Hospitalization within the first year after stroke: the Dijon stroke registry.
Lainay Claire,Benzenine Eric,Durier Jérôme,Daubail Benoit,Giroud Maurice,Quantin Catherine,Béjot Yannick
BACKGROUND AND PURPOSE:This population-based study aimed to identify unplanned hospitalization within the first year after stroke to determine factors associated with it and consequences on survival. METHODS:All first-ever acute strokes occurring in Dijon, France, from 2009 to 2011, were prospectively collected from a population-based registry. Demographics and clinical data, including stroke severity measured by the National Institutes of Health Stroke Scale and disability after stroke, were recorded. For each patient, the first unplanned hospitalization that occurred within 1 year after stroke was retrieved by linking data with the national French Hospital Discharge Database. Predictors of hospitalization and survival at 1 year were identified using logistic regression models. RESULTS:Among the 613 patients recorded, 94 (15.3%) were excluded because of early death. Of the 519 remaining patients, 167 (32.2%) were hospitalized at 1 year. Subsequent hospitalization led to in-hospital death for 16 (9.6%) patients. In multivariable analyses, only a history of hypertension and atrial fibrillation were associated with hospitalization. In stratified analyses, the National Institutes of Health Stroke Scale score was associated with a higher risk of hospitalization (odds ratio, 1.13; 95% confidence interval, 1.03-1.22; P=0.006), whereas only a trend was noted for disability (odds ratio, 2.26; 95% confidence interval, 0.82-6.22; P=0.113) in patients who returned home after the index stroke. Hospitalization was negatively associated with being alive at 1 year (odds ratio, 0.36; 95% confidence interval, 0.19-0.66; P<0.01). CONCLUSIONS:Stroke survivors are at high risk of hospitalization after the episode, and subsequent admission is associated with poor survival, thus highlighting the need for follow-up interventions after discharge to prevent readmission.
Preventable readmissions within 30 days of ischemic stroke among Medicare beneficiaries.
Lichtman Judith H,Leifheit-Limson Erica C,Jones Sara B,Wang Yun,Goldstein Larry B
BACKGROUND AND PURPOSE:The Centers for Medicare and Medicaid Services proposes to use 30-day hospital readmissions after ischemic stroke as part of the Hospital Inpatient Quality Reporting Program for payment determination beginning in 2016. The proportion of poststroke readmissions that is potentially preventable is unknown. METHODS:Thirty-day readmissions for all Medicare fee-for-service beneficiaries aged≥65 years discharged alive with a primary diagnosis of ischemic stroke (International Classification of Diseases, Ninth Revision, Clinical Modification 433, 434, 436) between December 2005 and November 2006 were analyzed. Preventable readmissions were identified based on 14 Prevention Quality Indicators developed for use with administrative data by the US Agency for Healthcare Research and Quality. National, hospital-level, and regional preventable readmission rates were estimated. Random-effects logistic regression was also used to determine patient-level factors associated with preventable readmissions. RESULTS:Among 307 887 ischemic stroke discharges, 44 379 (14.4%) were readmitted within 30 days; 5322 (1.7% of all discharges) were the result of a preventable cause (eg, pneumonia), and 39 057 (12.7%) were for other reasons (eg, cancer). In multivariate analysis, older age and cardiovascular-related comorbid conditions were strong predictors of preventable readmissions. Preventable readmission rates were highest in the Southeast, Mid-Atlantic, and US territories and lowest in the Mountain and Pacific regions. CONCLUSIONS:On the basis of Agency for Healthcare Research and Quality Prevention Quality Indicators, we found that a small proportion of readmissions after ischemic stroke were classified as preventable. Although other causes of readmissions not reflected in the Agency for Healthcare Research and Quality measures could also be avoidable, hospital-level programs intended to reduce all-cause readmissions and costs should target high-risk patients.
30-Day risk-standardized mortality and readmission rates after ischemic stroke in critical access hospitals.
Lichtman Judith H,Leifheit-Limson Erica C,Jones Sara B,Wang Yun,Goldstein Larry B
BACKGROUND AND PURPOSE:The critical access hospital (CAH) designation was established to provide rural residents with local access to emergency and inpatient care. CAHs, however, have poorer short-term outcomes for pneumonia, heart failure, and myocardial infarction compared with other hospitals. We assessed whether 30-day risk-standardized mortality rates (RSMRs) and risk-standardized readmission rates (RSRRs) after ischemic stroke differ between CAHs and non-CAHs. METHODS:The study included all fee-for-service Medicare beneficiaries 65 years of age or older with a primary discharge diagnosis of ischemic stroke (International Classification of Diseases, 9th revision codes 433, 434, 436) in 2006. Hierarchical generalized linear models calculated hospital-level RSMRs and RSRRs, adjusting for patient demographics, medical history, and comorbid conditions. Non-CAHs were categorized by hospital volume quartiles and the RSMR and RSRR posterior probabilities in comparison with CAHs were determined using linear regression with Markov chain Monte Carlo simulation. RESULTS:There were 10 267 ischemic stroke discharges from 1165 CAHs and 300 114 discharges from 3381 non-CAHs. The RSMRs of CAHs were higher than non-CAHs (11.9%± 1.4% vs 10.9%± 1.7%; P<0.001), but the RSRRs were comparable (13.7%± 0.6% vs 13.7%± 1.4%; P=0.3). The RSMRs for the 2 higher volume quartiles of non-CAHs were lower than CAHs (posterior probability of RSMRs higher than CAHs=0.007 for quartile 3; P<0.001 for quartile 4), but there were no differences for lower volume hospitals; RSRRs did not vary by annual hospital volume. CONCLUSIONS:CAHs had higher RSMRs compared with non-CAHs, but readmission rates were similar. The observed differences may be partly explained by patient characteristics and annual hospital volume.
Alcohol use and hospital readmissions following stroke: A safety net hospital experience.
Parikh Simy,George Paul,Wilson Kevin,Rybin Denis,Hohler Anna DePold
Journal of the neurological sciences
OBJECTIVE:The purpose of this study is to identify predictors of stroke-related readmissions at 30days on a safety net hospital level and suggest interventions to reduce the number of readmissions. BACKGROUND:Hospital readmissions are an important measure of the quality of health care services. Readmissions indicate unresolved problems from the index admission, inadequate post-hospitalization care, or a mixture of these factors. Additionally, hospital readmissions are associated with a substantial economic burden on the health care system. The study's purpose is to identify predictors of stroke-related readmissions within 30days on a hospital level and suggest interventions to reduce the number of readmissions. METHODS:We conducted a single-center retrospective study of patients admitted to Boston Medical Center (BMC) and diagnosed with ischemic and hemorrhagic stroke. Unadjusted and adjusted logistic regressions were used to evaluate possible predictors of stroke related readmissions. RESULTS:Of 352 patients admitted with a diagnosis of ischemic or hemorrhagic stroke at BMC during the study period, 44 (12.5%) patients were readmitted to BMC within 30days. Current alcohol abuse was significantly associated with readmission (OR 95% CI 1.03-5.62). Discharge against medical advice was also associated, though the sample size was small. CONCLUSIONS:These results suggest that early inpatient and post-hospitalization interventions to address alcohol abuse during the index hospital admission may reduce the rate of hospital readmission within 30days. The results have prompted interventions on the stroke service such as early inpatient social work and addiction medicine involvement for patients with risk factors of alcohol abuse.
Patient and hospital factors associated with 30-day unplanned readmission in patients with stroke.
Lee Sang Ah,Park Eun-Cheol,Shin Jaeyong,Ju Yeong Jun,Choi Young,Lee Hoo-Yeon
Journal of investigative medicine : the official publication of the American Federation for Clinical Research
Stroke is frequently associated with readmission; moreover, readmission is regarded as an important indicator of the quality of stroke care. Thus, we investigated factors associated with 30-day readmission in patients with stroke in South Korea. We used claims data from 2013 for stroke (I60-I62) patients (n=44 729) in 94 hospitals and classified unplanned readmission according to the Centers for Medicare and Medicaid guidelines. We used multilevel models to investigate patient (age, gender, type of insurance, admission via emergency room, length of stay, type of stroke, Elixhauser Index Score) and hospital (stroke care quality grade, location of hospital, type of hospital, number of doctors and nurses per 100 beds) factors associated with readmission within 30 days of discharge. Among the 44 729 patients admitted due to stroke, 9.2% (n=4124) were readmitted to hospital and 7.6% (n=3379) had unplanned readmissions. Regarding patient characteristics, medical aid and longer hospital stay were associated with 30-day readmission rate. Among hospital factors, patients admitted to a low-grade hospital or a non-capital area hospital were more likely to be readmitted within 30 days of discharge. We identified patient and hospital factors associated with 30-day readmission among stroke patients. In particular, patients admitted to hospitals with higher quality stroke care showed lower readmission rates.
Readmission after stroke in a hospital-based registry: risk, etiologies, and risk factors.
Lin Huey-Juan,Chang Wei-Lun,Tseng Mei-Chiun
OBJECTIVE:Readmission among stroke survivors is common and costly. This prospective cohort study aimed to explore the readmission risk, causes, and risk factors after discharge from stroke hospitalization in Taiwan. METHODS:Hospitalized patients with acute stroke between August 1, 2006, and December 31, 2008, were prospectively under continuous surveillance on the medical records for any readmission. The main reasons for readmission were categorized by chart review as recurrent stroke, neurologic sequelae of stroke, other cardiovascular event, infection, gastrointestinal ulcer with bleeding, and others. Kaplan-Meier method was used to estimate the probabilities of readmission over time and Cox proportional hazards models were used to evaluate the risk factors for the first readmission. RESULTS:Of the 2,657 study patients, rehospitalization occurred in 815 (31%) within 1 year after discharge. The probability of readmission at 30 days was 10% (95% confidence interval 9%-11%), at 90 days 17% (16%-19%), at 180 days 24% (22%-26%), and at 360 days 36% (34%-38%). The most frequent reasons for rehospitalization were infection (28%), recurrent stroke (18%), and other cardiovascular event (10%). Increasing age, previous stroke/TIA, atrial fibrillation, coronary artery disease, having complications at the index hospitalization, longer length of stay, and dependency at discharge were the independent predictors for readmission. CONCLUSIONS:Stroke survivors have high likelihood of readmission within 1 year following discharge, with infections and recurrent vascular events being the most common reasons. Identification of high-risk subgroups might foster preventive interventions.
Modeling and simulation analysis of the relationship between lesion recurrence on brain images and clinical recurrence in patients with ischemic stroke.
Lim Hyeong-Seok,Bae Kyun-Seop
Journal of clinical pharmacology
The objective of current study is to assess the relationship between characteristics of patients with acute ischemic stroke and clinical recurrences to identify predictors for the prognosis by modeling and simulation. Primary endpoint was clinical recurrence of ischemic stroke, and secondary endpoint was occurrence of any of the following clinical recurrence of ischemic stroke, transient ischemic attack, acute coronary syndrome, or vascular deaths. Time to event models were developed by NONMEM(®) using prospectively collected clinical data from 270 patients over 5 years, where 7.0% and 9.3% of them experienced lesion recurrence on MRI at 1 month (LR1M) and clinical recurrence, respectively. Exponential models best described the data. LR1M and diabetes mellitus history were significant predictors for primary endpoint. Times to recurrence for patients with LRIM (+) and diabetes mellitus (+) were predicted to be 0.095 and 0.317 of those for patients with LRIM (-) and diabetes mellitus (-), respectively. LR1M was only predictor for secondary endpoint with predicted time to recurrence in patients with LR1M (+) compared to 0.141 of LR1M (-). Quantitative prediction of clinical recurrence using MRI could improve personalized therapy by identifying patients at risk of recurrence, and could enable efficient clinical trials by stratifying the patients.
Multifactorial analysis of factors affecting recurrence of stroke in Japan.
Omori Toyonori,Kawagoe Masahiro,Moriyama Michiko,Yasuda Takeshi,Ito Yasuhiro,Hyakuta Takeshi,Nagatsuka Kazuyuki,Matsumoto Masayasu
Asia-Pacific journal of public health
Data on factors affecting stroke recurrence are relatively limited. The authors examined potential factors affecting stroke recurrence, retrospectively. The study participants were 1087 patients who were admitted to stroke centers suffering from first-ever ischemic stroke and returned questionnaires with usable information after discharge. The authors analyzed the association between clinical parameters of the patients and their prognosis. Recurrence rate of during an average of 2 years after discharge was 21.3%, and there were differences among stroke subtypes. It was found that the disability level of the patients after discharge correlated well with the level at discharge (r s = 0.66). Multivariate logistic regression analysis of the data shows that modified Rankin Scale score, National Institute of Health Stroke Scale score, gender, age, and family history had statistically significant impacts on stroke recurrence, and the impact was different depending on subtypes. These findings suggest that aggressive and persistent health education for poststroke patients and management of risk factors are essential to reduce stroke recurrence.
Ischemic Stroke in Young Adults of Northern China: Characteristics and Risk Factors for Recurrence.
Li Fang,Yang Li,Yang Rui,Xu Wei,Chen Fu-Ping,Li Nan,Zhang Jin-Biao
BACKGROUND:Young adults accounted for 10-14% of ischemic stroke patients. The risk factors may differ in this population from elder patients. In addition, the factors associated with stroke recurrence in this population have not been well investigated. OBJECTIVE:The study aimed to investigate the characteristics and risk factors associated with recurrence of ischemic stroke in young adults. METHODS:Clinical data of 1,395 patients of age 18-45 years who were treated between 2008 and 2014 in 3 centers located in northern China was reviewed. The first onset of stroke was taken as the initial events and recurrent stroke as the end point events. The end point events, age, gender, duration after first onset of stroke, history of disease, National Institutes of Health Stroke Scale (NIHSS) score at admission, Trial of Org 10172 in Acute Stroke Treatment classifications of the cause of stroke and adherence to medication were recorded. These factors were analyzed and compared between recurrence and non-recurrence group. Information about recurrent stroke was collected through clinical (readmission to hospital with ischemic stroke) or telephone follow-up survey. Logistic regression was used to analyze the risk factors of recurrence. RESULTS:The most common causes of stroke were large vessel atherosclerosis and small vessel occlusion, followed by cardioembolism. NIHSS score at admission (OR 1.088; 95% CI 1.028-1.152; p = 0.004) were associated with recurrence. CONCLUSIONS:Vascular disease, especially premature atherosclerosis, is the major risk factor for ischemic stroke in the young adult population of northern China. Timely screening of the cause of stroke with severe NIHSS score needs further attention.
Socioeconomic Status and the Risk of Stroke Recurrence: Persisting Gaps Observed in a Nationwide Swedish Study 2001 to 2012.
Pennlert Johanna,Asplund Kjell,Glader Eva-Lotta,Norrving Bo,Eriksson Marie
BACKGROUND AND PURPOSE:This nationwide observational study aimed to investigate how socioeconomic status is associated with risk of stroke recurrence and how possible associations change over time. METHODS:This study included 168 295 patients, previously independent in activities of daily living, with a first-ever stroke in the Swedish Stroke Register (Riksstroke) 2001 to 2012. Riksstroke was linked with Statistics Sweden as to add individual information on education and income. Subdistribution hazard regression was used to analyze time from 28 days after first stroke to stroke recurrence, accounting for the competing risk of other causes of death. RESULTS:Median time of follow-up was 3.0 years. During follow-up, 23 560 patients had a first recurrent stroke, and 53 867 died from other causes. The estimated cumulative incidence of stroke recurrence was 5.3% at 1 year, and 14.3% at 5 years. Corresponding incidence for other deaths were 10.3% and 30.2%. Higher education and income were associated with a reduced risk of stroke recurrence. After adjusting for confounding variables, university versus primary school education returned a hazard ratio of 0.902; 95% confidence interval, 0.864 to 0.942, and the highest versus the lowest income tertile a hazard ratio of 0.955; 95% confidence interval, 0.922 to 0.989. The risk of stroke recurrence decreased during the study period, but the inverse effect of socioeconomic status on risk of recurrence did not change significantly. CONCLUSIONS:Despite a declining risk of stroke recurrence over time, the differences in recurrence risk between different socioeconomic groups remained at a similar level in Sweden during 2001 to 2012.
Systematic review: predictors of successful transition to community-based care for adults with chronic care needs.
Jacob Lolita,Poletick Eileen Blechman
Care management journals : Journal of case management ; The journal of long term home health care
Difficult transition from acute hospital back to the community can be challenging. Problems encountered during this process can lead to unplanned readmission and emergency department visits. It is important for care managers to be able to identify patients susceptible to difficult transition and to understand strategies to reduce risk of unplanned hospital readmission. This qualitative systematic review of 10 studies of discharge interventions and patient characteristics finds little evidence that enhanced discharge support is related to improved physical status at home, but there is mixed support for its role in preventing or delaying hospital readmissions in certain discharge diagnoses, specifically heart failure and stroke. Additionally, those with adequate social support and confidence in their self-care ability tend to experience fewer readmissions than do those living alone and those who perceive themselves as not ready to return home.
Long-term mortality, morbidity and hospital care following intracerebral hemorrhage: an 11-year cohort study.
McGuire Alistair J,Raikou Maria,Whittle Ian,Christensen Michael C
Cerebrovascular diseases (Basel, Switzerland)
BACKGROUND AND PURPOSE:Intracerebral hemorrhage (ICH) represents the severest form of stroke, yet examinations of long-term prognosis and associated health care use are rare. This study assessed survival, morbidity and cost of hospital care over 11 years following a first-ever ICH in the UK. METHODS:We used a population-based retrospective inception cohort design using data from the Hospital Record Linkage System in Scotland. Long-term survival, morbidity and treatment provided in hospitals were evaluated in all patients with a first diagnosis of ICH in 1995. A cohort of ischemic stroke (IS) patients was also examined for comparison. RESULTS:A total of 705 patients with ICH and 8,893 with IS were identified. The mean age was 65 years (SD = 17.2) for ICH and 73 years (SD = 11.8) for IS at stroke onset. The acute in-hospital mortality was 45.7 and 30.1% for ICH and IS, 51.2 and 39.9% at 1 year, while 76.0 and 80.4% were dead 11 years later. The cumulative risk of nonfatal or fatal ICH was 8.0, 12.7 and 13.7% at 1, 5 and 10 years, and 7.0, 11.1 and 12.9% for IS in the ICH cohort. The mean cost of initial hospital care was GBP 10,332 (SD = 19,919) for ICH and GBP 9,937 (SD = 15,777) for IS. The mean total costs over 11 years were GBP 18,629 (SD = 29,943) for ICH and GBP 21,505 (SD = 27,190) for IS. CONCLUSION:Following a first ICH, individuals have a poorer short-term prognosis than individuals with IS, yet both ICH and IS imply significant follow-up care.
Follow-up services for stroke survivors after hospital discharge--a randomized control study.
Andersen Hanne Elkjaer,Eriksen Karen,Brown Anne,Schultz-Larsen Kirsten,Forchhammer Birgitte Hysse
OBJECTIVE:To evaluate whether follow-up services for stroke survivors could improve functional outcome and reduce readmission rate. In this paper results of functional outcome are reported. DESIGN:Randomized controlled trial allocating patients to one of three different types of aftercare: (1) follow-up home visits by a physician, (2) physiotherapist instruction in the patient's home, or (3) standard aftercare. SUBJECTS:Stroke patients with persisting impairment and disability who, after completing inpatient rehabilitation, were discharged to their homes. OUTCOME MEASURES:Six months after discharge, functional outcome was assessed with Functional Quality of Movement, Barthel Index, Frenchay Activity Index and Index of Extended Activites of Daily Living. RESULTS:One-hundred and fifty-five stroke patients were included in the study. Fifty-four received follow-up home visits by a physician, 53 were given instructions by a physiotherapist in their home and 48 received standard aftercare only. No statistically significant differences in functional outcome six months after discharge were demonstrated between the three groups. However, all measurements showed a tendency towards higher scores indicating better function in both interventions groups compared with the control group. CONCLUSION:Follow-up services after stroke may be a way of improving functional outcome. The results of the present study should be evaluated in future trials. More research in this field is needed, especially studies of how to support stroke survivors to resume social and leisure activities.
Medical resource use and costs of health care after acute stroke in Germany.
Rossnagel K,Nolte C H,Muller-Nordhorn J,Jungehulsing G J,Selim D,Bruggenjurgen B,Villringer A,Willich S N
European journal of neurology
The purpose of this study was to determine the 12 months medical resource use following admission to hospital with acute stroke and to calculate costs from a societal perspective. Data of consecutive patients with confirmed stroke were analysed. Acute hospital data were taken from medical records, socio-demographic variables from patients' interviews. A follow-up questionnaire about resource utilization was completed by patients or proxies 12 months after acute hospital admission. Costs were calculated by multiplying medical resource units used with cost factors per unit. Mean age of a total of 383 patients was 65 years and 41% were female. The median length of the initial stay in the acute hospital was 12 days at an average cost of 4650 per patient (49% of direct costs). Rehabilitation (16%), readmission (11%), medication (9%), and nursing costs (6%) were other contributors to the direct costs which amounted to a total of 9452 +/- 7599 per patient during 12 months. Indirect cost amounted to a total of 2014 +/- 5312. Patients' age, severity and type of stroke influenced the total stroke-associated costs. The large economic burden of stroke indicates the need for assessing and improving efficient health care for affected patients.
Effect of area-based deprivation on the severity, subtype, and outcome of ischemic stroke.
Aslanyan Stella,Weir Christopher J,Lees Kennedy R,Reid John L,McInnes Gordon T
BACKGROUND AND PURPOSE:Markers of low socioeconomic status (deprivation) are associated with stroke and its causes. In the United Kingdom, area-based deprivation measures are available routinely through links with postal codes. We hypothesized that deprivation is associated with ischemic stroke risk factors, severity, subtype, and outcome. METHODS:We studied 2026 patients, each with at least 2 years of outcome follow-up by record linkage after first admission with ischemic stroke to an acute stroke unit. Baseline factors recorded routinely were age, sex, medical history, blood pressure, and stroke severity and subtype. Deprivation was assessed by the Womersley score (WS) and Murray score (MS). RESULTS:Higher WS and MS were associated with stroke at younger age (eg, WS linear regression coefficient (r)=-0.26; 95% confidence interval [CI], -0.51 to -0.01 per additional point), smoking (odds ratio [OR], 1.12; 95% CI, 1.08 to 1.17), and claudication (OR, 1.09; 95% CI, 1.01 to 1.17); WS was associated with higher systolic blood pressure (r=0.13; 95% CI, 0.02 to 0.24); and MS was associated with severe stroke. Deprivation was not associated with case fatality in univariate analysis or after correction for all baseline factors. Deprivation was associated with readmission to hospital as a result of any vascular event in univariate analysis (hazard ratio [HR], 1.05; 95% CI, 1.02 to 1.09) and after correction for all baseline factors (HR, 1.06; 95% CI, 1.02 to 1.10). CONCLUSIONS:Tackling health inequalities in stroke should focus on stroke primary prevention by tackling deprivation, including promoting changes in lifestyle.
Steps against recurrent stroke plus: patient transition program.
Bretz Miranda N,Graves Alex,West Angie,Kiesz Karen C,Toth Lynn,Welch Marie
The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses
Stroke is a devastating health event that affects 800,000 people annually in the United States. Nearly 20% of strokes are recurrent strokes. Research shows that support after discharge from the hospital poststroke is frequently inadequate. The purpose of "Steps Against Recurrent Stroke (STARS) Plus: Patient Transition Program" was to design and deliver a program to facilitate optimal recovery for stroke survivors and prevent recurrent stroke. The program began at discharge from the hospital and continued through the first year of rehabilitation and recovery. Twelve hospitals participated; 261 patients enrolled, and contact was established with 193. Outcomes were gathered based on patient self-report of health status using the Short-Form Health Survey at 30, 90, 180, and 360 days. A dependent sample t test was completed comparing participants' 30- and 360-day follow-up scores. Results demonstrated an overall increase in subjective pain. A repeated multivariate analysis of variance was conducted to compare 30- and 360-day Short-Form Health Survey scores across age and subscales. Results revealed that those in the younger and older age groups reported poorer health outcomes. Findings demonstrate a reduction in rehospitalization after stroke, increased medication adherence, strong patient satisfaction, and significant differences in health-related outcome measures across age groups, suggesting that middle-aged stroke survivors experience better health outcomes than younger or older age groups. Future programs should consider targeting pain management in all ages and education targeted at younger and older age groups, because they reported poorer health outcomes. The findings from this program should contribute to the guidance and insight for others developing transitional interventions for stroke survivors.
Emergency readmission criterion: a technique for determining the emergency readmission time window.
Demir Eren,Chaussalet Thierry J,Xie Haifeng,Millard Peter H
IEEE transactions on information technology in biomedicine : a publication of the IEEE Engineering in Medicine and Biology Society
A frequently chosen time window in defining readmission is 28 days after discharge. Yet in the literature, shorter and longer periods such as 14 days or 90-180 days have also been suggested. In this paper, we develop a modeling approach that systematically tackles the issue surrounding the appropriate choice of a time window as a definition of readmission. The approach is based on the intuitive idea that patients who are discharged from hospital can be broadly divided in to two groups-a group that is at high risk of readmission and a group that is at low risk. Using the national data (England), we demonstrate the usefulness of the approach in the case of chronic obstructive pulmonary disease (COPD), stroke, and congestive heart failure (CHF) patients, which are known to be the leading causes of early readmission. Our findings suggest that there are marked differences in the optimal width of the time window for COPD, stroke, and CHF patients. Furthermore, time windows and the probabilities of being in the high-risk group for COPD, stroke, and CHF patients for each of the 29 acute and specialist trusts in the London area indicate wide variability between hospitals. The novelty of this modeling approach lies in its ability to define an appropriate time window based on evidence objectively derived from operational data. Therefore, it can separately provide a unique approach in examining variability between hospitals, and potentially contribute to a better definition of readmission as a performance indicator.
Readmissions after stroke: linked data from the Australian Stroke Clinical Registry and hospital databases.
Kilkenny Monique F,Dewey Helen M,Sundararajan Vijaya,Andrew Nadine E,Lannin Natasha,Anderson Craig S,Donnan Geoffrey A,Cadilhac Dominique A
The Medical journal of Australia
OBJECTIVES:To assess the feasibility of linking a national clinical stroke registry with hospital admissions and emergency department data; and to determine factors associated with hospital readmission after stroke or transient ischaemic attack (TIA) in Australia. DESIGN AND SETTING:Data from the Australian Stroke Clinical Registry (AuSCR) at a single Victorian hospital were linked to coded, routinely collected hospital datasets for admissions (Victorian Admitted Episodes Dataset) and emergency presentations (Victorian Emergency Minimum Dataset) in Victoria from 15 June 2009 to 31 December 2010, using stepwise deterministic data linkage techniques. MAIN OUTCOME MEASURES:Association of patient characteristics, social circumstances, processes of care and discharge outcomes with all-cause readmissions within 1 year from time of hospital discharge after an index admission for stroke or TIA. RESULTS:Of 788 patients registered in the AuSCR, 46% (359/781) were female, 83% (658/788) had a stroke, and the median age was 76 years. Data were successfully linked for 782 of these patients (99%). Within 1 year of their index stroke or TIA event, 42% of patients (291/685) were readmitted, with 12% (35/286) readmitted due to a stroke or TIA. Factors significantly associated with 1-year hospital readmission were two or more presentations to an emergency department before the index event (adjusted odds ratio [aOR], 1.57; 95% CI, 1.02-2.43), higher Charlson comorbidity index score (aOR, 1.19; 95% CI, 1.07-1.32) and diagnosis of TIA on the index admission (aOR, 2.15; 95% CI, 1.30-3.56). CONCLUSIONS:Linking clinical registry data with routinely collected hospital data for stroke and TIA is feasible in Victoria. Using these linked data, we found that readmission to hospital is common in this patient group and is related to their comorbid conditions.
Hospital readmission risks in older adults following inpatient subacute care: A six-month follow-up study.
Lee Den-Ching A,Williams Cylie,Lalor Aislinn F,Brown Ted,Haines Terry P
Archives of gerontology and geriatrics
BACKGROUND:High rates of unplanned hospital readmissions are a burden on healthcare systems and individuals. This study examined factors at, and after initial hospital discharge and their associations with unplanned hospital readmission for older adults up to six months post-discharge from subacute care. METHODS:Older subacute care patients were surveyed prior to discharge, and assessed monthly post-discharge for six months. Data included the Geriatric Depression Scale, Phone-Fitt sub-scales, Friendship Scale, modified Lubben Social Network Scale, unplanned hospital readmission, self-reported physical capacity and falls in the last month were collected. Regression analyses were used to examine relationships between unplanned hospital readmission and variables that may predispose this outcome. RESULTS:Participants (n = 311) completed the baseline assessment. N = 218 (70%) completed all at six-month post-discharge. Eighty-nine (29%) participants shared 143 readmissions. Those with cancer history (adjusted OR [95% CI]) (1.97 [1.15, 3.39]), neurological disease other than stroke (2.95 [1.32, 6.57]) and dependence on others to assist in bending tasks (1.94 [1.14, 3.29]) at initial discharge were associated with readmission within six months post-discharge. Those who fell in the last month (adjusted OR [robust 95% CI]) (2.28 [1.43, 3.64]), being less physical active (0.98 [0.96, 0.99]), and dependence on others in moving around residence (2.63 [1.37, 5.06]) after initial discharge were associated with a readmission in the next month within six months post-discharge. CONCLUSION:Trials investigating the effectiveness of strategies to reduce falls, build physical capacity, increase physical activity level, and connection with health care services after discharge to prevent readmission are warranted.
Towards a better understanding of readmissions after stroke: partnering with stroke survivors and caregivers.
White Carole L,Brady Tracy L,Saucedo Laura L,Motz Deb,Sharp Johanna,Birnbaum Lee A
Journal of clinical nursing
AIMS AND OBJECTIVES:To describe the experience of readmission from the perspective of the stroke survivor and family caregiver. BACKGROUND:Older stroke survivors are at an increased risk for readmission with approximately 40% being readmitted in the first year after stroke. Patients and their families are best positioned to provide information about factors associated with readmission, yet their perspectives have rarely been elicited. DESIGN:Descriptive qualitative study. METHODS:This study included older stroke survivors who were readmitted to acute care from home in the six months following stroke, and their family caregivers. Participants were interviewed by telephone at approximately two weeks after discharge and a sub-set was also interviewed in person during the readmission. Interviews were audio-taped and content analysis was used to identify themes. RESULTS:From the 29 semi-structured interviews conducted with 20 stroke survivors and/or their caregivers, the following themes were identified: preparing to go home after the stroke, what to expect at home, complexity of medication management, support for self-care in the community and the influence of social factors. CONCLUSIONS:This study provides the critical perspective of the stroke survivor and family caregiver into furthering our understanding of readmissions after stroke. Participants identified several areas for intervention including better discharge preparation and the need for support in the community for medication management and self-care. The findings suggest that interventions designed to reduce readmissions after stroke should be multifaceted in approach and extend across the continuum of care. RELEVANCE TO CLINICAL PRACTICE:The hospital level has been the focus of interventions to reduce preventable readmissions, but the results of this study suggest the importance of community-level care. The individual nature of each situation must be taken into account, including the postdischarge environment and the availability of social support.
Hospital readmission in persons with stroke following postacute inpatient rehabilitation.
Ottenbacher K J,Graham J E,Ottenbacher A J,Lee J,Al Snih S,Karmarkar A,Reistetter T,Ostir G V
The journals of gerontology. Series A, Biological sciences and medical sciences
BACKGROUND:Readmission is an important quality indicator following acute care hospitalization. We examined factors associated with hospital readmission in persons with stroke following postacute inpatient rehabilitation. METHODS:Prospective cohort study including 674 persons with stroke who received rehabilitation at 11 facilities located in eight states and the District of Columbia. Measures included hospital readmission within 3 months of discharge, sociodemographic characteristics, length of stay, primary payment source, comorbidities, stroke type, standardized assessments of motor and cognitive function, depressive symptoms, and social support. RESULTS:Mean age was 71.5 years (SD = 10.5). Twenty-five percent of patients reported high depressive symptoms. Overall, 18% (n = 122) of the sample was rehospitalized. Univariate analyses showed that people who were rehospitalized were more likely (p < .05) to be non-Hispanic white, married, demonstrate less functional independence at discharge, experience longer lengths of stay in rehabilitation, and report more depressive symptoms and lower social support. In the fully adjusted multivariable hierarchical generalized linear model, motor functional status (OR = 0.98, 95% CI 0.96-0.99), depressive symptoms (OR = 1.80, 95% CI 1.06-3.05), and social support (OR = 2.28, 95% CI 1.29-4.03) remained statistically significant. In addition, a minority-by-depressive symptoms interaction term also reached statistical significance. CONCLUSION:Functional status, depressive symptoms, and social support were important predictors of hospital readmission. These variables are not included in most administrative data sets. Future research to develop useful risk-adjustment models for rehospitalization following postacute inpatient rehabilitation services should include large diverse samples and explore practical sources for additional meaningful information.
Stroke Risk Factors, Genetics, and Prevention.
Boehme Amelia K,Esenwa Charles,Elkind Mitchell S V
Stroke is a heterogeneous syndrome, and determining risk factors and treatment depends on the specific pathogenesis of stroke. Risk factors for stroke can be categorized as modifiable and nonmodifiable. Age, sex, and race/ethnicity are nonmodifiable risk factors for both ischemic and hemorrhagic stroke, while hypertension, smoking, diet, and physical inactivity are among some of the more commonly reported modifiable risk factors. More recently described risk factors and triggers of stroke include inflammatory disorders, infection, pollution, and cardiac atrial disorders independent of atrial fibrillation. Single-gene disorders may cause rare, hereditary disorders for which stroke is a primary manifestation. Recent research also suggests that common and rare genetic polymorphisms can influence risk of more common causes of stroke, due to both other risk factors and specific stroke mechanisms, such as atrial fibrillation. Genetic factors, particularly those with environmental interactions, may be more modifiable than previously recognized. Stroke prevention has generally focused on modifiable risk factors. Lifestyle and behavioral modification, such as dietary changes or smoking cessation, not only reduces stroke risk, but also reduces the risk of other cardiovascular diseases. Other prevention strategies include identifying and treating medical conditions, such as hypertension and diabetes, that increase stroke risk. Recent research into risk factors and genetics of stroke has not only identified those at risk for stroke but also identified ways to target at-risk populations for stroke prevention.
Stroke risk factors in an incident population in urban and rural Tanzania: a prospective, community-based, case-control study.
The Lancet. Global health
BACKGROUND:The burden of stroke on health systems in low-income and middle-income countries is increasing. However, high-quality data for modifiable stroke risk factors in sub-Saharan Africa are scarce, with no community based, case-control studies previously published. We aimed to identify risk factors for stroke in an incident population from rural and urban Tanzania. METHODS:Stroke cases from urban Dar-es-Salaam and the rural Hai district were recruited in a wider study of stroke incidence between June 15, 2003, and June 15, 2006. We included cases with fi rst-ever and recurrent stroke. Community-acquired controls recruited from the background census populations of the two study regions were matched with cases for age and sex and were interviewed and assessed. Data relating to medical and social history were recorded and blood samples taken. FINDINGS:We included 200 stroke cases (69 from Dar-es-Salaam and 131 from Hai) and 398 controls (138 from Dar-es-Salaam and 260 from Hai). Risk factors were similar at both sites, with previous cardiac event (odds ratio [OR] 7.39, 95% CI 2.42-22.53; p<0.0001), HIV infection (5.61, 2.41-13.09; p<0.0001), a high ratio of total cholesterol to HDL cholesterol (4.54, 2.49-8.28; p<0.0001), smoking (2.72, 1.49-4.96; p=0.001), and hypertension (2.14, 1.09-4.17; p=0.026) identified as significant independent risk factors for stroke. In Hai, additional risk factors of diabetes (4.04, 1.29-12.64) and low HDL cholesterol (9.84, 4.06-23.84) were also significant. INTERPRETATION:We have identified many of the risk factors for stroke already reported for other world regions. HIV status was an independent risk factor for stroke within an antiretroviral-naive population. Clinicians should be aware of the increased risk of stroke in people with HIV, even in the absence of antiretroviral treatment.
Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study.
O'Donnell Martin J,Chin Siu Lim,Rangarajan Sumathy,Xavier Denis,Liu Lisheng,Zhang Hongye,Rao-Melacini Purnima,Zhang Xiaohe,Pais Prem,Agapay Steven,Lopez-Jaramillo Patricio,Damasceno Albertino,Langhorne Peter,McQueen Matthew J,Rosengren Annika,Dehghan Mahshid,Hankey Graeme J,Dans Antonio L,Elsayed Ahmed,Avezum Alvaro,Mondo Charles,Diener Hans-Christoph,Ryglewicz Danuta,Czlonkowska Anna,Pogosova Nana,Weimar Christian,Iqbal Romaina,Diaz Rafael,Yusoff Khalid,Yusufali Afzalhussein,Oguz Aytekin,Wang Xingyu,Penaherrera Ernesto,Lanas Fernando,Ogah Okechukwu S,Ogunniyi Adesola,Iversen Helle K,Malaga German,Rumboldt Zvonko,Oveisgharan Shahram,Al Hussain Fawaz,Magazi Daliwonga,Nilanont Yongchai,Ferguson John,Pare Guillaume,Yusuf Salim,
Lancet (London, England)
BACKGROUND:Stroke is a leading cause of death and disability, especially in low-income and middle-income countries. We sought to quantify the importance of potentially modifiable risk factors for stroke in different regions of the world, and in key populations and primary pathological subtypes of stroke. METHODS:We completed a standardised international case-control study in 32 countries in Asia, America, Europe, Australia, the Middle East, and Africa. Cases were patients with acute first stroke (within 5 days of symptom onset and 72 h of hospital admission). Controls were hospital-based or community-based individuals with no history of stroke, and were matched with cases, recruited in a 1:1 ratio, for age and sex. All participants completed a clinical assessment and were requested to provide blood and urine samples. Odds ratios (OR) and their population attributable risks (PARs) were calculated, with 99% confidence intervals. FINDINGS:Between Jan 11, 2007, and Aug 8, 2015, 26 919 participants were recruited from 32 countries (13 447 cases [10 388 with ischaemic stroke and 3059 intracerebral haemorrhage] and 13 472 controls). Previous history of hypertension or blood pressure of 140/90 mm Hg or higher (OR 2·98, 99% CI 2·72-3·28; PAR 47·9%, 99% CI 45·1-50·6), regular physical activity (0·60, 0·52-0·70; 35·8%, 27·7-44·7), apolipoprotein (Apo)B/ApoA1 ratio (1·84, 1·65-2·06 for highest vs lowest tertile; 26·8%, 22·2-31·9 for top two tertiles vs lowest tertile), diet (0·60, 0·53-0·67 for highest vs lowest tertile of modified Alternative Healthy Eating Index [mAHEI]; 23·2%, 18·2-28·9 for lowest two tertiles vs highest tertile of mAHEI), waist-to-hip ratio (1·44, 1·27-1·64 for highest vs lowest tertile; 18·6%, 13·3-25·3 for top two tertiles vs lowest), psychosocial factors (2·20, 1·78-2·72; 17·4%, 13·1-22·6), current smoking (1·67, 1·49-1·87; 12·4%, 10·2-14·9), cardiac causes (3·17, 2·68-3·75; 9·1%, 8·0-10·2), alcohol consumption (2·09, 1·64-2·67 for high or heavy episodic intake vs never or former drinker; 5·8%, 3·4-9·7 for current alcohol drinker vs never or former drinker), and diabetes mellitus (1·16, 1·05-1·30; 3·9%, 1·9-7·6) were associated with all stroke. Collectively, these risk factors accounted for 90·7% of the PAR for all stroke worldwide (91·5% for ischaemic stroke, 87·1% for intracerebral haemorrhage), and were consistent across regions (ranging from 82·7% in Africa to 97·4% in southeast Asia), sex (90·6% in men and in women), and age groups (92·2% in patients aged ≤55 years, 90·0% in patients aged >55 years). We observed regional variations in the importance of individual risk factors, which were related to variations in the magnitude of ORs (rather than direction, which we observed for diet) and differences in prevalence of risk factors among regions. Hypertension was more associated with intracerebral haemorrhage than with ischaemic stroke, whereas current smoking, diabetes, apolipoproteins, and cardiac causes were more associated with ischaemic stroke (p<0·0001). INTERPRETATION:Ten potentially modifiable risk factors are collectively associated with about 90% of the PAR of stroke in each major region of the world, among ethnic groups, in men and women, and in all ages. However, we found important regional variations in the relative importance of most individual risk factors for stroke, which could contribute to worldwide variations in frequency and case-mix of stroke. Our findings support developing both global and region-specific programmes to prevent stroke. FUNDING:Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Health Research Board Ireland, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland (Sweden), AstraZeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MSD, Chest, Heart and Stroke Scotland, and The Stroke Association, with support from The UK Stroke Research Network.
Global burden of stroke and risk factors in 188 countries, during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.
Feigin Valery L,Roth Gregory A,Naghavi Mohsen,Parmar Priya,Krishnamurthi Rita,Chugh Sumeet,Mensah George A,Norrving Bo,Shiue Ivy,Ng Marie,Estep Kara,Cercy Kelly,Murray Christopher J L,Forouzanfar Mohammad H,
The Lancet. Neurology
BACKGROUND:The contribution of modifiable risk factors to the increasing global and regional burden of stroke is unclear, but knowledge about this contribution is crucial for informing stroke prevention strategies. We used data from the Global Burden of Disease Study 2013 (GBD 2013) to estimate the population-attributable fraction (PAF) of stroke-related disability-adjusted life-years (DALYs) associated with potentially modifiable environmental, occupational, behavioural, physiological, and metabolic risk factors in different age and sex groups worldwide and in high-income countries and low-income and middle-income countries, from 1990 to 2013. METHODS:We used data on stroke-related DALYs, risk factors, and PAF from the GBD 2013 Study to estimate the burden of stroke by age and sex (with corresponding 95% uncertainty intervals [UI]) in 188 countries, as measured with stroke-related DALYs in 1990 and 2013. We evaluated attributable DALYs for 17 risk factors (air pollution and environmental, dietary, physical activity, tobacco smoke, and physiological) and six clusters of risk factors by use of three inputs: risk factor exposure, relative risks, and the theoretical minimum risk exposure level. For most risk factors, we synthesised data for exposure with a Bayesian meta-regression method (DisMod-MR) or spatial-temporal Gaussian process regression. We based relative risks on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks, such as high body-mass index (BMI), through other risks, such as high systolic blood pressure (SBP) and high total cholesterol. FINDINGS:Globally, 90·5% (95% UI 88·5-92·2) of the stroke burden (as measured in DALYs) was attributable to the modifiable risk factors analysed, including 74·2% (95% UI 70·7-76·7) due to behavioural factors (smoking, poor diet, and low physical activity). Clusters of metabolic factors (high SBP, high BMI, high fasting plasma glucose, high total cholesterol, and low glomerular filtration rate; 72·4%, 95% UI 70·2-73·5) and environmental factors (air pollution and lead exposure; 33·4%, 95% UI 32·4-34·3) were the second and third largest contributors to DALYs. Globally, 29·2% (95% UI 28·2-29·6) of the burden of stroke was attributed to air pollution. Although globally there were no significant differences between sexes in the proportion of stroke burden due to behavioural, environmental, and metabolic risk clusters, in the low-income and middle-income countries, the PAF of behavioural risk clusters in males was greater than in females. The PAF of all risk factors increased from 1990 to 2013 (except for second-hand smoking and household air pollution from solid fuels) and varied significantly between countries. INTERPRETATION:Our results suggest that more than 90% of the stroke burden is attributable to modifiable risk factors, and achieving control of behavioural and metabolic risk factors could avert more than three-quarters of the global stroke burden. Air pollution has emerged as a significant contributor to global stroke burden, especially in low-income and middle-income countries, and therefore reducing exposure to air pollution should be one of the main priorities to reduce stroke burden in these countries. FUNDING:Bill & Melinda Gates Foundation, American Heart Association, US National Heart, Lung, and Blood Institute, Columbia University, Health Research Council of New Zealand, Brain Research New Zealand Centre of Research Excellence, and National Science Challenge, Ministry of Business, Innovation and Employment of New Zealand.
Comparative study on short-term and long-term prognostic determinants in patients with acute cerebral infarction.
Wang Jie,Yu Xiao-Du,Li Guang-Qin
International journal of clinical and experimental medicine
BACKGROUND:At present, there are many studies on prognostic determinants in patients with acute cerebral infarction, while studies on short-term and long-term prognostic determinants are less. The purpose of this study was to explore the short-term and long-term association and same and different points of prognostic determinants in patients with acute cerebral infarction for guiding clinical treatment. METHODS:201 patients with acute cerebral infarction were included in the study, whose neurological functions were assessed via National Institute of Health Stroke Scale (NIHSS) within 24 h and computed tomography or magnetic resonance imaging were performed within 48 h of symptom onset. All of the patients were administered with same medication regimen (including medication and rehabilitation). The NIHSS and the modified Rankin Scale were used to assess the extent of disability at 15 d after admission and one year, respectively. Short-term and long-term prognostic determinants and its association were analyzed by single and multivariable logistic regression. RESULTS:Infarct volume correlated with short-term prognosis (OR = 3.543, 95% CI: 1.632~10.212), while it showed no correlation with long-term prognosis; concurrent infection was independent risk factor for short-term prognosis of acute cerebral infarction (OR = 2.532, 95% CI: 1.803~6.886). Baseline NIHSS score independently correlated with short-term and long-term prognosis (odds ratio, respectively: OR = 1.880, 95% CI: 1.462~6.679; OR = 1.761, 95% CI: 1.372~6.758); gender (OR = 0.311, 95% CI: 0.140~0.681) and basal ganglia infarction (OR = 2.263, 95% CI: 1.349~11.662) were independently associated with long-term prognosis, while it showed no significant correlation with short-term prognosis. Short-term prognosis effect was an independent predictor for long-term prognosis (OR = 0.487, 95% CI: 0.141~0.895). Age, hospitalization time, short-term and long-term prognosis of patients showed no significant correlation. CONCLUSION:There were differences between short-term and long-term prognosis of acute cerebral infarction. Short-term prognosis effect was an independent predictor for long-term prognosis. For controllable factors, active intervene should be taken in order to improve prognosis of patients.
Surveillance for Certain Health Behaviors and Conditions Among States and Selected Local Areas - Behavioral Risk Factor Surveillance System, United States, 2013 and 2014.
Gamble Sonya,Mawokomatanda Tebitha,Xu Fang,Chowdhury Pranesh P,Pierannunzi Carol,Flegel David,Garvin William,Town Machell
Morbidity and mortality weekly report. Surveillance summaries (Washington, D.C. : 2002)
PROBLEM:Chronic diseases and conditions (e.g., heart diseases, stroke, arthritis, and diabetes) are the leading causes of morbidity and mortality in the United States. These conditions are costly to the U.S. economy, yet they are often preventable or controllable. Behavioral risk factors (e.g., excessive alcohol consumption, tobacco use, poor diet, frequent mental distress, and insufficient sleep) are linked to the leading causes of morbidity and mortality. Adopting positive health behaviors (e.g., staying physically active, quitting tobacco use, obtaining routine physical checkups, and checking blood pressure and cholesterol levels) can reduce morbidity and mortality from chronic diseases and conditions. Monitoring the health risk behaviors, chronic diseases and conditions, access to health care, and use of preventive health services at multilevel public health points (states, territories, and metropolitan and micropolitan statistical areas [MMSA]) can provide important information for development and evaluation of health intervention programs. REPORTING PERIOD:2013 and 2014. DESCRIPTION OF THE SYSTEM:The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, random-digit-dialed telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. BRFSS collects data on health risk behaviors, chronic diseases and conditions, access to health care, and use of preventive health services and practices related to the leading causes of death and disability in the United States and participating territories. This is the first BRFSS report to include age-adjusted prevalence estimates. For 2013 and 2014, these age-adjusted prevalence estimates are presented for all 50 states, the District of Columbia, the Commonwealth of Puerto Rico, Guam, and selected MMSA. RESULTS:Age-adjusted prevalence estimates of health status indicators, health care access and preventive practices, health risk behaviors, chronic diseases and conditions, and cardiovascular conditions vary by state, territory, and MMSA. Each set of proportions presented refers to the range of age-adjusted prevalence estimates of selected BRFSS measures as reported by survey respondents. The following are estimates for 2013. Adults reporting frequent mental distress: 7.7%-15.2% in states and territories and 6.3%-19.4% in MMSA. Adults with inadequate sleep: 27.6%-49.2% in states and territories and 26.5%-44.4% in MMSA. Adults aged 18-64 years having health care coverage: 66.9%-92.4% in states and territories and 60.5%-97.6% in MMSA. Adults identifying as current cigarette smokers: 10.1%-28.8% in states and territories and 6.1%-33.6% in MMSA. Adults reporting binge drinking during the past month: 10.5%-25.2% in states and territories and 7.2%-25.3% in MMSA. Adults with obesity: 21.0%-35.2% in states and territories and 12.1%-37.1% in MMSA. Adults aged ≥45 years with some form of arthritis: 30.6%-51.0% in states and territories and 27.6%-52.4% in MMSA. Adults aged ≥45 years who have had coronary heart disease: 7.4%-17.5% in states and territories and 6.2%-20.9% in MMSA. Adults aged ≥45 years who have had a stroke: 3.1%-7.5% in states and territories and 2.3%-9.4% in MMSA. Adults with high blood pressure: 25.2%-40.1% in states and territories and 22.2%-42.2% in MMSA. Adults with high blood cholesterol: 28.8%-38.4% in states and territories and 26.3%-39.6% in MMSA. The following are estimates for 2014. Adults reporting frequent physical distress: 7.8%-16.0% in states and territories and 6.2%-18.5% in MMSA. Women aged 21-65 years who had a Papanicolaou test during the past 3 years: 67.7%-87.8% in states and territories and 68.0%-94.3% in MMSA. Adults aged 50-75 years who received colorectal cancer screening on the basis of the 2008 U.S. Preventive Services Task Force recommendation: 42.8%-76.7% in states and territories and 49.1%-79.6% in MMSA. Adults with inadequate sleep: 28.4%-48.6% in states and territories and 25.4%-45.3% in MMSA. Adults reporting binge drinking during the past month: 10.7%-25.1% in states and territories and 6.7%-26.3% in MMSA. Adults aged ≥45 years who have had coronary heart disease: 8.0%-17.1% in states and territories and 7.6%-19.2% in MMSA. Adults aged ≥45 years with some form of arthritis: 31.2%-54.7% in states and territories and 28.4%-54.7% in MMSA. Adults with obesity: 21.0%-35.9% in states and territories and 19.7%-42.5% in MMSA. INTERPRETATION:Prevalence of certain chronic diseases and conditions, health risk behaviors, and use of preventive health services varies among states, territories, and MMSA. The findings of this report highlight the need for continued monitoring of health status, health care access, health behaviors, and chronic diseases and conditions at state and local levels. PUBLIC HEALTH ACTION:State and local health departments and agencies can continue to use BRFSS data to identify populations at risk for certain unhealthy behaviors and chronic diseases and conditions. Data also can be used to design, monitor, and evaluate public health programs at state and local levels.
Comparison of risk perceptions and beliefs across common chronic diseases.
Wang Catharine,O'Neill Suzanne M,Rothrock Nan,Gramling Robert,Sen Ananda,Acheson Louise S,Rubinstein Wendy S,Nease Donald E,Ruffin Mack T,
OBJECTIVES:Few studies have compared perceptions of risk, worry, severity and control across multiple diseases. This paper examines how these perceptions vary for heart disease, diabetes, stroke, and colon, breast, and ovarian cancers. METHODS:The data for this study came from the Family Healthware Impact Trial (FHITr), conducted in the United States from 2005 to 2007. Healthy adults (N=2362) from primary care practices recorded their perceptions at baseline for each disease. Analyses were conducted controlling for study site and personal risk factors. RESULTS:Perceived risk was significantly higher for cancers than for other diseases. Men worried most about getting heart disease; women worried most about getting breast cancer, followed by heart disease. Diabetes was perceived to be the least severe condition. Heart disease was perceived to be the most controllable compared to cancers, which were perceived to be the least controllable. Women had higher perceived risk and worry ratings compared to men for several diseases. CONCLUSIONS:These data highlight how individuals comparatively view chronic diseases. Addressing prior disease perceptions when communicating multiple disease risks may facilitate an accurate understanding of risk for diseases, and help individuals to effectively identify and engage in relevant behaviors to reduce their risk.
A Hybrid Risk Assessment Model for Cardiovascular Disease Using Cox Regression Analysis and a 2-means clustering algorithm.
Vivekanandan T,Narayanan Swathi Jamjala
Computers in biology and medicine
Cardiovascular disease (CVD) refers to a state that indicates narrowed or blocked blood vessels, and it can lead to cardiac arrest, chest pain (angina) or stroke. CVD is a leading cause of silent massive heart attacks and is a major threat to life. The mere prediction of the presence or absence of CVD alone is inefficient in current scenarios. Rather, a major need has arisen for the prediction of CVD, the acquisition of knowledge about CVD and the assessment of the likelihood that an individual will experience cardiac arrest. The objective of establishing an individual CVD risk assessment has been attained in this paper using a hybrid model. The CVD of an individual is due to various controllable and uncontrollable factors. The computation and analysis of all these factors are difficult and time consuming. Only a few attributes are identified to be the most critical. This optimization of the critical features is performed using a modified Differential Evolution (DE) algorithm. The identified critical factors are sufficient to predict the presence/absence of CVD. In this paper, these identified critical features of individuals are considered using Cox regression analysis that evaluates the prevalence rates of the critical attributes. These individual prevalence rates together predict the cumulative prevalence ratios of the respective individuals. This cumulative prevalence ratio of an individual, along with the class attribute, is processed using the 2-means clustering technique to determine the risk of a particular individual developing CVD. The evaluation of the risk assessment model is carried out in this paper by calculating the prediction accuracy of the Cox regression analysis and the Davies-Bouldin (DB) index for 2-means clustering. The Cox regression analysis results in a 91% CVD prediction accuracy using the critical attributes and is comparatively higher than that of other models. The DB index of 2-means clustering with specific initial means for clusters of individuals with CVD is 0.282 and that for clusters of individuals without CVD is 0.2836, which are comparatively lower than those of the traditional k-means clustering algorithm.
Social work's partnership in community-based stroke prevention for older adults: a collaborative model.
Mjelde-Mossey Lee Ann
Social work in health care
Stroke prevention includes public education and community- based screenings to identify stroke risks. Even though more than half of all strokes are preventable, the incidence has increased in recent years and remains the leading cause of adult disability. Age is highly associated with stroke and twice as likely to occur with each decade after age 55. Risks fall into one of two categories. One category, such as obesity and high blood pressure, are controllable through behavior change and/or preventive medical care. The other category of risks, such as age or race, are not controllable. Stroke risks tend to occur in multiples that interact to heighten individual effects, thus, interdisciplinary methods to identify and reduce risk may be required. Social workers can play a key role in these partnerships. Social work's skills base in gerontology, psychosocial interventions, and empowerment through community organization are ideal for early intervention and behavior change. This article describes a collaborative community-based model for screening older adults for stroke risk and lessons learned from a three-month risk reduction follow-up.
Migraine and risk of perioperative ischemic stroke and hospital readmission: hospital based registry study.
Timm Fanny P,Houle Timothy T,Grabitz Stephanie D,Lihn Anne-Louise,Stokholm Janne B,Eikermann-Haerter Katharina,Nozari Ala,Kurth Tobias,Eikermann Matthias
BMJ (Clinical research ed.)
OBJECTIVE: To evaluate whether patients with migraine are at increased risk of perioperative ischemic stroke and whether this may lead to an increased hospital readmission rate. DESIGN: Prospective hospital registry study. SETTING: Massachusetts General Hospital and two satellite campuses between January 2007 and August 2014. PARTICIPANTS: 124 558 surgical patients (mean age 52.6 years; 54.5% women). MAIN OUTCOME MEASURES: The primary outcome was perioperative ischemic stroke occurring within 30 days after surgery in patients with and without migraine and migraine aura. The secondary outcome was hospital readmission within 30 days of surgery. Exploratory outcomes included post-discharge stroke and strata of neuroanatomical stroke location. RESULTS: 10 179 (8.2%) patients had any migraine diagnosis, of whom 1278 (12.6%) had migraine with aura and 8901 (87.4%) had migraine without aura. 771 (0.6%) perioperative ischemic strokes occurred within 30 days of surgery. Patients with migraine were at increased risk of perioperative ischemic stroke (adjusted odds ratio 1.75, 95% confidence interval 1.39 to 2.21) compared with patients without migraine. The risk was higher in patients with migraine with aura (adjusted odds ratio 2.61, 1.59 to 4.29) than in those with migraine without aura (1.62, 1.26 to 2.09). The predicted absolute risk is 2.4 (2.1 to 2.8) perioperative ischemic strokes for every 1000 surgical patients. This increases to 4.3 (3.2 to 5.3) for every 1000 patients with any migraine diagnosis, 3.9 (2.9 to 5.0) for migraine without aura, and 6.3 (3.2 to 9.5) for migraine with aura. : Patients with migraine had a higher rate of readmission to hospital within 30 days of discharge (adjusted odds ratio 1.31, 1.22 to 1.41). CONCLUSIONS: Surgical patients with a history of migraine are at increased risk of perioperative ischemic stroke and have an increased 30 day hospital readmission rate. Migraine should be considered in the risk assessment for perioperative ischemic stroke.
Effect of clinical and social risk factors on hospital profiling for stroke readmission: a cohort study.
Keyhani Salomeh,Myers Laura J,Cheng Eric,Hebert Paul,Williams Linda S,Bravata Dawn M
Annals of internal medicine
BACKGROUND:The Centers for Medicare & Medicaid Services (CMS) and Veterans Health Administration (VA) will report 30-day stroke readmission rates as a measure of hospital quality. A national debate on whether social risk factors should be included in models developed for hospital profiling is ongoing. OBJECTIVE:To compare a CMS-based model of 30-day readmission with a more comprehensive model that includes measures of social risk (such as homelessness) or clinical factors (such as stroke severity and functional status). DESIGN:Data from a retrospective cohort study were used to develop a CMS-based 30-day readmission model that included age and comorbid conditions based on codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (model 1). This model was then compared with one that included administrative social risk factors (model 2). Finally, the CMS model (model 1) was compared with a model that included social risk and clinical factors from chart review (model 3). These 3 models were used to rank hospitals by 30-day risk-standardized readmission rates and examine facility rankings among the models. SETTING:Hospitals in the VA. PARTICIPANTS:Patients hospitalized with stroke in 2007. MEASUREMENTS:30-day readmission rates. RESULTS:The 30-day readmission rate was 12.8%. The c-statistics for the 3 models were 0.636, 0.646, and 0.661, respectively. All hospitals were classified as performing "as expected" using all 3 models (that is, performance did not differ from the VA national average); therefore, the addition of detailed clinical information or social risk factors did not alter assessment of facility performance. LIMITATION:A predominantly male veteran cohort limits the generalizability of these findings. CONCLUSION:In the VA, more comprehensive models that included social risk and clinical factors did not affect hospital comparisons based on 30-day readmission rates. PRIMARY FUNDING SOURCE:U.S. Department of Veterans Affairs.
30-Day Readmissions After Endovascular Thrombectomy for Acute Ischemic Stroke.
Elgendy Islam Y,Omer Mohamed A,Kennedy Kevin F,Mansoor Hend,Mahmoud Ahmed N,Mojadidi Mohammad K,Abraham Michael G,Enriquez Jonathan R,Jneid Hani,Spertus John A,Bhatt Deepak L
JACC. Cardiovascular interventions
OBJECTIVES:The authors sought to investigate the incidence, predictors, and causes of 30-day nonelective readmissions after endovascular thrombectomy (EVT). BACKGROUND:Randomized trials have demonstrated that EVT improves outcomes in patients with acute ischemic stroke. METHODS:The Nationwide Readmissions Database, years 2013 and 2014, was used to identify hospitalizations for a primary diagnosis of acute ischemic stroke during which patients underwent EVT, with or without intravenous thrombolysis. The incidence and reasons of 30-day readmissions were investigated. A hierarchical Cox regression model was used to identify independent predictors of 30-day nonelective readmissions. A propensity score-matched analysis was performed to compare the risk of 30-day nonelective readmissions in those who underwent EVT versus thrombolysis alone. RESULTS:Among 2,055,365 weighted hospitalizations with acute ischemic stroke and survival to discharge, 10,795 (0.5%) underwent EVT. The 30-day readmission rate was 12.4% within a median of 9 days (interquartile range: 4 to 18 days). Diabetes mellitus, coagulopathy, Medicare or Medicaid insurance, and gastrostomy during the index hospitalization were independent predictors of 30-day readmission, but coadministration of thrombolytics with EVT was not an independent predictor. The most common reasons for readmission were infections (17.2%), cardiac causes (17.0%), and recurrent stroke or transient ischemic attack (14.8%). Compared with thrombolysis alone, the hazard of 30-day readmissions was similar (hazard ratio: 0.98; 95% confidence interval: 0.91 to 1.05; p = 0.55). CONCLUSIONS:In patients hospitalized with acute ischemic stroke who underwent EVT, 30-day nonelective readmissions were common, occurring in approximately 1 in 8 patients, but were similar to those of patients treated with thrombolysis alone. Risk of readmission was associated with certain patient demographics, comorbidities, and complications, but not thrombolysis coadministration. Infections, cardiac causes, and recurrent stroke or transient ischemic attack are the most common reasons for readmission after EVT, emphasizing the need for comprehensive multidisciplinary treatment in the transition to outpatient care.
Post-Acute Care Data for Predicting Readmission After Ischemic Stroke: A Nationwide Cohort Analysis Using the Minimum Data Set.
Fehnel Corey R,Lee Yoojin,Wendell Linda C,Thompson Bradford B,Potter N Stevenson,Mor Vincent
Journal of the American Heart Association
BACKGROUND:Reducing hospital readmissions is a key component of reforms for stroke care. Current readmission prediction models lack accuracy and are limited by data being from only acute hospitalizations. We hypothesized that patient-level factors from a nationwide post-acute care database would improve prediction modeling. METHODS AND RESULTS:Medicare inpatient claims for the year 2008 that used International Classification of Diseases, Ninth Revision codes were used to identify ischemic stroke patients older than age 65. Unique individuals were linked to comprehensive post-acute care assessments through use of the Minimum Data Set (MDS). Logistic regression was used to construct risk-adjusted readmission models. Covariates were derived from MDS variables. Among 39 178 patients directly admitted to nursing homes after hospitalization due to acute stroke, there were 29 338 (75%) with complete MDS assessments. Crude rates of readmission and death at 30 days were 8448 (21%) and 2791 (7%), respectively. Risk-adjusted models identified multiple independent predictors of all-cause 30-day readmission. Model performance of the readmission model using MDS data had a c-statistic of 0.65 (95% CI 0.64 to 0.66). Higher levels of social engagement, a marker of nursing home quality, were associated with progressively lower odds of readmission (odds ratio 0.71, 95% CI 0.55 to 0.92). CONCLUSIONS:Individual clinical characteristics from the post-acute care setting resulted in only modest improvement in the c-statistic relative to previous models that used only Medicare Part A data. Individual-level characteristics do not sufficiently account for the risk of acute hospital readmission.
Predictors of 30-day hospital readmission following ischemic and hemorrhagic stroke.
Strowd Roy E,Wise Starla M,Umesi U Natalie,Bishop Laura,Craig Jeffrey,Lefkowitz David,Reynolds Patrick S,Tegeler Charles,Arnan Martinson,Duncan Pamela W,Bushnell Cheryl D
American journal of medical quality : the official journal of the American College of Medical Quality
Stroke patients have a high rate of 30-day readmission. Understanding the characteristics of patients at high risk of readmission is critical. A retrospective case-control study was designed to determine factors associated with 30-day readmission after stroke. A total of 79 cases with acute ischemic or hemorrhagic strokes readmitted to the same hospital within 30 days were compared with 86 frequency-matched controls. Readmitted patients were more likely to have had ≥2 hospitalizations in the year prior to stroke (21.5% vs 2.3% in controls, P < .001), and in the multivariate model, admission National Institutes of Health Stroke Score (NIHSS; odds ratio [OR] = 1.072; 95% confidence interval [CI] = 1.021-1.126 per 1 point increase; P = .005), prior hospitalizations (OR = 2.205; 95% CI = 1.426-3.412 per admission; P < .001), and absence of hyperlipidemia (OR = 0.444; 95% CI = 0.221-0.894; P = .023) were independently associated with readmission. The research team concludes that admission NIHSS and frequent prior hospitalizations are associated with 30-day readmission after stroke. If validated, these characteristics identify high-risk patients and focus efforts to reduce readmission.
Factors associated with 28-day hospital readmission after stroke in Australia.
Kilkenny Monique F,Longworth Mark,Pollack Michael,Levi Christopher,Cadilhac Dominique A, ,
BACKGROUND AND PURPOSE:Understanding the factors that contribute to early readmission after discharge following stroke is limited. We aimed to describe the factors associated with 28-day readmission after hospitalization for stroke. METHODS:Factors associated with readmission were classified from the medical record standardized audits of 50 to 100 consecutively admitted patients with stroke from 35 Australian hospitals during multiple time periods (2000-2010). Factors were compared between patients readmitted and not readmitted after stroke hospitalization (n=43) grouped using 5 categories: patient characteristics (n=16; eg, age), clinical processes of care (n=13; eg, admitted into a stroke unit), social circumstances (n=3; eg, living home alone prior), health system (n=6; eg, location of hospital), and health outcome (n=5; eg, length of stay). Multilevel logistic regression modeling was used to examine the association with these independent factors selected if statistical significance P<0.15 or if considered clinically important and readmission status. RESULTS:Among 3328 patients, 6.5% were readmitted within 28 days (mean age, 75; 48% female; 92% ischemic). After bivariate analyses 14/43 factors from 4/5 categories were associated with readmission after hospitalization for stroke. Two factors from patient and health outcome categories remained independently associated with readmission after multivariable analyses. These were dependent premorbid functional status (adjusted odds ratio, 1.87; 95% confidence interval, 1.25-2.81) and having a severe adverse event during the initial hospitalization for stroke (adjusted odds ratio, 2.81; 95% confidence interval, 1.55-5.12). CONCLUSIONS:This is the first study to comprehensively evaluate factors associated with 28-day readmission after stroke. The factors associated with 28-day readmission are diverse and include potentially modifiable and nonmodifiable factors.
Factors Associated With 90-Day Readmission After Stroke or Transient Ischemic Attack: Linked Data From the Australian Stroke Clinical Registry.
Kilkenny Monique F,Dalli Lachlan L,Kim Joosup,Sundararajan Vijaya,Andrew Nadine E,Dewey Helen M,Johnston Trisha,Alif Sheikh M,Lindley Richard I,Jude Martin,Blacker David,Gange Nisal,Grimley Rohan,Katzenellenbogen Judith M,Thrift Amanda G,Lannin Natasha A,Cadilhac Dominique A,
Background and Purpose- Readmissions after stroke are common and appear to be associated with comorbidities or disability-related characteristics. In this study, we aimed to determine the patient and health-system level factors associated with all-cause and unplanned hospital readmission within 90 days after acute stroke or transient ischemic attack (TIA) in Australia. Methods- We used person-level linkages between data from the Australian Stroke Clinical Registry (2009-2013), hospital admissions data and national death registrations from 4 Australian states. Time to first readmission (all-cause or unplanned) for discharged patients was examined within 30, 90, and 365 days, using competing risks regression to account for deaths postdischarge. Covariates included age, stroke severity (ability to walk on admission), stroke type, admissions before stroke/TIA and the Charlson Comorbidity Index (derived from , [Australian modified] coded hospital data in the preceding 5 years). Results- Among the 13 594 patients discharged following stroke/TIA (45% female; 65% ischemic stroke; 11% intracerebral hemorrhage; 4% undetermined stroke; and 20% TIA), 25% had an all-cause readmission and 15% had an unplanned readmission within 90 days. In multivariable analyses, the factors independently associated with a greater risk of unplanned readmission within 90 days were being female (subhazard ratio, 1.13 [95% CI, 1.03-1.24]), greater Charlson Comorbidity Index scores (subhazard ratio, 1.11 [95% CI, 1.09-1.12]) and having an admission ≤90 days before the index event (subhazard ratio, 1.85 [95% CI, 1.59-2.15]). Compared with being discharged to rehabilitation or aged care, those who were discharged directly home were more likely to have an unplanned readmission within 90 days (subhazard ratio, 1.44 [95% CI, 1.33-1.55]). These factors were similar for readmissions within 30 and 365 days. Conclusions- Apart from comorbidities and patient-level characteristics, readmissions after stroke/TIA were associated with discharge destination. Greater support for transition to home after stroke/TIA may be needed to reduce unplanned readmissions.
One-year versus five-year hospital readmission after ischemic stroke and TIA.
Bjerkreim Anna Therese,Naess Halvor,Khanevski Andrej Netland,Thomassen Lars,Waje-Andreassen Ulrike,Logallo Nicola
BACKGROUND:The burden of hospital readmission after stroke is substantial, but little knowledge exists on factors associated with long-term readmission after stroke. In a cohort comprising patients with ischemic stroke and transient ischemic attack (TIA), we examined and compared factors associated with readmission within 1 year and first readmission during year 2-5. METHODS:Patients with ischemic stroke or TIA who were discharged alive between July 2007 and October 2012, were followed for 5 years by review of medical charts. The timing and primary cause of the first unplanned readmission were registered. Cox regression was used to identify independent risk factors for readmission within 1 year and first readmission during year 2-5 after discharge. RESULTS:The cohort included 1453 patients, of whom 568 (39.1%) were readmitted within 1 year. Of the 830 patients that were alive and without readmission 1 year after discharge, 439 (52.9%) were readmitted within 5 years. Patients readmitted within 1 year were older, had more severe strokes, poorer functional outcome, and a higher occurrence of complications during index admission than patients readmitted during year 2-5. Cardiovascular comorbidity and secondary preventive treatment did not differ between the two groups of readmitted patients. Higher age, poorer functional outcome, coronary artery disease and hypertension were independently associated with readmission within both 1 year and during year 2-5. Peripheral artery disease was independently associated with readmission within 1 year, and atrial fibrillation was associated with readmission during year 2-5. CONCLUSIONS:More than half of all patients who survived the first year after stroke without any readmissions were readmitted within 5 years. Patients readmitted within 1 year and between years 2-5 shared many risk factors for readmission, but they differed in age, functional outcome and occurrence of complications during the index admission.
Risk factors associated with 31-day unplanned readmission in 50,912 discharged patients after stroke in China.
Wen Tiancai,Liu Baoyan,Wan Xia,Zhang Xiaoping,Zhang Jin,Zhou Xuezhong,Lau Alexander Y L,Zhang Yanning
BACKGROUND:Unplanned readmission within 31 days of discharge after stroke is a useful indicator for monitoring quality of hospital care. We evaluated the risk factors associated with 31-day unplanned readmission of stroke patients in China. METHODS:We identified 50,912 patients from 375 hospitals in 29 provinces, municipalities or autonomous districts across China who experienced an unplanned readmission after stroke between 2015 and 2016, and extracted data from the inpatients' cover sheet data from the Medical Record Monitoring Database. Patients were grouped into readmission within 31 days or beyond for analysis. Chi-squared test was used to analyze demographic information, health system and clinical process-related factors according to the data type. Multilevel logistic modeling was used to examine the effects of patient (level 1) and hospital (level 2) characteristics on an unplanned readmission ≤31 days. RESULTS:Among 50,912 patients, 14,664 (28.8%) were readmitted within 31 days after discharge. The commonest cause of readmissions were recurrent stroke (34.8%), hypertension (22.94%), cardio/cerebrovascular disease (13.26%) and diabetes/diabetic complications (7.34%). Higher risks of unplanned readmissions were associated with diabetes (OR = 1.089, P = 0.001), use of clinical pathways (OR = 1.174, P < 0.001), and being discharged without doctor's advice (OR = 1.485, P < 0.001). Lower risks were associated with basic medical insurances (OR ranging from 0.225 to 0.716, P < 0.001) and commercial medical insurance (OR = 0.636, P = 0.021), compared to self-paying for medical services. And patients aged 50 years old and above (OR ranging from 0.650 to 0.985, P < 0.05), with haemorrhagic stroke (OR = 0.467, P < 0.001), with length of stay more than 7 days in hospital (OR ranging from 0.082 to 0.566, P < 0.001), also had lower risks. CONCLUSIONS:Age, type of stroke, medical insurance status, type of discharge, use of clinical pathways, length of hospital stay and comorbidities were the most influential factors for readmission within 31 days.
Age-related differences in the rate and diagnosis of 30-day readmission after hospitalization for acute ischemic stroke.
Hirayama Atsushi,Goto Tadahiro,Faridi Mohammad K,Camargo Carlos A,Hasegawa Kohei
International journal of stroke : official journal of the International Stroke Society
Background Little is known about the association between age and readmission within 30 days after hospitalization for acute ischemic stroke. Aim To examine the age-related differences in rate and principal reason of 30-day readmissions in patients hospitalized for acute ischemic stroke. Methods In this retrospective, population-based cohort study using State Inpatient Databases from eight US states, we identified all adults hospitalized for acute ischemic stroke. We grouped the patients into four age categories: < 65, 65-74, 75-84, and ≥85 years. Outcomes were any-cause readmission within 30 days of discharge from the index hospitalization for acute ischemic stroke and the principal diagnosis of 30-day readmission. Results We identified 620,788 hospitalizations for acute ischemic stroke. The overall 30-day readmission rate was 16.6% with an increase with advanced age. Compared to patients aged <65 years, the readmission rate was significantly higher in age 65-74 years (OR 1.19; 95% CI 1.16-1.21), in age 75-84 years (OR 1.29; 95% CI 1.27-1.31), and in ≥ 85 years (OR 1.24; 95% CI 1.22-1.27; all P<0.001). There was heterogeneity in the age-readmission rate association between men and women (P < 0.001). Overall, 45.8% of readmissions were assigned stroke-related conditions or rehabilitation care. Compared to younger adults, older adults were more likely to present with non-stroke-related conditions (46.1% in < 65 years, 50.6% in 65-74 years, 57.1% in 75-84 years, and 62.9% in ≥ 85 years; P<0.001). Conclusions Advanced age was associated with a higher 30-day readmission rate after acute ischemic stroke. Compared with younger adults, older adults were more likely to be readmitted for non-stroke-related conditions.
Nationwide Estimates of 30-Day Readmission in Patients With Ischemic Stroke.
Vahidy Farhaan S,Donnelly John P,McCullough Louise D,Tyson Jon E,Miller Charles C,Boehme Amelia K,Savitz Sean I,Albright Karen C
BACKGROUND AND PURPOSE:Readmission within 30 days of hospital discharge for ischemic stroke is an important quality of care metric. We aimed to provide nationwide estimates of 30-day readmission in the United States, describe important reasons for readmission, and sought to explore factors associated with 30-day readmission, particularly the association with recanalization therapy. METHODS:We conducted a weighted analysis of the 2013 Nationwide Readmission Database to represent all US hospitalizations. Adult patients with acute ischemic stroke including those who received intravenous tissue-type plasminogen activator and intra-arterial therapy were identified using -Ninth Revision codes. Readmissions were defined as any readmission during the 30-day post-index hospitalization discharge period for the eligible patient population. Proportions and 95% confidence intervals for overall 30-day readmissions and for unplanned and potentially preventable readmissions are reported. Survey design logistic regression models were fit for determining crude and adjusted odds ratios and 95% confidence interval for association between recanalization therapy and 30-day readmission. RESULTS:Of the 319 317 patients with acute ischemic stroke, 12.1% (95% confidence interval, 11.9-12.3) were readmitted. Of these, 89.6% were unplanned and 12.9% were potentially preventable. More than 20% of all readmissions were attributable to acute cerebrovascular disease. Readmitted patients were older and had a higher comorbidity burden. After controlling for age, sex, insurance status, and comorbidities, patients who underwent recanalization therapy had significantly lower odds of 30-day readmission (odds ratio, 0.82; 95% confidence interval, 0.77-0.89). CONCLUSIONS:Up to 12% of patients with ischemic stroke get readmitted within 30 days post-discharge period, and recanalization therapy is associated with 11% to 23% lower odds of 30-day readmission.