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Abreu P, Correia M, Azevedo E, Sousa-Pinto B, Magalhães R. Rapid systematic review of readmissions costs after stroke. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2024; 22:22. [PMID: 38475856 DOI: 10.1186/s12962-024-00518-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 01/22/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Stroke readmissions are considered a marker of health quality and may pose a burden to healthcare systems. However, information on the costs of post-stroke readmissions has not been systematically reviewed. OBJECTIVES To systematically review information about the costs of hospital readmissions of patients whose primary diagnosis in the index admission was a stroke. METHODS A rapid systematic review was performed on studies reporting post-stroke readmission costs in EMBASE, MEDLINE, and Web of Science up to June 2021. Relevant data were extracted and presented by readmission and stroke type. The original study's currency values were converted to 2021 US dollars based on the purchasing power parity for gross domestic product. The reporting quality of each of the included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. RESULTS Forty-four studies were identified. Considerable variability in readmission costs was observed among countries, readmissions, stroke types, and durations of the follow-up period. The UK and the USA were the countries reporting the highest readmission costs. In the first year of follow-up, stroke readmission costs accounted for 2.1-23.4%, of direct costs and 3.3-21% of total costs. Among the included studies, only one identified predictors of readmission costs. CONCLUSION Our review showed great variability in readmission costs, mainly due to differences in study design, countries and health services, follow-up duration, and reported readmission data. The results of this study can be used to inform policymakers and healthcare providers about the burden of stroke readmissions. Future studies should not solely focus on improving data standardization but should also prioritize the identification of stroke readmission cost predictors.
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Affiliation(s)
- Pedro Abreu
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal.
- Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina, Universidade do Porto, Porto, Portugal.
| | - Manuel Correia
- Department of Neurology, Hospital Santo António- Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Elsa Azevedo
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Bernardo Sousa-Pinto
- MEDCIDS-Department of Community Medicine, Information and Health Decision Sciences, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Rui Magalhães
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
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Lv J, Zhang M, Fu Y, Chen M, Chen B, Xu Z, Yan X, Hu S, Zhao N. An interpretable machine learning approach for predicting 30-day readmission after stroke. Int J Med Inform 2023; 174:105050. [PMID: 36965404 DOI: 10.1016/j.ijmedinf.2023.105050] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/13/2023] [Accepted: 03/17/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Stroke is the second leading cause of death worldwide and has a significantly high recurrence rate. We aimed to identify risk factors for stroke recurrence and develop an interpretable machine learning model to predict 30-day readmissions after stroke. METHODS Stroke patients deposited in electronic health records (EHRs) in Xuzhou Medical University Hospital between February 1, 2021, and November 30, 2021, were included in the study, and deceased patients were excluded. We extracted 74 features from EHRs, and the top 20 features (chi-2 value) were used to build machine learning models. 80% of the patients were used for pre-training. Subsequently, a 20% holdout dataset was used for verification. The Shapley Additive exPlanations (SHAP) method was used to explore the interpretability of the model. RESULTS The cohort included 6,558 patients, of whom the mean (SD) age was 65 (11) years, 3,926 were males (59.86 %), and 132 (2.01 %) were readmitted within 30 days. The area under the receiver operating characteristic curve (AUROC) for the optimized model was 0.80 (95 % CI 0.68-0.80). We used the SHAP method to identify the top 10 risk factors (i.e., severe carotid artery stenosis, weak, homocysteine, glycosylated hemoglobin, sex, lymphocyte percentage, neutrophilic granulocyte percentage, urine glucose, fresh cerebral infarction, and red blood cell count). The AUROC of a model with the 10 features was 0.80 (95 % CI 0.69-0.80) and was not significantly different from that of the model with 20 risk factors. CONCLUSIONS Our methods not only showed good performance in predicting 30-day readmissions after stroke but also revealed risk factors that provided valuable insights for treatments.
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Affiliation(s)
- Ji Lv
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China; College of Computer Science and Technology, Jilin University, Changchun, Jilin Province 130000, China
| | - Mengmeng Zhang
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China; Laboratory of Emergency Medicine, Second Clinical Medical College of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China
| | - Yujie Fu
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China; Laboratory of Emergency Medicine, Second Clinical Medical College of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China
| | - Mengshuang Chen
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China; Laboratory of Emergency Medicine, Second Clinical Medical College of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China
| | - Binjie Chen
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China; Laboratory of Emergency Medicine, Second Clinical Medical College of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China
| | - Zhiyuan Xu
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China; Laboratory of Emergency Medicine, Second Clinical Medical College of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China
| | - Xianliang Yan
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China; Laboratory of Emergency Medicine, Second Clinical Medical College of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China.
| | - Shuqun Hu
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China; Laboratory of Emergency Medicine, Second Clinical Medical College of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China.
| | - Ningjun Zhao
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China; Laboratory of Emergency Medicine, Second Clinical Medical College of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China.
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Man S, Bruckman D, Tang AS, Uchino K, Schold JD. The Association of Socioeconomic Status and Discharge Destination with 30-Day Readmission after Ischemic Stroke. J Stroke Cerebrovasc Dis 2021; 30:106146. [PMID: 34644664 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 09/04/2021] [Accepted: 09/26/2021] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES This study aimed to explore the association of socioeconomic status and discharge destination with 30-day readmission after ischemic stroke. MATERIALS AND METHODS We examined 30-day all-cause readmission among patients hospitalized for ischemic stroke in states of Arkansas, Iowa, and Wisconsin in 2016 and 2017 and New York in 2016 using Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases. RESULTS Among the 52301 patients included, 51.1% were female. The 30-day readmission rates were 10.2%, 8.2%, 9.3%, 10.4%, 11.6%, and 11.2% for age group 18-34, 35-44, 45-54, 55-64, 65-74, and ≥75 years, respectively (p<0.001). In Generalized Estimating Equation analysis, patients with Medicare and Medicaid insurance were more likely to be readmitted, compared with private insurance, (adjusted Odds Ratio [aOR] 1.37, 95% CI 1.23-1.53; and aOR 1.26, 95% CI 1.09-1.45, respectively). Patients in the bottom quartile of zip code level median household income had higher 30-day readmission rate (12.4%) than those in the 2nd, 3rd and 4th quartile (10.3%, 10.1%, and 10.7%, respectively, p<0.001). Compared with those discharged home with self-care which had the lowest readmission rate (8.4%), patients who left against medical advice had the highest readmission rate (18.6%; aOR 2.23, 95% CI 1.75-2.83), followed by rehabilitation and skilled nursing facilities (13.2%; aOR 1.33, 95% CI 1.22-1.46), and home with home health care (11.3%, aOR 1.18, 95% CI 1.08-1.28). CONCLUSIONS Socioeconomic status and discharged destination affect readmission after stroke. These results provide evidence to inform vulnerable patient population as targets for readmission prevention.
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Affiliation(s)
- Shumei Man
- Department of Neurology, Neurological Institute, Cleveland Clinic, United States; Cerebrovascular Center, Neurological Institute, Cleveland Clinic, United States.
| | - David Bruckman
- Center for Populations Health Research, Department of Quantitative Health Sciences, Cleveland Clinic, United States
| | - Anne S Tang
- Center for Populations Health Research, Department of Quantitative Health Sciences, Cleveland Clinic, United States
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, United States
| | - Jesse D Schold
- Center for Populations Health Research, Department of Quantitative Health Sciences, Cleveland Clinic, United States
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Abreu P, Magalhães R, Baptista D, Azevedo E, Correia M. Admission and Readmission/Death Patterns in Hospitalized and Non-hospitalized First-Ever-in-a-Lifetime Stroke Patients During the First Year: A Population-Based Incidence Study. Front Neurol 2021; 12:685821. [PMID: 34566836 PMCID: PMC8455946 DOI: 10.3389/fneur.2021.685821] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/30/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Hospitalization and readmission rates after a first-ever-in-a-lifetime stroke (FELS) are considered measures of quality of care and, importantly, may give valuable information to better allocate health-related resources. We aimed to investigate the hospitalization pattern and the unplanned readmissions or death of hospitalized (HospS) and non-hospitalized stroke (NHospS) patients 1 year after a FELS, based on a community register. Methods: Data about hospitalization and unplanned readmissions and case fatality 1 year after a FELS were retrieved from the population-based register undertaken in Northern Portugal (ACIN2), comprising all FELS in 2009–2011. We used the Kaplan–Meier method to estimate 1-year readmission/death-free survival and Cox proportional hazard models to identify independent factors for readmission/death. Results: Of the 720 FELS, 35.7% were not hospitalized. Unplanned readmission/death within 1 year occurred in 33.0 and 24.9% of HospS and NHospS patients, respectively. The leading causes of readmission were infections, recurrent stroke, and cardiovascular events. Stroke-related readmissions were observed in more than half of the patients in both groups. Male sex, age, pre- and post-stroke functional status, and diabetes were independent factors of readmission/death within 1 year. Conclusion: About one-third of stroke patients were not hospitalized, and the readmission/death rate was higher in HospS patients. Still, that readmission/death rate difference was likely due to other factors than hospitalization itself. Our research provides novel information that may help implement targeted health-related policies to reduce the burden of stroke and its complications.
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Affiliation(s)
- Pedro Abreu
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Rui Magalhães
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Diana Baptista
- Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Elsa Azevedo
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Manuel Correia
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal.,Department of Neurology, Hospital Santo António - Centro Hospitalar Universitário do Porto, Porto, Portugal
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Gilmore-Bykovskyi AL, Hovanes M, Mirr J, Block L. Discharge Communication of Dementia-Related Neuropsychiatric Symptoms and Care Management Strategies During Hospital to Skilled Nursing Facility Transitions. J Geriatr Psychiatry Neurol 2021; 34:378-388. [PMID: 32812457 PMCID: PMC7892639 DOI: 10.1177/0891988720944245] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Provided the complexity of managing dementia-related neuropsychiatric symptoms (NPS), accurate communication about these symptoms at hospital discharge is critical to facilitating safe and effective transitions, particularly transitions from hospitals to skilled nursing facilities (SNF), which are often poorly managed. Skilled nursing facilities providers have cited undercommunication regarding NPS as a major challenge that contributes to poor outcomes including rehospitalization. This multisite retrospective cohort study identified omission rates for NPS and associated management strategies in discharge communication as compared to medical record documentation in the 72 hours preceding discharge among hospitalized patients with dementia. High rates of omission were found across NPS and management strategies: anxiety (94%), agitation/aggression (77%), hallucinations (85%), 1:1 supervision (90%), high fall risk (89%), use of restraints (91%). Omission rate for new or modified antipsychotic medication was 12.9%. Findings underscore the need for additional research on cross-setting communication regarding care needs of patients with dementia-who often cannot communicate these needs on their own-in facilitating high-quality transitions.
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Affiliation(s)
- Andrea L Gilmore-Bykovskyi
- 5228University of Wisconsin-Madison School of Nursing, Madison, WI, USA
- Division of Geriatrics, Department of Medicine, 5228University of Wisconsin-Madison School of Medicine & Public Health, Madison, WI, USA
- William S. Middleton Memorial Veterans Hospital, Geriatric Research Education and Clinical Center, Madison, WI, USA
| | - Melissa Hovanes
- 5228University of Wisconsin-Madison School of Nursing, Madison, WI, USA
| | - Jacquelyn Mirr
- Division of Geriatrics, Department of Medicine, 5228University of Wisconsin-Madison School of Medicine & Public Health, Madison, WI, USA
- Mercy Hospital St. Louis, MO, USA
| | - Laura Block
- 5228University of Wisconsin-Madison School of Nursing, Madison, WI, USA
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Lineback CM, Garg R, Oh E, Naidech AM, Holl JL, Prabhakaran S. Prediction of 30-Day Readmission After Stroke Using Machine Learning and Natural Language Processing. Front Neurol 2021; 12:649521. [PMID: 34326805 PMCID: PMC8315788 DOI: 10.3389/fneur.2021.649521] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 06/04/2021] [Indexed: 01/04/2023] Open
Abstract
Background and Purpose: This study aims to determine whether machine learning (ML) and natural language processing (NLP) from electronic health records (EHR) improve the prediction of 30-day readmission after stroke. Methods: Among index stroke admissions between 2011 and 2016 at an academic medical center, we abstracted discrete data from the EHR on demographics, risk factors, medications, hospital complications, and discharge destination and unstructured textual data from clinician notes. Readmission was defined as any unplanned hospital admission within 30 days of discharge. We developed models to predict two separate outcomes, as follows: (1) 30-day all-cause readmission and (2) 30-day stroke readmission. We compared the performance of logistic regression with advanced ML algorithms. We used several NLP methods to generate additional features from unstructured textual reports. We evaluated the performance of prediction models using a five-fold validation and tested the best model in a held-out test dataset. Areas under the curve (AUCs) were used to compare discrimination of each model. Results: In a held-out test dataset, advanced ML methods along with NLP features out performed logistic regression for all-cause readmission (AUC, 0.64 vs. 0.58; p < 0.001) and stroke readmission prediction (AUC, 0.62 vs. 0.52; p < 0.001). Conclusion: NLP-enhanced machine learning models potentially advance our ability to predict readmission after stroke. However, further improvement is necessary before being implemented in clinical practice given the weak discrimination.
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Affiliation(s)
- Christina M Lineback
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Ravi Garg
- Department of Neurology, Biological Sciences, Division and Center for Healthcare Delivery Science and Innovation, University of Chicago, Chicago, IL, United States
| | - Elissa Oh
- Department of Neurology, Biological Sciences, Division and Center for Healthcare Delivery Science and Innovation, University of Chicago, Chicago, IL, United States
| | - Andrew M Naidech
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States.,Department of Neurology, Biological Sciences, Division and Center for Healthcare Delivery Science and Innovation, University of Chicago, Chicago, IL, United States
| | - Jane L Holl
- Department of Neurology, Biological Sciences, Division and Center for Healthcare Delivery Science and Innovation, University of Chicago, Chicago, IL, United States
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, IL, United States
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Rowan JM, Yonashiro-Cho J, Wilber KH, Gassoumis ZD. Who is in the revolving door? Policy and practice implications of recurrent reports to adult protective services. J Elder Abuse Negl 2020; 32:489-508. [PMID: 33308080 DOI: 10.1080/08946566.2020.1852142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Repeat referral to adult protective services APS (recurrence) is a much-discussed topic among APS agencies as it may indicate ongoing harm, yet there is limited research examining prevalence or causes. This paper provides a foundational investigation of recurrence within a California APS county program. Drawing from thirty-three months of de-identified reports, we used logistic regression to examine the impact of intake report characteristics on repeat referral within one year after baseline case closure. One-fifth of the sample was recurrent (19.9%, n=987/4,958), with self-neglect being the most common type of report to recur (14.3%, n=307/2,141). Overall recurrence was predicted by female gender, older age, living alone, and multiple elder abuse, neglect, and exploitation (ANE) types reported at baseline, and report placed by social service provider, friends, family, landlords, and victim self-reports. Reporters personally related to the victim and social service providers are potential partners in identifying ANE, and alternate intervention approaches may be necessary.
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Affiliation(s)
- Julia M Rowan
- Leonard Davis School of Gerontology, University of Southern California , Los Angeles, California, USA
| | - Jeanine Yonashiro-Cho
- Keck School of Medicine, University of Southern California , Los Angeles, California, USA
| | - Kathleen H Wilber
- Leonard Davis School of Gerontology, University of Southern California , Los Angeles, California, USA
| | - Zachary D Gassoumis
- Keck School of Medicine, University of Southern California , Los Angeles, California, USA
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8
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A Machine Learning Approach to Predicting Readmission or Mortality in Patients Hospitalized for Stroke or Transient Ischemic Attack. APPLIED SCIENCES-BASEL 2020. [DOI: 10.3390/app10186337] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Readmissions after stroke are not only associated with greater levels of disability and a higher risk of mortality but also increase overall medical costs. Predicting readmission risk and understanding its causes are thus essential for healthcare resource allocation and quality improvement planning. By using machine learning techniques on initial admission data, this study aimed to develop prediction models for readmission or mortality after stroke. During model development, resampling methods were implemented to balance the class distribution. Two-layer nested cross-validation was used to build and evaluate the prediction models. A total of 3422 patients were included for analysis. The 90-day rate of readmission or mortality was 17.6%. This study identified several important predictive factors, including age, prior emergency department visits, pre-stroke functional status, stroke severity, body mass index, consciousness level, and use of a nasogastric tube. The Naïve Bayes model with class weighting to compensate for class imbalance achieved the highest discriminatory capacity in terms of the area under the receiver operating characteristic curve (0.661). Despite having room for improvement, the prediction models could be used for early risk assessment of patients with stroke. Identification of patients at high risk for readmission or mortality immediately after admission has the potential of enabling early discharge planning and transitional care interventions.
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Kim Y, Glance LG, Holloway RG, Li Y. Medicare Shared Savings Program and readmission rate among patients with ischemic stroke. Neurology 2020; 95:e1071-e1079. [PMID: 32554774 DOI: 10.1212/wnl.0000000000010080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 02/27/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Hospitals participating in the Medicare Shared Savings Program (MSSP) share with the Centers for Medicare and Medicaid Services (CMS) the savings generated by reduced cost of care. Our aim was to determine whether MSSP is associated with changes in readmissions and mortality for Medicare patients hospitalized with ischemic stroke, and whether MSSP has a different impact on safety net hospitals (SNHs) compared to non-SNHs. METHODS This study was based on the CMS Hospital Compare data for risk-standardized 30-day readmission and mortality rates for Medicare patients hospitalized with ischemic strokes between 2010 and 2017. With a propensity score-matched sample, hospital-level difference-in-difference analysis was used to determine whether MSSP was associated with changes in hospital readmission and mortality as well as to examine the impact of MSSP on SNHs compared to non-SNHs. RESULTS MSSP-participating hospitals had slightly greater reductions in readmission rates compared to matched nonparticipating hospitals (difference, 0.25 percentage points; 95% confidence interval [CI], -0.42 to -0.08). Mortality rates decreased among all hospitals, but mortality reduction was not significantly different between MSSP-participating hospitals and matched hospitals (difference, 0.06 percentage points; 95% CI, -0.28 to 0.17). Prior to MSSP, readmission rates in SNHs were higher compared to non-SNHs, but MSSP did not have significantly different impact on hospital readmission and mortality rates for SNHs and non-SNHs. CONCLUSION MSSP led to slightly fewer readmissions without increases in mortality for Medicare patients hospitalized with ischemic stroke. Similar reductions in readmission rates were observed in SNHs and non-SNHs participating in MSSP, indicating persistent gaps between SNHs and non-SNHs.
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Affiliation(s)
- Yeunkyung Kim
- From the Department of Public Health Sciences, Division of Health Policy and Outcomes Research (Y.K., L.G.G., Y.L.), Department of Anesthesiology (L.G.G.), and Department of Neurology (R.G.H.), University of Rochester Medical Center, NY.
| | - Laurent G Glance
- From the Department of Public Health Sciences, Division of Health Policy and Outcomes Research (Y.K., L.G.G., Y.L.), Department of Anesthesiology (L.G.G.), and Department of Neurology (R.G.H.), University of Rochester Medical Center, NY
| | - Robert G Holloway
- From the Department of Public Health Sciences, Division of Health Policy and Outcomes Research (Y.K., L.G.G., Y.L.), Department of Anesthesiology (L.G.G.), and Department of Neurology (R.G.H.), University of Rochester Medical Center, NY
| | - Yue Li
- From the Department of Public Health Sciences, Division of Health Policy and Outcomes Research (Y.K., L.G.G., Y.L.), Department of Anesthesiology (L.G.G.), and Department of Neurology (R.G.H.), University of Rochester Medical Center, NY
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10
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Leppert MH, Sillau S, Lindrooth RC, Poisson SN, Campbell JD, Simpson JR. Relationship between early follow-up and readmission within 30 and 90 days after ischemic stroke. Neurology 2020; 94:e1249-e1258. [PMID: 32079738 DOI: 10.1212/wnl.0000000000009135] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 11/06/2019] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To examine whether early follow-up with primary care or neurology is associated with lower all-cause readmissions within 30 and 90 days after acute ischemic stroke admission. METHODS We performed a retrospective cohort study of patients who were discharged home after acute ischemic stroke, identified by ICD-9 and ICD-10 codes, using PharMetrics, a nationally representative claims database of insured Americans from 2009 to 2015. The primary predictor was outpatient primary care or neurology follow-up within 30 and 90 days of discharge, and the primary outcome was all-cause 30- and 90-day readmissions. Multivariable Cox models were used with primary care and neurology visits specified as time-dependent covariates, with adjustment for patient demographics, comorbid conditions, and stroke severity measures. RESULTS The cohort included 14,630 patients. Readmissions within 30 days occurred in 7.3% of patients, and readmissions within 90 days occurred in 13.7% of patients. By 30 days, 59.3% had a primary care visit, and 24.4% had a neurology visit. Primary care follow-up was associated with reduced 30-day readmissions (hazard ratio [HR] 0.84, 95% confidence interval [CI] 0.72-0.98). Primary care follow-up before 90 days did not reach significance (HR 0.92, 95% CI 0.83-1.03). Neurology follow-up was not associated with reduced readmissions within 30 or 90 days (HR 1.05, 95% CI; HR 1.00, 95% CI, respectively). CONCLUSION Early outpatient follow-up with primary care is associated with a reduction in 30-day hospital readmissions. Early outpatient follow-up may represent an important opportunity for intervention after acute stroke admissions.
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Affiliation(s)
- Michelle H Leppert
- From the Department of Neurology (M.H.L., S.S., S.N.P., J.R.S.), University of Colorado School of Medicine, Aurora; Colorado Cardiovascular Outcomes Research Group (M.H.L.), Denver; and Colorado School of Public Health (R.C.L.) and Skagg School of Pharmacy and Pharmaceutical Sciences (J.D.C.), University of Colorado Anschutz Medical Campus, Aurora.
| | - Stefan Sillau
- From the Department of Neurology (M.H.L., S.S., S.N.P., J.R.S.), University of Colorado School of Medicine, Aurora; Colorado Cardiovascular Outcomes Research Group (M.H.L.), Denver; and Colorado School of Public Health (R.C.L.) and Skagg School of Pharmacy and Pharmaceutical Sciences (J.D.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Richard C Lindrooth
- From the Department of Neurology (M.H.L., S.S., S.N.P., J.R.S.), University of Colorado School of Medicine, Aurora; Colorado Cardiovascular Outcomes Research Group (M.H.L.), Denver; and Colorado School of Public Health (R.C.L.) and Skagg School of Pharmacy and Pharmaceutical Sciences (J.D.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Sharon N Poisson
- From the Department of Neurology (M.H.L., S.S., S.N.P., J.R.S.), University of Colorado School of Medicine, Aurora; Colorado Cardiovascular Outcomes Research Group (M.H.L.), Denver; and Colorado School of Public Health (R.C.L.) and Skagg School of Pharmacy and Pharmaceutical Sciences (J.D.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Jonathan D Campbell
- From the Department of Neurology (M.H.L., S.S., S.N.P., J.R.S.), University of Colorado School of Medicine, Aurora; Colorado Cardiovascular Outcomes Research Group (M.H.L.), Denver; and Colorado School of Public Health (R.C.L.) and Skagg School of Pharmacy and Pharmaceutical Sciences (J.D.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Jennifer R Simpson
- From the Department of Neurology (M.H.L., S.S., S.N.P., J.R.S.), University of Colorado School of Medicine, Aurora; Colorado Cardiovascular Outcomes Research Group (M.H.L.), Denver; and Colorado School of Public Health (R.C.L.) and Skagg School of Pharmacy and Pharmaceutical Sciences (J.D.C.), University of Colorado Anschutz Medical Campus, Aurora
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Shah VS, Kreatsoulas D, Dornbos D, Cua S, Powers CJ. The impact of pre-operative symptoms on carotid endarterectomy Outcomes: Analysis of the ACS-NSQIP carotid endarterectomy database. J Clin Neurosci 2020; 73:51-56. [PMID: 32019726 DOI: 10.1016/j.jocn.2020.01.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 12/01/2019] [Accepted: 01/26/2020] [Indexed: 10/25/2022]
Abstract
Carotid artery stenosis accounts for up to 20% of ischemic strokes. Since the 1950 s, one of the primary surgical treatment for this condition is carotid endarterectomy (CEA). Because of improvement of medical therapy for carotid artery atherosclerosis and the increased use of carotid artery stents, CEA is indicated if the risk of stroke and death are low. The goal of this study is to characterize the impact of pre-operative stroke and stroke risk factors on post-operative CEA patient outcomes, using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Vascular Module on CEA. Using the Targeted Vascular Module of the ACS-NSQIP, 22,116 patients who underwent CEA were identified from 2011 to 2016. Univariate analysis and multivariable logistic regression analyses were conducted to identify significant risk factors that predispose patients to stroke. Patients with pre-operative stroke comprise 42.1% of the group, with post-operative stroke being the second most common complication (2.1%). Pre-operative stroke patients were also at a higher risk for transient ischemic attacks, post-operative restenosis, post-operative distal embolization, and other complications. Patients with pre-operative risk factors, including stroke or stroke-like symptoms, high risk physiologic factors, high risk anatomic factors, and contralateral internal carotid artery stenosis were at a higher risk of developing post-operative stroke and other complications. Patients with these pre-operative risk factors should be closely monitored for post-operative complications in an effort to improve patient outcomes.
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Affiliation(s)
- Varun S Shah
- The Ohio State University College of Medicine, Columbus, OH USA
| | - Daniel Kreatsoulas
- The Ohio State University Wexner Medical Center, Department of Neurological Surgery, Columbus, OH USA
| | - David Dornbos
- The Ohio State University Wexner Medical Center, Department of Neurological Surgery, Columbus, OH USA
| | - Santino Cua
- The Ohio State University College of Medicine, Columbus, OH USA
| | - Ciarán J Powers
- The Ohio State University Wexner Medical Center, Department of Neurological Surgery, Columbus, OH USA.
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Bjerkreim AT, Khanevski AN, Thomassen L, Selvik HA, Waje-Andreassen U, Naess H, Logallo N. Five-year readmission and mortality differ by ischemic stroke subtype. J Neurol Sci 2019; 403:31-37. [DOI: 10.1016/j.jns.2019.06.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 05/15/2019] [Accepted: 06/04/2019] [Indexed: 01/25/2023]
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The Impact of Ischaemic Stroke Subtype on 30-day Hospital Readmissions. Stroke Res Treat 2019; 2018:7195369. [PMID: 30643624 PMCID: PMC6311302 DOI: 10.1155/2018/7195369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 11/19/2018] [Indexed: 12/04/2022] Open
Abstract
Background Stroke aetiology may affect the risk and causes of readmission after ischaemic stroke (IS) and transient ischaemic attack (TIA) due to differences in risk factors, functional outcome, and treatment. We aimed to examine frequencies, causes, and risk of 30-day readmission by stroke subtype, determine predictors of 30-day readmission, and study the impact of 30-day readmissions on one-year mortality. Methods All surviving patients admitted with IS or TIA from July 2007 to December 2013 were followed by review of medical records for all unplanned readmissions within 30 days after discharge. Stroke subtype was classified as large-artery atherosclerosis (LAA), cardioembolism (CE), small vessel occlusion (SVO), stroke of other determined aetiology (SOE), or stroke of undetermined aetiology (SUE). Cox regression analyses were performed to assess the risk of 30-day readmission for the stroke subtypes and identify predictors of 30-day readmission, and its impact on one-year mortality. Results Of 1874 patients, 200 (10.7%) were readmitted within 30 days [LAA 42/244 (17.2%), CE 75/605 (12.4%), SVO 12/205 (5.9%), SOE 6/32 (18.8%), SUE 65/788 (8.3%)]. The most frequent causes of readmissions were stroke-related event, infection, recurrent stroke/ TIA, and cardiac disease. After adjusting for age, sex, functional outcome, length of stay, and the risk factor burden, patients with LAA and SOE subtype had significantly higher risks of readmission for any cause, recurrent stroke or TIA, and stroke-related events. Predictors of 30-day readmission were higher age, peripheral arterial disease, enteral feeding, and LAA subtype. Thirty-day readmission was an independent predictor of one-year mortality. Conclusions Patients with LAA or SOE have a high risk of 30-day readmission, possibly caused by an increased risk of recurrent stroke and stroke-related events. Awareness of the risk of readmission for different causes and appropriate handling according to stroke subtype may be useful for preventing some readmissions after stroke.
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Wen T, Liu B, Wan X, Zhang X, Zhang J, Zhou X, Lau AYL, Zhang Y. Risk factors associated with 31-day unplanned readmission in 50,912 discharged patients after stroke in China. BMC Neurol 2018; 18:218. [PMID: 30587162 PMCID: PMC6306006 DOI: 10.1186/s12883-018-1209-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 11/29/2018] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Tiancai Wen
- School of Computer Science, Northwestern Polytechnical University Xi’an, Shangxi Province, 710129 China
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, 100700 China
- Data Center of Traditional Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing, 100700 China
| | - Baoyan Liu
- Data Center of Traditional Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing, 100700 China
| | - Xia Wan
- Institute of Basic Medical Sciences at Chinese Academy of Medical Sciences / School of Basic Medicine at Peking Union Medical College, Beijing, 100005 China
| | - Xiaoping Zhang
- Data Center of Traditional Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing, 100700 China
| | - Jin Zhang
- Data Center of Traditional Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing, 100700 China
| | - Xuezhong Zhou
- School of Computer and Information Technology, Beijing Jiaotong University, Beijing, 100044 China
| | | | - Yanning Zhang
- School of Computer Science, Northwestern Polytechnical University Xi’an, Shangxi Province, 710129 China
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Lee SA, Park EC, Shin J, Ju YJ, Choi Y, Lee HY. Patient and hospital factors associated with 30-day unplanned readmission in patients with stroke. J Investig Med 2018; 67:52-58. [DOI: 10.1136/jim-2018-000748] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/23/2018] [Accepted: 06/23/2018] [Indexed: 11/03/2022]
Abstract
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.
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Freburger JK, Li D, Johnson AM, Fraher EP. Physical and Occupational Therapy From the Acute to Community Setting After Stroke: Predictors of Use, Continuity of Care, and Timeliness of Care. Arch Phys Med Rehabil 2018; 99:1077-1089.e7. [DOI: 10.1016/j.apmr.2017.03.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 02/08/2017] [Accepted: 03/02/2017] [Indexed: 02/07/2023]
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Terman SW, Reeves MJ, Skolarus LE, Burke JF. Association Between Early Outpatient Visits and Readmissions After Ischemic Stroke. Circ Cardiovasc Qual Outcomes 2018; 11:e004024. [PMID: 29653998 PMCID: PMC5901901 DOI: 10.1161/circoutcomes.117.004024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 03/19/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Reducing hospital readmission is an important goal to optimize poststroke care and reduce costs. Early outpatient follow-up may represent one important strategy to reduce readmissions. We examined the association between time to first outpatient contact and readmission to inform postdischarge transitions. METHODS AND RESULTS We performed a retrospective cohort study of all Medicare fee-for-service patients discharged home after an acute ischemic stroke in 2012 identified by the InternationalClassification of Diseases, Ninth Revision, Clinical Modification codes. Our primary predictor variable was whether patients had a primary care or neurology visit within 30 days of discharge. Our primary outcome variable was all-cause 30-day hospital readmission. We used separate multivariable Cox models with primary care and neurology visits specified as time-dependent covariates, adjusted for numerous patient- and systems-level factors. The cohort included 78 345 patients. Sixty-one percent and 16% of patients, respectively, had a primary care and neurology visit within 30 days of discharge. Visits occurred a median (interquartile range) 7 (4-13) and 15 (5-22) days after discharge for primary care and neurology, respectively. Thirty-day readmission occurred in 9.4% of patients. Readmissions occurred a median 14 (interquartile range, 7-21) days after discharge. Patients who had a primary care visit within 30 days of discharge had a slightly lower adjusted hazard of readmission than those who did not (hazard ratio, 0.98; 95% confidence interval, 0.97-0.98). The association was nearly identical for 30-day neurology visits (hazard ratio, 0.98; 95% confidence interval, 0.97-0.98). CONCLUSIONS Thirty-day outpatient follow-up was associated with a small reduction in hospital readmission among elderly patients with stroke discharged home. Further work should assess how outpatient care may be improved to further reduce readmissions.
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Affiliation(s)
- Samuel W Terman
- Department of Neurology (S.W.T., L.E.S., J.F.B.) and Stroke Program (L.E.S., J.F.B.), University of Michigan, Ann Arbor. Department of Epidemiology, Michigan State University, East Lansing (M.J.R.). Department of Veterans Affairs, VA Center for Clinical Management and Research, Ann Arbor VA Healthcare System, MI (J.F.B.).
| | - Mathew J Reeves
- Department of Neurology (S.W.T., L.E.S., J.F.B.) and Stroke Program (L.E.S., J.F.B.), University of Michigan, Ann Arbor. Department of Epidemiology, Michigan State University, East Lansing (M.J.R.). Department of Veterans Affairs, VA Center for Clinical Management and Research, Ann Arbor VA Healthcare System, MI (J.F.B.)
| | - Lesli E Skolarus
- Department of Neurology (S.W.T., L.E.S., J.F.B.) and Stroke Program (L.E.S., J.F.B.), University of Michigan, Ann Arbor. Department of Epidemiology, Michigan State University, East Lansing (M.J.R.). Department of Veterans Affairs, VA Center for Clinical Management and Research, Ann Arbor VA Healthcare System, MI (J.F.B.)
| | - James F Burke
- Department of Neurology (S.W.T., L.E.S., J.F.B.) and Stroke Program (L.E.S., J.F.B.), University of Michigan, Ann Arbor. Department of Epidemiology, Michigan State University, East Lansing (M.J.R.). Department of Veterans Affairs, VA Center for Clinical Management and Research, Ann Arbor VA Healthcare System, MI (J.F.B.)
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Schubert I, Hammer A, Köster I. [Severity assessment strategies based on administrative data using stroke as an example]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2017; 126:66-75. [PMID: 28807634 DOI: 10.1016/j.zefq.2017.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/27/2017] [Accepted: 06/28/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Information on disease severity is relevant for many studies with claims data in health service research, but only limited information is available in routine data. Stroke serves as an example to analyse whether the combination of different information in claims data can provide insight into the severity of a disease. METHOD As a first step, a literature search was conducted. Strategies to assess the severity of a disease by means of routine data were examined with regard to approval and applicability to German sickness fund data. In order to apply and extend the identified procedures, the statutory health insurance sample AOK Hessen/KV Hessen (VSH) served as data source. It is an 18.75 % random sample of persons insured by the AOK Hessen, with 2013 being the most recent year. Stroke patients were identified by the ICD-10 GM code I63 and I64. Patients with said diagnoses being coded as a hospital discharge diagnosis in 2012 were included due to an acute event in 2012 (n=944). The follow-up time was one year. RESULTS Ten studies covering seven different methods to assess stroke severity were identified. Codes for coma (4.2 % of stroke patients in the SHI sample) as well as coma and/or the application of a PEG tube (9.8 % of the stroke patients) were applied as a proxy for disease severity of acute cases. Taking age, sex and comorbidity into consideration, patients in a coma show a significantly increased risk of mortality compared to those without coma. Three operationalisations were chosen as possible proxies for disease severity of stroke in the further course of disease: i) sequelae (hemiplegia, neurological neglect), ii) duration of the index inpatient stay, and iii) nursing care/ care level 3 for the first time after stroke. The latter proxy has the highest explanatory value for SHI costs. CONCLUSION The studies identified use many variables mainly based on hospital information in order to describe disease severity. With the exception of coma, these proxies were neither validated nor did the authors provide more detailed grounds for their use. An identified score for stroke severity could not be applied to SHI data. To develop a comparable score requires a linkage of clinical and administrative data. Since routine data include information from all sectors of care, it should be explored whether these data (for example, the patients' care needs) are suitable to assess disease severity. For validation, separate databases and, optimally, primary patient data are necessary.
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Affiliation(s)
- Ingrid Schubert
- PMV forschungsgruppe an der Klinik und Poliklinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters der Universität zu Köln, Köln, Deutschland.
| | - Antje Hammer
- Institut für Patientensicherheit, Universitätsklinikum Bonn, Bonn, Deutschland.
| | - Ingrid Köster
- PMV forschungsgruppe an der Klinik und Poliklinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters der Universität zu Köln, Köln, Deutschland.
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Community Use of Physical and Occupational Therapy After Stroke and Risk of Hospital Readmission. Arch Phys Med Rehabil 2017; 99:26-34.e5. [PMID: 28807692 DOI: 10.1016/j.apmr.2017.07.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 06/29/2017] [Accepted: 07/18/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To determine whether receipt of therapy and number and timing of therapy visits decreased hospital readmission risk in stroke survivors discharged home. DESIGN Retrospective cohort analysis of Medicare claims (2010-2013). SETTING Acute care hospital and community. PARTICIPANTS Patients hospitalized for stroke who were discharged home and survived the first 30 days (N=23,413; mean age ± SD, 77.6±7.5y). INTERVENTIONS Physical and occupational therapist use in the home and/or outpatient setting in the first 30 days after discharge (any use, number of visits, and days to first visit). MAIN OUTCOME MEASURES Hospital readmission 30 to 60 days after discharge. Covariates included demographic characteristics, proxy variables for functional status, hospitalization characteristics, comorbidities, and prior health care use. Multivariate logistic regression analyses were conducted to examine the relation between therapist use and readmission. RESULTS During the first 30 days after discharge, 31% of patients saw a therapist in the home, 11% saw a therapist in an outpatient setting, and 59% did not see a therapist. Relative to patients who had no therapist contact, those who saw an outpatient therapist were less likely to be readmitted to the hospital (odds ratio, 0.73; 95% confidence interval, 0.59-0.90). Although the point estimates did not reach statistical significance, there was some suggestion that the greater the number of therapist visits in the home and the sooner the visits started, the lower the risk of hospital readmission. CONCLUSIONS After controlling for observable demographic-, clinical-, and health-related differences, we found that individuals who received outpatient therapy in the first 30 days after discharge home after stroke were less likely to be readmitted to the hospital in the subsequent 30 days, relative to those who received no therapy.
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Horney C, Capp R, Boxer R, Burke RE. Factors Associated With Early Readmission Among Patients Discharged to Post-Acute Care Facilities. J Am Geriatr Soc 2017; 65:1199-1205. [DOI: 10.1111/jgs.14758] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 09/09/2016] [Accepted: 10/26/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Carolyn Horney
- Department of Medicine; Division of Geriatric Medicine; University of Colorado; Aurora Colorado
- Geriatric Section; Medicine Service; Denver VA Medical Center; Denver Colorado
| | - Roberta Capp
- Department of Emergency Medicine; University of Colorado School of Medicine; Aurora Colorado
| | - Rebecca Boxer
- Department of Medicine; Division of Geriatric Medicine; University of Colorado; Aurora Colorado
- Geriatrics Research; Education and Clinical Center; VA Eastern Colorado Health Care System; Denver Colorado
| | - Robert E. Burke
- Research and Hospital Medicine Sections; Medicine Service; Denver VA Medical Center; Denver Colorado
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Mu F, Hurley D, Betts KA, Messali AJ, Paschoalin M, Kelley C, Wu EQ. Real-world costs of ischemic stroke by discharge status. Curr Med Res Opin 2017; 33:371-378. [PMID: 27826997 DOI: 10.1080/03007995.2016.1257979] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The objective of this study was to estimate the acute healthcare costs of ischemic stroke during hospitalization and the quarterly all-cause healthcare costs for the first year after discharge by discharge status. METHODS Adult patients with a hospitalization with a diagnosis of ischemic stroke (ICD-9-CM: 434.xx or 436.xx) between 1 January 2006 and 31 March 2015 were identified from a large US commercial claims database. Patients were classified into three cohorts based on their discharge status from the first stroke hospitalization, i.e. dead at discharge, discharged with disability, or discharged without disability. Third-party (medical and pharmacy) and out-of-pocket costs were adjusted to 2015 USD. RESULTS A total of 7919 patients dead at discharge, 45,695 patients discharged with disability, and 153,778 patients discharged without disability were included in this analysis. The overall average age was 59.7 years and 52.3% were male. During hospitalization, mean total costs (third-party and out-of-pocket) were $68,370 for patients dead at discharge, $73,903 for patients discharged with disability, and $24,448 for patients discharged without disability (p < .001 for each pairwise comparison); mean third-party costs were $63,605 for patients dead at discharge, $67,861 for patients discharged with disability and $19,267 for patients discharged without disability (p < .001 for each pairwise comparison). During the first year after discharge, mean total costs for patients discharged with disability vs. without disability were $46,850 vs. $30,132 (p < .001). Mean third-party costs for patients discharged with disability vs. without disability were $19,116 vs. $10,976 during the first quarter after discharge, $10,236 vs. $6926 during the second quarter, $8241 vs. $5810 during the third quarter, and $6875 vs. $5292 during the fourth quarter (p < .001 for each quarter). CONCLUSION The results demonstrated the high economic burden of ischemic stroke, especially among patients discharged with disability with the highest costs incurred during the inpatient stays.
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Affiliation(s)
- F Mu
- a Analysis Group Inc. , Boston , MA , USA
| | - D Hurley
- b HUTH Global LLC , Seattle , WA , USA
| | - K A Betts
- a Analysis Group Inc. , Boston , MA , USA
| | | | - M Paschoalin
- c Genentech Inc. , South San Francisco , CA , USA
| | - C Kelley
- a Analysis Group Inc. , Boston , MA , USA
| | - E Q Wu
- a Analysis Group Inc. , Boston , MA , USA
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Nicholson G, Gandra SR, Halbert RJ, Richhariya A, Nordyke RJ. Patient-level costs of major cardiovascular conditions: a review of the international literature. CLINICOECONOMICS AND OUTCOMES RESEARCH 2016; 8:495-506. [PMID: 27703385 PMCID: PMC5036826 DOI: 10.2147/ceor.s89331] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Robust cost estimates of cardiovascular (CV) events are required for assessing health care interventions aimed at reducing the economic burden of major adverse CV events. This review synthesizes international cost estimates of CV events. METHODS MEDLINE database was searched electronically for English language studies published during 2007-2012, with cost estimates for CV events of interest - unstable angina, myocardial infarction, heart failure, stroke, and CV revascularization. Included studies provided at least one estimate of patient-level direct costs in adults for any identified country. Information on study characteristics and cost estimates were collected. All costs were adjusted for inflation to 2013 values. RESULTS Across the 114 studies included, the average cost was US $6,466 for unstable angina, $11,664 for acute myocardial infarction, $11,686 for acute heart failure, $11,635 for acute ischemic stroke, $37,611 for coronary artery bypass graft, and $13,501 for percutaneous coronary intervention. The ranges for cost estimates varied widely across countries with US cost estimate being at least twice as high as European Union costs for some conditions. Few studies were found on populations outside the US and European Union. CONCLUSION This review showed wide variation in the cost of CV events within and across countries, while showcasing the continuing economic burden of CV disease. The variability in costs was primarily attributable to differences in study population, costing methodologies, and reporting differences. Reliable cost estimates for assessing economic value of interventions in CV disease are needed.
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Nakagawa K, Ahn HJ, Taira DA, Miyamura J, Sentell TL. Ethnic Comparison of 30-Day Potentially Preventable Readmissions After Stroke in Hawaii. Stroke 2016; 47:2611-7. [PMID: 27608816 DOI: 10.1161/strokeaha.116.013669] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 07/27/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE Ethnic disparities in readmission after stroke have been inadequately studied. We sought to compare potentially preventable readmissions (PPR) among a multiethnic population in Hawaii. METHODS Hospitalization data in Hawaii from 2007 to 2012 were assessed to compare ethnic differences in 30-day PPR after stroke-related hospitalizations. Multivariable models using logistic regression were performed to assess the impact of ethnicity on 30-day PPR after controlling for age group (<65 and ≥65 years), sex, insurance, county of residence, substance use, history of mental illness, and Charlson Comorbidity Index. RESULTS Thirty-day PPR was seen in 840 (8.4%) of 10 050 any stroke-related hospitalizations, 712 (8.7%) of 8161 ischemic stroke hospitalizations, and 128 (6.8%) of 1889 hemorrhagic stroke hospitalizations. In the multivariable models, only the Chinese ethnicity, compared with whites, was associated with 30-day PPR after any stroke hospitalizations (odds ratio [OR] [95% confidence interval {CI}], 1.40 [1.05-1.88]) and ischemic stroke hospitalizations (OR, 1.42 [CI, 1.04-1.96]). When considering only one hospitalization per individual, the impact of Chinese ethnicity on PPR after any stroke hospitalization (OR, 1.22 [CI, 0.89-1.68]) and ischemic stroke hospitalization (OR, 1.21 [CI, 0.86-1.71]) was attenuated. Other factors associated with 30-day PPR after any stroke hospitalizations were Charlson Comorbidity Index (per unit increase) (OR, 1.21 [CI, 1.18-1.24]), Medicaid (OR, 1.42 [CI, 1.07-1.88]), Hawaii county (OR, 0.78 [CI, 0.62-0.97]), and mental illness (OR, 1.37 [CI, 1.10-1.70]). CONCLUSIONS In Hawaii, Chinese may have a higher risk of 30-day PPR after stroke compared with whites. However, this seems to be driven by the high number of repeated PPR within the Chinese ethnic group.
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Affiliation(s)
- Kazuma Nakagawa
- From the Neuroscience Institute, The Queen's Medical Center, Honolulu, HI (K.N.); Department of Medicine, John A. Burns School of Medicine (K.N.), Office of Biostatistics and Quantitative Health Sciences, John A. Burns School of Medicine (H.J.A.), Office of Public Health Studies (T.L.S.), University of Hawaii, Honolulu; Daniel K. Inouye College of Pharmacy, University of Hawaii, Hilo (D.A.T.); and Hawaii Health Information Corporation, Honolulu (J.M.).
| | - Hyeong Jun Ahn
- From the Neuroscience Institute, The Queen's Medical Center, Honolulu, HI (K.N.); Department of Medicine, John A. Burns School of Medicine (K.N.), Office of Biostatistics and Quantitative Health Sciences, John A. Burns School of Medicine (H.J.A.), Office of Public Health Studies (T.L.S.), University of Hawaii, Honolulu; Daniel K. Inouye College of Pharmacy, University of Hawaii, Hilo (D.A.T.); and Hawaii Health Information Corporation, Honolulu (J.M.)
| | - Deborah A Taira
- From the Neuroscience Institute, The Queen's Medical Center, Honolulu, HI (K.N.); Department of Medicine, John A. Burns School of Medicine (K.N.), Office of Biostatistics and Quantitative Health Sciences, John A. Burns School of Medicine (H.J.A.), Office of Public Health Studies (T.L.S.), University of Hawaii, Honolulu; Daniel K. Inouye College of Pharmacy, University of Hawaii, Hilo (D.A.T.); and Hawaii Health Information Corporation, Honolulu (J.M.)
| | - Jill Miyamura
- From the Neuroscience Institute, The Queen's Medical Center, Honolulu, HI (K.N.); Department of Medicine, John A. Burns School of Medicine (K.N.), Office of Biostatistics and Quantitative Health Sciences, John A. Burns School of Medicine (H.J.A.), Office of Public Health Studies (T.L.S.), University of Hawaii, Honolulu; Daniel K. Inouye College of Pharmacy, University of Hawaii, Hilo (D.A.T.); and Hawaii Health Information Corporation, Honolulu (J.M.)
| | - Tetine L Sentell
- From the Neuroscience Institute, The Queen's Medical Center, Honolulu, HI (K.N.); Department of Medicine, John A. Burns School of Medicine (K.N.), Office of Biostatistics and Quantitative Health Sciences, John A. Burns School of Medicine (H.J.A.), Office of Public Health Studies (T.L.S.), University of Hawaii, Honolulu; Daniel K. Inouye College of Pharmacy, University of Hawaii, Hilo (D.A.T.); and Hawaii Health Information Corporation, Honolulu (J.M.)
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Mittal MK, Rabinstein AA, Mandrekar J, Brown RD, Flemming KD. A population-based study for 30-d hospital readmissions after acute ischemic stroke. Int J Neurosci 2016; 127:305-313. [PMID: 27356861 DOI: 10.1080/00207454.2016.1207642] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine post-stroke 30-d readmission rate, its predictors, its impact on mortality and to identify potentially preventable causes of post-stroke 30-d readmission in a population-based study. PATIENTS AND METHODS We identified all acute ischemic strokes (AIS) using the International Classification of Diseases 9th revision codes (433.x1, 434.xx and 436) via the Rochester Epidemiology Project (REP) between January 2007 and December 2011. Acute stroke care in Olmsted County is provided by two medical centers, Saint Marys Hospital and Olmsted Medical Center Hospital. All readmissions to these two hospitals were accounted for this study. Thirty-day readmission data was abstracted through manual chart review. The REP linkage database was used to identify the status (living/dead) of all patients at last follow up. RESULTS Forty-one (7.6%, 95% CI 5.7%-10.2%) of total 537 AIS patients were readmitted 30-d post-stroke. In a multivariable logistic regression model, discharge to nursing home following index stroke (OR: 0.29, 95% CI 0.08-0.84) was an independent negative predictor of unplanned 30-d readmission. In a subgroup of patients with dementia, being married at time of index stroke was found to be a negative predictor of readmission (OR: 0.10, 95% CI 0.005-0.58). Only 2.8% of the patients had potentially preventable readmissions. Hospital readmission had no significant impact on patient's short-term (three months) or long-term (one or two years) mortality (p > 0.05). CONCLUSION Post-stroke 30-d readmission rate is low in AIS patients from Olmsted County. Further research is needed in regarding discharge checklists, protocols and stroke transitional programs to reduce potentially preventable readmissions.
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Affiliation(s)
- Manoj K Mittal
- a Department of Neurology/Mayo Clinic , Rochester , MN , USA
| | | | - Jay Mandrekar
- b Division of Biomedical Statistics and Informatics/Mayo Clinic , Rochester , MN , USA
| | - Robert D Brown
- a Department of Neurology/Mayo Clinic , Rochester , MN , USA
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Yu S, Arima H, Bertmar C, Hirakawa Y, Priglinger M, Evans K, Krause M. Depression but not anxiety predicts recurrent cerebrovascular events. Acta Neurol Scand 2016; 134:29-34. [PMID: 26411629 DOI: 10.1111/ane.12503] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Depression and anxiety after stroke occur frequently and have been suggested to have negative influence on functional outcomes. However, the effect of emotional symptoms on stroke recurrence is uncertain. The aim of this study was to define the effect of emotional symptoms on recurrent cerebrovascular events in patients with ischemic stroke. MATERIALS AND METHODS This was a hospital-based cohort study including patients with ischemic stroke who participated in a Community Stroke Care Program that provided secondary stroke prevention strategies during 6 months transition period after discharge. We examined the association between depression and anxiety and the risk of recurrent cerebrovascular events using logistic regression model. Depression and anxiety were defined as a score of 7 or more in Hospital Anxiety and Depression Scale at 2 weeks after discharge. Recurrent cerebrovascular events comprised any recurrent stroke and transient ischemic attack (TIA) occurring during 6 months after discharge. RESULTS Among 182 patients, 29 (15.9%) were depressed and 41 (22.5%) had anxiety symptoms. During the follow-up period, 9 patients experienced recurrent cerebrovascular events (5 of stroke and 4 of TIA). Depression was associated with recurrent cerebrovascular events at 6 months after adjustment for age, sex, and stroke severity (OR 5.22, 95% CI 1.08-25.12; P = 0.04), whereas anxiety was not (OR 0.98, 95% CI 0.2-4.92; P = 0.982). CONCLUSIONS Depression occurring early after stroke was associated with the increased risk of recurrent cerebrovascular events in ischemic stroke survivors. Care plan to detect and manage depression should be implemented to prevent recurrent stroke.
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Affiliation(s)
- S. Yu
- Department of Neurology; Korea University College of Medicine; Seoul Korea
- The George Institute for Global Health; Royal Prince Alfred Hospital and University of Sydney; Sydney NSW Australia
- Department of Neurology; Royal North Shore Hospital; St Leonards and University of Sydney; Sydney NSW Australia
| | - H. Arima
- The George Institute for Global Health; Royal Prince Alfred Hospital and University of Sydney; Sydney NSW Australia
| | - C. Bertmar
- Department of Neurology; Royal North Shore Hospital; St Leonards and University of Sydney; Sydney NSW Australia
| | - Y. Hirakawa
- The George Institute for Global Health; Royal Prince Alfred Hospital and University of Sydney; Sydney NSW Australia
| | - M. Priglinger
- Department of Neurology; Royal North Shore Hospital; St Leonards and University of Sydney; Sydney NSW Australia
| | - K. Evans
- Department of Neurology; Royal North Shore Hospital; St Leonards and University of Sydney; Sydney NSW Australia
| | - M. Krause
- Department of Neurology; Royal North Shore Hospital; St Leonards and University of Sydney; Sydney NSW Australia
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Abstract
BACKGROUND Aims of this study are to explore the associations of readmission to psychiatric hospital over time, to develop a statistical model for early readmission to psychiatric hospital and to assess the feasibility of predicting early readmission. METHOD The sample comprised 7891 general psychiatric discharges in South London, taken from a large anonymised repository of electronic patient records. We initially explored time to readmission using Cox regression - this included investigation of time-dependent effects. Subsequently, we used logistic regression to create a predictive model for 90-day readmission. We investigated the effect on readmission of a set of variables that included demographic variables, diagnosis and legal status during the index admission, previous service use, housing variables and individual item scores on the Health of the Nation Outcome Scales (HoNOS) at admission and at discharge. RESULTS Fifteen per cent of those discharged were readmitted within 90 days. Cox regression demonstrated that the estimated baseline hazard of readmission declined steeply after discharge and that the effects of several predictors, especially diagnosis, changed over time - most notably, personality disorder was associated with increased readmission relative to schizophrenia at the time of discharge, but did not significantly differ by 1-year postdischarge. In the logistic regression, increased readmission was associated with personality disorder diagnosis; shorter length of the index admission (excepting zero length admissions); number of discharges in the preceding 2 years; and having a high score at discharge on the HoNOS overactive and aggressive behaviour item, cognitive problems item or hallucinations and delusions items. Detention under Section 3 or a forensic section of the Mental Health Act during the index admission was associated with reduced readmission. The coefficient of discrimination for the logistic regression, which is equivalent to r 2, was 0.04 and the estimated area under the receiver operating curve was 0.65. CONCLUSIONS The association found between early readmission and personality disorder diagnosis merits further investigation, as does the possible trade-off between reduction in length of stay and increased readmission. Other novel findings such as the associations found with HoNOS item scores also merit replication. As with previous studies, we found that the rate of readmission declines steeply after hospital discharge, so that the period immediately subsequent to discharge is a period of comparatively high risk. However, prediction of early readmission within this high-risk group remains challenging - it seems most likely that many unmeasured influences operate subsequent to the time of discharge.
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Bjerkreim AT, Thomassen L, Waje-Andreassen U, Selvik HA, Næss H. Hospital Readmission after Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2016; 25:157-62. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.09.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 08/31/2015] [Accepted: 09/10/2015] [Indexed: 10/22/2022] Open
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Association of Rehabilitation Intensity for Stroke and Risk of Hospital Readmission. Phys Ther 2015; 95:1660-7. [PMID: 26089042 DOI: 10.2522/ptj.20140610] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 06/11/2015] [Indexed: 02/09/2023]
Abstract
BACKGROUND Little is known about the use of rehabilitation in the acute care setting and its impact on hospital readmissions. OBJECTIVE The objective of this study was to examine the association between the intensity of rehabilitation services received during the acute care stay for stroke and the risk of 30-day and 90-day hospital readmission. DESIGN A retrospective cohort analysis of all acute care hospitals in Arkansas and Florida was conducted. METHODS Patients (N=64,065) who were admitted for an incident stroke in 2009 or 2010 were included. Rehabilitation intensity was categorized as none, low, medium-low, medium-high, or high based on the sum and distribution of physical therapy, occupational therapy, and speech therapy charges within each hospital. Cox proportional hazards regression was used to estimate hazard ratios, controlling for demographic characteristics, illness severity, comorbidities, hospital variables, and state. RESULTS Relative to participants who received the lowest intensity therapy, those who received higher-intensity therapy had a decreased risk of 30-day readmission. The risk was lowest for the highest-intensity group (hazard ratio=0.86; 95% confidence interval=0.79, 0.93). Individuals who received no therapy were at an increased risk of hospital readmission relative to those who received low-intensity therapy (hazard ratio=1.30; 95% confidence interval=1.22, 1.40). The findings were similar, but with smaller effects, for 90-day readmission. Furthermore, patients who received higher-intensity therapy had more comorbidities and greater illness severity relative to those who received lower-intensity therapy. LIMITATIONS The results of the study are limited in scope and generalizability. Also, the study may not have adequately accounted for all potentially important covariates. CONCLUSIONS Receipt of and intensity of rehabilitation therapy in the acute care of stroke is associated with a decreased risk of hospital readmission.
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Causes and Predictors for Hospital Readmission after Ischemic Stroke. J Stroke Cerebrovasc Dis 2015; 24:2095-101. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.05.019] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 05/08/2015] [Accepted: 05/17/2015] [Indexed: 11/23/2022] Open
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Effect of an Evidence-Based Mobility Intervention on the Level of Function in Acute Intracerebral and Subarachnoid Hemorrhagic Stroke Patients on a Neurointensive Care Unit. Arch Phys Med Rehabil 2015; 96:1191-9. [DOI: 10.1016/j.apmr.2015.02.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 12/24/2014] [Accepted: 02/09/2015] [Indexed: 11/20/2022]
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Joyce A, Robbins J, Hind J. Nutrient Intake From Thickened Beverages and Patient-Specific Implications for Care. Nutr Clin Pract 2014; 30:440-5. [DOI: 10.1177/0884533614561792] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Amanda Joyce
- Essentia Health Duluth Clinic, Duluth, Minnesota
| | - JoAnne Robbins
- Department of Medicine and Public Health, University of Wisconsin–Madison, and Clinical Center, Madison, Wisconsin
| | - Jacqueline Hind
- University of Wisconsin–Madison School of Medicine and Public Health, Madison, Wisconsin
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Strowd RE, Wise SM, Umesi UN, Bishop L, Craig J, Lefkowitz D, Reynolds PS, Tegeler C, Arnan M, Duncan PW, Bushnell CD. Predictors of 30-day hospital readmission following ischemic and hemorrhagic stroke. Am J Med Qual 2014; 30:441-6. [PMID: 24919597 DOI: 10.1177/1062860614535838] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Roy E Strowd
- Wake Forest School of Medicine, Winston Salem, NC
| | | | | | - Laura Bishop
- Wake Forest School of Medicine, Winston Salem, NC
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Liotta EM, Singh M, Kosteva AR, Beaumont JL, Guth JC, Bauer RM, Prabhakaran S, Rosenberg NF, Maas MB, Naidech AM. Predictors of 30-day readmission after intracerebral hemorrhage: a single-center approach for identifying potentially modifiable associations with readmission. Crit Care Med 2013; 41:2762-9. [PMID: 23963121 PMCID: PMC3841230 DOI: 10.1097/ccm.0b013e318298a10f] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To determine whether patient's demographics or severity of illness predict hospital readmission within 30 days following spontaneous intracerebral hemorrhage, to identify readmission associations that may be modifiable at the single-center level, and to determine the impact of readmission on outcomes. DESIGN We collected demographic, clinical, and hospital course data for consecutive patients with spontaneous intracerebral hemorrhage enrolled in an observational study. Readmission within 30 days was determined retrospectively by an automated query with manual confirmation. We identified the reason for readmission and tested for associations between readmission and functional outcomes using modified Rankin Scale (a validated functional outcome measure from 0, no symptoms, to 6, death) scores before intracerebral hemorrhage and at 14 days, 28 days, and 3 months after intracerebral hemorrhage. SETTING Neurologic ICU of a tertiary care hospital. PATIENTS Critically ill patients with spontaneous intracerebral hemorrhage. INTERVENTIONS Patients received standard critical care management for intracerebral hemorrhage. MEASUREMENTS AND MAIN RESULTS Of 246 patients (mean age, 65 yr; 51% female), 193 patients (78%) survived to discharge. Of these, 22 patients (11%) were readmitted at a median of 9 days (interquartile range, 4-15 d). The most common readmission diagnoses were infections after discharge (n = 10) and vascular events (n = 6). Age, history of stroke and hypertension, severity of neurologic deficit at admission, Acute Physiology and Chronic Health Evaluation score, ICU and hospital length of stay, ventilator-free days, days febrile, and surgical procedures were not predictors of readmission. History of coronary artery disease was associated with readmission (p = 0.03). Readmitted patients had similar modified Rankin Scale and severity of neurologic deficit at 14 days but higher (worse) modified Rankin Scale scores at 3 months (median [interquartile range], 5 [3-6] vs 3 [1-4]; p = 0.01). CONCLUSIONS Severity of illness and hospital complications were not associated with 30-day readmission. The most common indication for readmission was infection after discharge, and readmission was associated with worse functional outcomes at 3 months. Preventing readmission after intracerebral hemorrhage may depend primarily on optimizing care after discharge and may improve functional outcomes at 3 months.
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Affiliation(s)
- Eric M. Liotta
- Department of Neurology, Northwestern University—Feinberg School of Medicine, Chicago, IL
| | - Mandeep Singh
- Department of Anesthesiology, Northwestern University—Feinberg School of Medicine, Chicago, IL
| | - Adam R. Kosteva
- Department of Neurology, Northwestern University—Feinberg School of Medicine, Chicago, IL
| | - Jennifer L. Beaumont
- Department of Medical Social Sciences, Northwestern University—Feinberg School of Medicine, Chicago, IL
| | - James C. Guth
- Department of Neurology, Northwestern University—Feinberg School of Medicine, Chicago, IL
| | - Rebecca M. Bauer
- Department of Anesthesiology, Northwestern University—Feinberg School of Medicine, Chicago, IL
| | - Shyam Prabhakaran
- Department of Neurology, Northwestern University—Feinberg School of Medicine, Chicago, IL
| | - Neil F. Rosenberg
- Department of Neurology, Northwestern University—Feinberg School of Medicine, Chicago, IL
| | - Matthew B. Maas
- Department of Neurology, Northwestern University—Feinberg School of Medicine, Chicago, IL
- Department of Anesthesiology, Northwestern University—Feinberg School of Medicine, Chicago, IL
| | - Andrew M. Naidech
- Department of Neurology, Northwestern University—Feinberg School of Medicine, Chicago, IL
- Department of Anesthesiology, Northwestern University—Feinberg School of Medicine, Chicago, IL
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Nahab F, Takesaka J, Mailyan E, Judd L, Culler S, Webb A, Frankel M, Choi D, Helmers S. Avoidable 30-day readmissions among patients with stroke and other cerebrovascular disease. Neurohospitalist 2013; 2:7-11. [PMID: 23983857 DOI: 10.1177/1941874411427733] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There are limited data on factors associated with 30-day readmissions and the frequency of avoidable readmissions among patients with stroke and other cerebrovascular disease. METHODS University HealthSystem Consortium (UHC) database records were used to identify patients discharged with a diagnosis of stroke or other cerebrovascular disease at a university hospital from January 1, 2007 to December 31, 2009 and readmitted within 30 days to the index hospital. Logistic regression models were used to identify patient and clinical characteristics associated with 30-day readmission. Two neurologists performed chart reviews on readmissions to identify avoidable cases. RESULTS Of 2706 patients discharged during the study period, 174 patients had 178 readmissions (6.4%) within 30 days. The only factor associated with 30-day readmission was the index length of stay >10 days (vs <5 days; odds ratio [OR] 2.3, 95% CI [1.4, 3.7]). Of 174 patients readmitted within 30 days (median time to readmission 10 days), 92 (53%) were considered avoidable readmissions including 38 (41%) readmitted for elective procedures within 30 days of discharge, 27 (29%) readmitted after inadequate outpatient care coordination, 15 (16%) readmitted after incomplete initial evaluations, 8 (9%) readmitted due to delayed palliative care consultation, and 4 (4%) readmitted after being discharged with inadequate discharge instructions. Only 5% of the readmitted patients had outpatient follow-up recommended within 1 week. CONCLUSIONS More than half of the 30-day readmissions were considered avoidable. Coordinated timing of elective procedures and earlier outpatient follow-up may prevent the majority of avoidable readmissions among patients with stroke and other cerebrovascular disease.
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Affiliation(s)
- Fadi Nahab
- Department of Neurology, Emory University, Atlanta, GA, USA
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King BJ, Gilmore-Bykovskyi AL, Roiland RA, Polnaszek BE, Bowers BJ, Kind AJH. The consequences of poor communication during transitions from hospital to skilled nursing facility: a qualitative study. J Am Geriatr Soc 2013; 61:1095-102. [PMID: 23731003 PMCID: PMC3714367 DOI: 10.1111/jgs.12328] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine how skilled nursing facility (SNF) nurses transition the care of individuals admitted from hospitals, the barriers they experience, and the outcomes associated with variation in the quality of transitions. DESIGN Qualitative study using grounded dimensional analysis, focus groups, and in-depth interviews. SETTING Five Wisconsin SNFs. PARTICIPANTS Twenty-seven registered nurses. MEASUREMENTS Semistructured questions guided the focus group and individual interviews. RESULTS SNF nurses rely heavily on written hospital discharge communication to transition individuals into the SNF effectively. Nurses cited multiple inadequacies of hospital discharge information, including regular problems with medication orders (including the lack of opioid prescriptions for pain), little psychosocial or functional history, and inaccurate information regarding current health status. These communication inadequacies necessitated repeated telephone clarifications, created care delays (including delays in pain control), increased SNF staff stress, frustrated individuals and family members, contributed directly to negative SNF facility image, and increased risk of rehospitalization. SNF nurses identified a specific list of information and components that they need to facilitate a safe, high-quality transition. CONCLUSION Nurses note multiple deficiencies in hospital-to-SNF transitions, with poor quality discharge communication being identified as the major barrier to safe and effective transitions. This information should be used to refine and support the dissemination of evidence-based interventions that support transitions of care, including the Interventions to Reduce Acute Care Transfers program.
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Affiliation(s)
- Barbara J King
- School of Nursing, University of Wisconsin at Madison, Madison, Wisconsin 53792, USA.
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Kilkenny MF, Longworth M, Pollack M, Levi C, Cadilhac DA. Factors Associated With 28-Day Hospital Readmission After Stroke in Australia. Stroke 2013; 44:2260-8. [DOI: 10.1161/strokeaha.111.000531] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Olson DM, Cox M, Pan W, Sacco RL, Fonarow GC, Zorowitz R, Labresh KA, Schwamm LH, Williams L, Goldstein LB, Bushnell CD, Peterson ED. Death and rehospitalization after transient ischemic attack or acute ischemic stroke: one-year outcomes from the adherence evaluation of acute ischemic stroke-longitudinal registry. J Stroke Cerebrovasc Dis 2012; 22:e181-8. [PMID: 23273788 DOI: 10.1016/j.jstrokecerebrovasdis.2012.11.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 09/11/2012] [Accepted: 11/01/2012] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Longitudinal data directly comparing the rates of death and rehospitalization of patients discharged after transient ischemic attack (TIA) versus acute ischemic stroke (AIS) are lacking. METHODS Data were analyzed from 2802 patients (TIA n = 552; AIS n = 2250) admitted to 100 U.S. hospitals participating in the Get With The Guidelines-Stroke and the Adherence Evaluation of Acute Ischemic Stroke-Longitudinal registry. The primary composite outcome was the adjusted rate of all-cause death and rehospitalization over 1 year after discharge. Four additional single or combined outcomes were explored. RESULTS Compared with AIS, TIA patients were older (median 69 v 66 years; P = .007) and more likely female (53.3% v 44.2%; P < .0001). Secondary prevention medication use after hospital discharge was less intensive after TIA, with underuse for both conditions. All-cause death or rehospitalization at 1 year was similar for TIA and AIS patients (37.7% v 34.6%; P = .271); the frequency for TIA patients was higher after covariate adjustment (hazard ratio [HR] 1.19; 95% confidence interval [CI] 1.01-1.41). One-year all-cause mortality was similar among those with TIA compared to AIS patients (3.8% v 5.7%; P = .071; adjusted HR 0.86; 95% CI 0.52-1.42). All-cause rehospitalizations were higher for TIA compared to AIS patients (36.4% v 33.0%; P = .186; adjusted HR 1.20; 95% CI 1.02-1.42), but similar for stroke rehospitalizations (10.1% v 7.4%; P = .037; adjusted HR 1.38, 95% CI 0.997-1.92). CONCLUSIONS Patients with TIA have similar or worse 12-month postdischarge risk of death or rehospitalization as compared with those with AIS. Outcomes after TIA and AIS might be improved with better adherence to secondary preventive guidelines.
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Affiliation(s)
- Daiwai M Olson
- Department of Medicine, Duke Clinical Research Institute, Durham, NC, Durham, NC.
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Navarro AE, Enguídanos S, Wilber KH. Identifying risk of hospital readmission among Medicare aged patients: an approach using routinely collected data. Home Health Care Serv Q 2012; 31:181-95. [PMID: 22656916 DOI: 10.1080/01621424.2012.681561] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Readmission provisions in the Patient Protection and Affordable Care Act of March 2010 have created urgent fiscal accountability requirements for hospitals, dependent upon a better understanding of their specific populations, along with development of mechanisms to easily identify these at-risk patients. Readmissions are disruptive and costly to both patients and the health care system. Effectively addressing hospital readmissions among Medicare aged patients offers promising targets for resources aimed at improved quality of care for older patients. Routinely collected data, accessible via electronic medical records, were examined using logistic models of sociodemographic, clinical, and utilization factors to identify predictors among patients who required rehospitalization within 30 days. Specific comorbidities and discharge care orders in this urban, nonprofit hospital had significantly greater odds of predicting a Medicare aged patient's risk of readmission within 30 days.
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Affiliation(s)
- Adria E Navarro
- Azusa Pacific University, Department of Graduate Social Work, School of Behavioral and Applied Sciences, Azusa, California 91702-7000, USA.
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Bhattacharya P, Khanal D, Madhavan R, Chaturvedi S. Why do ischemic stroke and transient ischemic attack patients get readmitted? J Neurol Sci 2011; 307:50-4. [PMID: 21636101 DOI: 10.1016/j.jns.2011.05.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Accepted: 05/17/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Readmission is an important indicator for the quality of healthcare services. The authors examined the reasons for 30-day readmission among urban stroke patients, and their clinical consequences. METHODS Consecutive patients admitted to a JCAHO certified primary stroke center with ischemic stroke or transient ischemic attacks (TIA) were included. Demographics, TOAST mechanism, risk factors, treatments administered and discharge destination were collected. Charts were reviewed for readmissions up to 30 days from discharge. Reasons for readmission and outcomes in terms of disability and discharge destination were determined. RESULTS Two hundred sixty-five patients (50.9% male; 79.6%African American; mean age 60.9 years) were included. There were 205(77.4%) strokes and 60(22.6%) TIAs. Thirteen (5%) patients died during their first admission. Of the remaining 252 patients, 25 (9.9%) were readmitted within 30 days. The reason for readmission was neurological in 8/25 patients (32%; 3 ischemic strokes, 1 hemorrhagic stroke and 4 TIAs); and non-neurological in 17/25 patients (68%). The frequent non-neurological reasons were infections (6/25), electrolyte disturbances (3/25) and trauma related to falls (2/25). Patients with coronary artery disease were more likely to be readmitted (45.5% vs. 14.7%; p=0.001) An NIH stroke scale ≥10 predicted readmission (50.0% vs. 25.4% for NIHSS<10; p value 0.02). Patients discharged home or to acute rehabilitation units were less likely to be readmitted than those discharged to subacute rehabilitation units or nursing homes (8.2% vs. 23.8%; p value=0.01). INTERPRETATION Disabling strokes are more likely to be readmitted. The reason is often non-neurological, and sometimes preventable. Physicians should review cases that return within 30 days and determine best practices that prevent readmission.
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Affiliation(s)
- Pratik Bhattacharya
- Department of Neurology, Wayne State University/Detroit Medical Center, Detroit, MI 48201, USA.
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Kind AJH, Smith MA, Liou JI, Pandhi N, Frytak JR, Finch MD. Discharge destination's effect on bounce-back risk in Black, White, and Hispanic acute ischemic stroke patients. Arch Phys Med Rehabil 2010; 91:189-95. [PMID: 20159120 DOI: 10.1016/j.apmr.2009.10.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 09/24/2009] [Accepted: 10/20/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine whether racial and ethnic effects on bounce-back risk (ie, movement to settings of higher care intensity within 30 d of hospital discharge) in acute stroke patients vary depending on initial posthospital discharge destination. DESIGN Retrospective analysis of administrative data. SETTING Four hundred twenty-two hospitals, southern/eastern United States. PARTICIPANTS All Medicare beneficiaries 65 years or more with hospitalization for acute ischemic stroke within one of the 422 target hospitals during the years 1999 or 2000 (N=63,679). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Adjusted predicted probabilities for discharge to and for bouncing back from each initial discharge site (ie, home, home with home health care, skilled nursing facility [SNF], or rehabilitation center) by race (ie, black, white, and Hispanic). Models included sociodemographics, comorbidities, stroke severity, and length of stay. RESULTS Blacks and Hispanics were significantly more likely to be discharged to home health care (blacks=21% [95% confidence interval (CI), 19.9-22.8], Hispanic=19% [17.1-21.7] vs whites=16% [15.5-16.8]) and less likely to be discharged to SNFs (blacks=26% [95% CI, 23.6-29.3], Hispanics=28% [25.4-31.6] vs whites=33% [31.8-35.1]) than whites. However, blacks and Hispanics were significantly more likely to bounce back when discharged to SNFs than whites (blacks=26% [95% CI, 24.2-28.6], Hispanics=28% [24-32.6] vs whites=21% [20.3-21.9]). Hispanics had a lower risk of bouncing back when discharged home than either blacks or whites (Hispanics=14% [95% CI, 11.3-17] vs blacks=20% [18.4-22.2], whites=18% [16.8-18.3]). Patients discharged to home health care or rehabilitation centers demonstrated no significant differences in bounce-back risk. CONCLUSIONS Racial/ethnic bounce-back risk differs depending on initial discharge destination. Additional research is needed to fully understand this variation in effect.
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Affiliation(s)
- Amy J H Kind
- Department of Medicine-Geriatrics Section, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, USA.
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Ney DM, Weiss JM, Kind AJH, Robbins J. Senescent swallowing: impact, strategies, and interventions. Nutr Clin Pract 2009; 24:395-413. [PMID: 19483069 DOI: 10.1177/0884533609332005] [Citation(s) in RCA: 220] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
The risk for disordered oropharyngeal swallowing (dysphagia) increases with age. Loss of swallowing function can have devastating health implications, including dehydration, malnutrition, pneumonia, and reduced quality of life. Age-related changes increase risk for dysphagia. First, natural, healthy aging takes its toll on head and neck anatomy and physiologic and neural mechanisms underpinning swallowing function. This progression of change contributes to alterations in the swallowing in healthy older adults and is termed presbyphagia, naturally diminishing functional reserve. Second, disease prevalence increases with age, and dysphagia is a comorbidity of many age-related diseases and/or their treatments. Sensory changes, medication, sarcopenia, and age-related diseases are discussed herein. Recent findings that health complications are associated with dysphagia are presented. Nutrient requirements, fluid intake, and nutrition assessment for older adults are reviewed relative to dysphagia. Dysphagia screening and the pros and cons of tube feeding as a solution are discussed. Optimal intervention strategies for elders with dysphagia ranging from compensatory interventions to more rigorous exercise approaches are presented. Compelling evidence of improved functional swallowing and eating outcomes resulting from active rehabilitation focusing on increasing strength of head and neck musculature is provided. In summary, although oropharyngeal dysphagia may be life threatening, so are some of the traditional alternatives, particularly for frail, elderly patients. Although the state of the evidence calls for more research, this review indicates that the behavioral, dietary, and environmental modifications emerging in this past decade are compassionate, promising, and, in many cases, preferred alternatives to the always present option of tube feeding.
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Affiliation(s)
- Denise M Ney
- University of Wisconsin, Department of Nutritional Sciences, and the William S. Middleton Memorial VA Hospital GRECC, 2500 Overlook Terrace, GRECC 11G, Madison, WI 53705, USA
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