Health care use, unmet needs, and functional disability among US stroke survivors: a pooled cross-sectional analysis of the National Health Interview Survey, 2019–2023

Abstract Background Stroke is a leading cause of adult disability in the United States, yet contemporary national estimates of health care use, unmet care needs, and functional disability among stroke survivors remain scarce. Methods We pooled four post-redesign waves of the US National Health Interview Survey (2019, 2021, 2022, 2023; 118,652 adults including 4,355 stroke survivors) and used survey-weighted analyses accounting for the complex multistage design. We compared stroke survivors with adults without stroke on emergency department (ED) visits, urgent care visits, unmet care needs (needed medical care that was not received or was delayed because of cost), difficulty walking or climbing steps, and ever-diagnosed depression. Modified Poisson regression estimated prevalence ratios (PRs). We examined time trends, the age patterning of unmet needs, correlates of unmet needs, and associations with other health outcomes among stroke survivors. Results Stroke survivors had markedly higher fully adjusted prevalences of ED visits (≥ 1: PR 1.43, 95% CI 1.36–1.50; ≥2: 1.61, 1.48–1.75), severe difficulty walking or climbing steps (1.81, 1.69–1.94), and depression (1.31, 1.24–1.39). The crude PR for unmet care needs was 1.19 (1.07–1.33) but rose to 1.77 (1.58–1.98) after age–sex adjustment, reflecting non-monotonic age patterning: unmet needs were elevated at ages 45–64 (PR 1.87, 1.60–2.18) and 65–79 (2.13, 1.74–2.61) but not at 18–44 or ≥ 80. Fully adjusted year-specific prevalence ratios fluctuated without a consistent direction across the four survey waves, and 95% confidence intervals overlapped for every outcome examined. Among stroke survivors, unmet needs were strongly associated with being uninsured (adjusted PR for insured vs. uninsured 0.23, 0.18–0.29) and inversely with age ≥ 80, and were associated with ED visits (1.24, 1.10–1.41 for ≥ 1; 1.36, 1.11–1.67 for ≥ 2), fair/poor health, and depression. Conclusions US stroke survivors face large, persistent disparities in ED use, severe functional disability (difficulty walking or climbing steps), and depression. Unmet care needs concentrate in middle-aged survivors and in the uninsured—actionable targets for policy and transitional-care interventions.