg-ment in this study. Firstly, stroke and other conditionswere self-reported by individuals and not verified by anyother source. Self-report measures are easily imple-mented to large samples, but have limitations such asTable 4 Multi-level negative binomial regression models showing the comparison of health professional visits between stroke andnon-stroke groupsVariable Crude ModelIRR (95%CI)Model 1IRR (95%CI)Model 1aIRR (95%CI)Model 1bIRR (95%CI)Model 1cIRR (95%CI)Family Doctor 1.6 (1.4\u20131.9)a 1.6 (1.4\u20131.8)a 1.3 (1.1\u20131.5)a 1.5 (1.3\u20131.7)a 1.4 (1.2\u20131.7)aEye Specialist 1.2 (0.9\u20131.7) 1.1 (0.8\u20131.6) 1.0 (0.8\u20131.4) 1.1 (0.8\u20131.5) 1.1 (0.8\u20131.4)Other Medical Specialists 2.0 (1.4\u20132.9)a 2.0 (1.4\u20132.8)a 1.7 (1.2\u20132.4)a 1.9 (1.3\u20132.6)a 1.9 (1.3\u20132.6)aNurse 3.7 (2.3\u20136.1)a 3.0 (1.8\u20134.8)a 2.7 (1.4\u20135.2)a 2.6 (1.6\u20134.2)a 2.6 (1.6\u20134.1)aDental Practitioner 0.7 (0.6\u20130.9)b 0.9 (0.7\u20131.1) 0.9 (0.8\u20131.2) 0.9 (0.7\u20131.1) 0.9 (0.7\u20131.1)Chiropractor 1.0 (0.4\u20132.5) 1.3 (0.5\u20132.5) 1.2 (0.5\u20132.6) 1.2 (0.5\u20132.9) 1.2 (0.5\u20132.9)Physiotherapist 1.5 (0.9\u20132.5) 1.8 (1.1\u20131.9)a 1.8 (1.1\u20132.9)a 1.8 (1.2\u20132.9)a 1.9 (1.1\u20133.1)aPsychologist 2.9 (0.3\u201329.8) 4.0 (1.1\u20135.7)a 4.5 (0.7\u201330.1)a 6.2 (0.4\u201390.1)a 4.1 (0.7\u201322.5)Social Worker\/ Counsellor 3.1 (1.7\u20135.6)a 3.2 (2.2\u20134.8)a 3.0 (1.5\u20135.8)a 3.3 (1.6\u20136.9)a 5.1 (1.9\u201313.1)aAudiologist\/ Speech or Occupational Therapist 3.2 (1.9\u20135.4)a 2.9 (1.2\u20132.1)a 2.5 (1.3\u20135.1)a 2.9 (1.6\u20135.3)a 2.9 (1.7\u20135.1)aCrude Model - Unadjusted incidence rate ratiosModel 1 - Incidence rate ratios were adjusted for age, sex, education and incomeModel 1a - Incidence rate ratios were adjusted for age, sex, education, income and mobilityModel 1b - Incidence rate ratios were adjusted for age, sex, education, income and mood\/anxiety disorderModel 1c - Incidence rate ratios were adjusted for age, sex, education, income and presence of cardiometabolic comorbid conditionIRR (95% CI) Incidence rate ratio (95% confidence interval)aStroke survivors significantly associated with higher healthcare service visits than those without strokebStroke survivors significantly associated with lower healthcare service visits than those without strokeObembe et al. BMC Health Services Research          (2019) 19:192 Page 6 of 8recall\/ response bias, introspective ability and social de-sirability bias. The study involved only people living inprivate households, therefore, the results may not begeneralized to all stroke survivors as there are some whoare residents of healthcare institutions. As administrativedata were used, many variables that were potential co-founders of stroke were not assessed or provided, in-cluding clinical parameters (such as stroke type, strokeseverity), family structure and support network, as wellas use of other healthcare resources, such as ambulanceuse and emergency room admissions. Therefore, not allprobable cofounding factors of stroke were adjusted forbecause the details were not available in this study. Weadjusted for mobility and comorbidities, but we werenot able to adjust for other determinants of stroke out-comes such as stroke type and severity (however, mobil-ity can be considered one surrogate for severity).Further studies that will include more detailed strokerisk factors and comorbidities are needed to addressthese limitations.ConclusionStroke survivors visited healthcare professionals morethan people without stroke, and were more likely to visitthose that manage problems that may arise after a stroke(e.g., family doctor, nurse, psychologist, physiotherapist).The effects of a stroke include mobility impairment andmood\/ anxiety disorders. Therefore, adequate access tostroke-related healthcare services should be provided forstroke survivors, as this may improve functional out-come and reduce future healthcare costs.AbbreviationsCFI: Canadian Foundation for Innovation; CI: 95% confidence intervals;CIHR: Canadian Community Health Survey; CIHR: Canadian Institutes ofHealth Research; CRDCN: Canadian Research Data Centre Network;IRR: Incidence rate ratios; SD: Standard deviation; SSHRC: Social Sciences andHumanities Research CouncilAcknowledgmentsData for this work were collected by Statistics Canada and provided by theUniversity of British Columbia Research Data Centre.FundingFunding from the Canadian Institutes of Health Research (CIHR FDN 143340)and the Canada Research Chairs Program to JE supports this study. AO issupported by a CIHR Postdoctoral Fellowship and the Michael SmithFoundation for Health Research Trainee Award. This research was supportedby funds to the Canadian Research Data Centre Network (CRDCN) from theSocial Sciences and Humanities Research Council (SSHRC), the CanadianInstitutes of Health Research (CIHR), the Canadian Foundation for Innovation(CFI), and Statistics Canada. Although the research and analysis are based ondata from Statistics Canada, the opinions expressed do not represent theviews of Statistics Canada. The funding bodies had no role in the design ofthe study and collection, analysis, and interpretation of data and in writingthe manuscript.Availability of data and materialsThe datasets used and\/or analysed during the current study are availablefrom the University of British Columbia Research Data Centre for researcherswho meet the criteria for access to confidential data.Authors\u2019 contributionsAO JE conceived and designed the study and drafted the manuscript; AO JELS analysed and interpreted the data, and revised the manuscript; BSinterpreted the data and reviewed the manuscript. All authors read andapproved the final manuscript.Ethics approval and consent to participateNot applicable.Consent for publicationNot applicable.Competing interestsJE (Operating grant) and AO (Fellowship) have received financial support forresearch from the Canadian Institutes of Health Research (CIHR). LS and BSdeclare that they have no competing interests.Publisher\u2019s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Department of Physical Therapy, The University of British Columbia,Vancouver, Canada. 2Rehabilitation Research Program, GF Strong RehabCentre, Vancouver Coastal Health Research Institute, Vancouver, Canada.3Graduate Program in Rehabilitation Sciences, The University of BritishColumbia, Vancouver, Canada.Received: 10 October 2018 Accepted: 18 March 2019References1. Ovbiagele B, Nguyen-Huynh MN. Stroke epidemiology: advancing ourunderstanding of disease mechanism and therapy. Neurotherapeutics. 2011;8:319\u201329. https:\/\/doi.org\/10.1007\/s13311-011-0053-1.2. Seshadri S, Beiser A, Kelly-Hayes M, Kase CS, Au R, Kannel WB, et al. Thelifetime risk of stroke: estimates from the Framingham study. Stroke. 2006;37:345\u201350.3. 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