Hospital Variation in Functional Recovery After Stroke

Contemporary Statistics of Acute Ischemic Stroke and Transient Ischemic Attack in 2021: Insights From the CRCS-K-NIH Registry

This report presents the latest statistics on the stroke population in South Korea, sourced from the Clinical Research Collaborations for Stroke in Korea-National Institute for Health (CRCS-K-NIH), a comprehensive, nationwide, multicenter stroke registry. The Korean cohort, unlike western populations, shows a male-to-female ratio of 1.5, attributed to lower risk factors in Korean women. The average ages for men and women are 67 and 73 years, respectively. Hypertension is the most common risk factor (67%), consistent with global trends, but there is a higher prevalence of diabetes (35%) and smoking (21%). The prevalence of atrial fibrillation (19%) is lower than in western populations, suggesting effective prevention strategies in the general population. A high incidence of large artery atherosclerosis (38%) is observed, likely due to prevalent intracranial arterial disease in East Asians and advanced imaging techniques. There has been a decrease in intravenous thrombolysis rates, from 12% in 2017-2019 to 10% in 2021, with no improvements in door-to-needle and door-to-puncture times, worsened by the coronavirus disease 2019 pandemic. While the use of aspirin plus clopidogrel for non-cardioembolic stroke and direct oral anticoagulants for atrial fibrillation is well-established, the application of direct oral anticoagulants for non-atrial fibrillation cardioembolic strokes in the acute phase requires further research. The incidence of early neurological deterioration (13%) and the cumulative incidence of recurrent stroke at 3 months (3%) align with global figures. Favorable outcomes at 3 months (63%) are comparable internationally, yet the lack of improvement in dependency at 3 months highlights the need for advancements in acute stroke care.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Determining the factors influencing the selection of post-acute care models by patients and their families: a qualitative content analysis

BACKGROUND

This study conducted in-depth interviews to explore the factors that influence the choice of a post-acute care (PAC) model (inpatient rehabilitation hospital, skilled nursing facility, home health, and outpatient rehabilitation) among stroke patients and their families.

METHODS

We conducted semi-structured, in-depth interviews of 21 stroke patients and their families at four hospitals in Taiwan. Content analysis was used in this qualitative study.

RESULTS

Results revealed five main factors that influence respondents' choice of PAC: (1) medical professionals' suggestions, (2) health care accessibility, (3) continuity and coordination of care, (4) willingness and prior experience of patients and their relatives and friends, and (5) economic factors.

CONCLUSIONS

This study identifies five main factors that affect the choice of PAC models among stroke patients and their families. We suggest that policymakers establish comprehensive health care resources based on the needs of patients and families. Health care providers shall provide professional recommendations and adequate information to support decision-making, which aligns with the preferences and values of patients and their families. From this research, we hope to improve the accessibility of PAC services in order to enhance the quality of care for stroke patients.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Association of serum albumin to globulin ratio with outcomes in acute ischemic stroke

BACKGROUND

Serum albumin to globulin ratio (A/G) has been widely used as a representative biomarker for assessing inflammation and nutrition status. However, in patients with acute ischemic stroke (AIS), the predictive value of serum A/G has rarely been reported. We aimed to evaluate whether serum A/G is associated with prognosis in stroke.

METHODS

We analyzed data from the Third China National Stroke Registry. The patients were categorized into quartile groups according to the serum A/G at admission. Clinical outcomes included poor functional outcomes (modified Rankin Scale [mRS] score of 3-6 or 2-6) and all-cause mortality at 3 months and1 year. Multivariable logistic regressions and Cox proportional hazards regressions were used to evaluate the association of serum A/G with the risk of poor functional outcomes and all-cause mortality.

RESULTS

A total of 11, 298 patients were included in this study. After adjustment for confounding factors, patients in the highest serum A/G quartile had a lower proportion of mRS score 2-6 (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.76-1.00) and mRS score 3-6 (OR, 0.87; 95% CI, 0.73-1.03) at 3 months follow-up. At 1 year follow-up, there was a significant association between higher serum A/G and mRS score 3-6 (OR, 0.68; 95% CI, 0.57-0.81). We also found that the highest serum A/G was related to decreased risk of all-cause mortality (hazard ratio [HR], 0.58; 95% CI, 0.36-0.94) at 3 months follow-up. Similar results were found at 1-year follow-up.

CONCLUSIONS

Lower serum A/G levels were associated with poor functional outcomes and all-cause mortality at 3 months and 1-year follow-up in patients with acute ischemic stroke.

Frequency-tuned electromagnetic field therapy improves post-stroke motor function: A pilot randomized controlled trial

BACKGROUND AND PURPOSE

Impaired upper extremity (UE) motor function is a common disability after ischemic stroke. Exposure to extremely low frequency and low intensity electromagnetic fields (ELF-EMF) in a frequency-specific manner (Electromagnetic Network Targeting Field therapy; ENTF therapy) is a non-invasive method available to a wide range of patients that may enhance neuroplasticity, potentially facilitating motor recovery. This study seeks to quantify the benefit of the ENTF therapy on UE motor function in a subacute ischemic stroke population.

METHODS

In a randomized, sham-controlled, double-blind trial, ischemic stroke patients in the subacute phase with moderately to severely impaired UE function were randomly allocated to active or sham treatment with a novel, non-invasive, brain computer interface-based, extremely low frequency and low intensity ENTF therapy (1-100 Hz, < 1 G). Participants received 40 min of active ENTF or sham treatment 5 days/week for 8 weeks; ~three out of the five treatments were accompanied by 10 min of concurrent physical/occupational therapy. Primary efficacy outcome was improvement on the Fugl-Meyer Assessment - Upper Extremity (FMA-UE) from baseline to end of treatment (8 weeks).

RESULTS

In the per protocol set (13 ENTF and 8 sham participants), mean age was 54.7 years (±15.0), 19% were female, baseline FMA-UE score was 23.7 (±11.0), and median time from stroke onset to first stimulation was 11 days (interquartile range (IQR) 8-15). Greater improvement on the FMA-UE from baseline to week 4 was seen with ENTF compared to sham stimulation, 23.2 ± 14.1 vs. 9.6 ± 9.0, p = 0.007; baseline to week 8 improvement was 31.5 ± 10.7 vs. 23.1 ± 14.1. Similar favorable effects at week 8 were observed for other UE and global disability assessments, including the Action Research Arm Test (Pinch, 13.4 ± 5.6 vs. 5.3 ± 6.5, p = 0.008), Box and Blocks Test (affected hand, 22.5 ± 12.4 vs. 8.5 ± 8.6, p < 0.0001), and modified Rankin Scale (-2.5 ± 0.7 vs. -1.3 ± 0.7, p = 0.0005). No treatment-related adverse events were reported.

CONCLUSIONS

ENTF stimulation in subacute ischemic stroke patients was associated with improved UE motor function and reduced overall disability, and results support its safe use in the indicated population. These results should be confirmed in larger multicenter studies.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT04039178, identifier: NCT04039178.

Between-Center Variation in Outcome After Endovascular Treatment of Acute Stroke: Analysis of Two Nationwide Registries

BACKGROUND

Insight in differences in patient outcomes between endovascular thrombectomy (EVT) centers can help to improve stroke care. We assessed between-center variation in functional outcome of patients with acute ischemic stroke who were treated with EVT. We analyzed to what extent this variation may be explained by modifiable center characteristics.

METHODS

We used nationwide registry data of patients with stroke treated with EVT in the Netherlands and in the Czech Republic. Primary outcome was modified Rankin Scale score at 90 days as an indicator of disability. We used multilevel ordinal logistic regression to quantify the between-center variation in outcomes and the impact of patient and center characteristics. Between-center variation was expressed as the relative difference in odds of a more favorable modified Rankin Scale score between a relatively better performing center (75th percentile) and a relatively worse performing center (25th percentile).

RESULTS

We included a total of 4518 patients treated in 33 centers. Adjusted for patient characteristics, the odds of a more favorable outcome in a center at the 75th percentile of the outcome distribution were 1.46 times higher (95% CI, 1.31-1.70) than the odds in a center at the 25th percentile. Adjustment for center characteristics, including the median time between stroke onset and reperfusion per center, decreased this relative difference in odds to 1.30 (95% CI, 1.18-1.50, P=0.01). This translates into an absolute difference in likelihood of good functional outcome of 8% after adjustment for patient characteristics and to 5% after further adjustment for modifiable center characteristics.

CONCLUSIONS

The considerable between-center variation in patient outcomes after EVT for acute ischemic stroke could be largely explained by center-specific characteristics, such as time to reperfusion. Improvement of these parameters may likely result in a decrease in center-specific differences, and an overall improvement in outcome of patients with acute ischemic stroke.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Estimating the cost and value of functional changes in communication ability following telepractice treatment for aphasia

Context

Aphasia is a post-stroke condition that can dramatically impact a person with aphasia’s (PWA) communication abilities. To date, few if any studies have considered the cost and cost-effectiveness of functional change in aphasia nor considered measures of patient’s value for aphasia treatment.

Objective

To assess the cost, cost-effectiveness, and perceived value associated with improved functional communication in individuals receiving telerehabilitation treatment for aphasia.

Design

Twenty PWA completed between 5 and 12 telehealth rehabilitation sessions of 45–60 minutes within a 6-week time frame using a Language-Oriented Treatment (LOT) designed to address a range of language issues among individuals with aphasia. National Outcomes Measures (NOMS) comprehension and verbal expression and the ASHA Quality of Communication Life (QCL) were completed prior to and at the completion of rehabilitation to obtain baseline and treatment measures.

Results

Age, education, and race are significantly correlated with improvement in the NOMS verbal expression. African Americans (OR = 2.0917) are twice as likely as Whites to experience improvement after treatment. The likelihood of improvement also increases with each additional year of education (OR = 1.002) but decrease with age (OR = 0.9463). A total of 15 PWA showed improvement in NOMS comprehension and nine patients showed improvement in NOMS verbal expression. Improving patients attended between five and 12 treatment sessions. The average cost of improvement in NOMS comprehension was $1,152 per patient and NOMS verbal expression was $1,128 per patient with individual treatment costs varying between $540 and $1,296. However, on average, the monetary equivalent in patient’s improved QCL was between $1,790.39 to $3,912,54—far exceeding the financial cost of treatment.

Conclusions

When measuring the functional improvement of patients with aphasia, patient’s quality of communication life received from treatment exceeded financial cost of services provided.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Comprehensive Stroke Care and Outcomes: Time for a Paradigm Shift

Worldwide, stroke is prevalent, costly, and disabling in >80 million survivors. The burden of stroke is increasing despite incredible progress and advancements in evidence-based acute care therapies and despite the substantial changes being made in acute care stroke systems, processes, and quality metrics. Although there has been increased global emphasis on the importance of postacute stroke care, stroke system changes have not expanded to include postacute care and outcome follow-up. Our objectives are to describe the gaps and challenges in postacute stroke care and suboptimal stroke outcomes; to report on stroke survivors' and caregivers' perceptions of current postacute stroke care and their call for improvements in follow-up services for recovery and secondary prevention; and, ultimately, to make the case that a paradigm shift is needed in the definition of comprehensive stroke care and the designation of Comprehensive Stroke Center. Three recommendations are made for a paradigm shift in comprehensive stroke care: (1) criteria should be established for designation of rehabilitation readiness for Comprehensive Stroke Centers, (2) The American Heart Association/American Stroke Association implement an expanded Get With The Guidelines-Stroke program and criteria for comprehensive stroke centers to be inclusive of rehabilitation readiness and measure outcomes at 90 days, and (3) a public health campaign should be launched to offer hopeful and actionable messaging for secondary prevention and recovery of function and health. Now is the time to honor the patients' and caregivers' strongest ask: better access and improved secondary prevention, stroke rehabilitation, and personalized care.

Prognostic value of cerebral infarction coefficient in patients with massive cerebral infarction

OBJECTIVE

We proposed the concept of the cerebral infarction coefficient, which is cerebral infarction volume/brain volume. This study aimed to evaluate the prognostic value of the cerebral infarction coefficient in patients with massive cerebral infarction (MCI).

METHODS

According to the modified Rankin score, 71 patients with acute MCI were divided into good prognosis and poor prognosis groups. Clinical and imaging data of the two groups were collected and univariate analysis was carried out. If there were significant differences in the data between the two groups, binary logistic regression analysis was performed.

RESULTS

The poor prognosis group had a significantly higher cerebral infarction volume, cerebral infarction coefficient, and D-dimer levels, older age, the highest body temperature, a higher rate of a history of atrial fibrillation, and a lower rate of a history of hypertension compared with the good prognosis group (all P < 0.05). Binary logistic regression analysis showed that the cerebral infarction coefficient was an independent risk factor for a poor prognosis of patients with MCI (P < 0.05, 95 % confidence interval, 2.091, 42.562), and the odds ratio was 8.506. The area under the receiver operating characteristic curve for the cerebral infarction coefficient was 0.753. When the cut-off value was 7.8 %, the sensitivity of predicting a poor prognosis of patients with MCI was 92.5 %.

CONCLUSION

The cerebral infarction coefficient may have predictive value in determining the prognosis of patients with MCI.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Comparison of Functional Status Improvements Among Patients With Stroke Receiving Postacute Care in Inpatient Rehabilitation vs Skilled Nursing Facilities

IMPORTANCE

Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes.

OBJECTIVE

To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF).

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included patients with stroke who were discharged from acute care hospitals to IRF or SNF from January 1, 2013, to November 30, 2014. Medicare claims were used to link to IRF and SNF assessments. Data analyses were conducted from January 17, 2017, through April 25, 2019.

EXPOSURES

Inpatient rehabilitation received in IRFs vs SNFs.

MAIN OUTCOMES AND MEASURES

Changes in mobility and self-care measures during an IRF or SNF stay were compared using multivariate analyses, inverse probability weighting with propensity score, and instrumental variable analyses. Mortality between 30 and 365 days after discharge was included as a control outcome as an indicator for unmeasured confounders.

RESULTS

Among 99 185 patients who experienced a stroke between January 1, 2013, and November 30, 2014, 66 082 patients (66.6%) were admitted to IRFs and 33 103 patients (33.4%) were admitted to SNFs. A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001). Compared with patients admitted to IRFs, patients admitted to SNFs were older (mean [SD] age, 79.4 [7.6] years vs 83.3 [7.8] years; P < .001) and had longer hospital length of stay (mean [SD], 4.6 [3.0] days vs 5.9 [4.2] days; P < .001) than those admitted to IRFs. In unadjusted analyses, patients with stroke admitted to IRF compared with those admitted to SNF had higher mean scores for mobility on admission (44.2 [95% CI, 44.1-44.3] points vs 40.8 [95% CI, 40.7-40.9] points) and at discharge (55.8 [95% CI, 55.7-55.9] points vs 44.4 [95% CI, 44.3-44.5] points), and for self-care on admission (45.0 [95% CI, 44.9-45.1] points vs 41.8 [95% CI, 41.7-41.9] points) and at discharge (58.6 [95% CI, 58.5-58.7] points vs 45.1 [95% CI, 45.0-45.2] points). Additionally, patients in IRF compared with those in SNF had larger improvements for mobility score (11.6 [95% CI, 11.5-11.7] points vs 3.5 [95% CI, 3.4-3.6] points) and for self-care score (13.6 [95% CI, 13.5-13.7] points vs 3.2 [95% CI, 3.1-3.3] points). Multivariable, propensity score, and instrumental variable analyses showed a similar magnitude of better improvements in patients admitted to IRF vs those admitted to SNF. The differences between SNF and IRF in odds of 30- to 365-day mortality (unadjusted odds ratio, 0.48 [95% CI, 0.46-0.49]) were reduced but not eliminated in multivariable analysis (adjusted odds ratio, 0.72 [95% CI, 0.69-0.74]) and propensity score analysis (adjusted odds ratio, 0.75 [95% CI, 0.72-0.77]). These differences were no longer statistically significant in the instrumental variable analyses.

CONCLUSIONS AND RELEVANCE

In this cohort study of a large national sample, inpatient rehabilitation in IRFs for patients with stroke was associated with substantially improved physical mobility and self-care function compared with rehabilitation in SNFs. This finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke.

Multidiscipline Stroke Post-Acute Care Transfer System: Propensity-Score-Based Comparison of Functional Status

Few studies have investigated the characteristics of stroke inpatients after post-acute care (PAC) rehabilitation, and few studies have applied propensity score matching (PSM) in a natural experimental design to examine the longitudinal impacts of a medical referral system on functional status. This study coupled a natural experimental design with PSM to assess the impact of a medical referral system in stroke patients and to examine the longitudinal effects of the system on functional status. The intervention was a hospital-based, function oriented, 12-week to 1-year rehabilitative PAC intervention for patients with cerebrovascular diseases. The average duration of PAC in the intra-hospital transfer group (31.52 days) was significantly shorter than that in the inter-hospital transfer group (37.1 days) (p < 0.001). The intra-hospital transfer group also had better functional outcomes. The training effect was larger in patients with moderate disability (Modified Rankin Scale, MRS = 3) and moderately severe disability (MRS = 4) compared to patients with slight disability (MRS = 2). Intensive post-stroke rehabilitative care delivered by per-diem payment is effective in terms of improving functional status. To construct a vertically integrated medical system, strengthening the qualified local hospitals with PAC wards, accelerating the inter-hospital transfer, and offering sufficient intensive rehabilitative PAC days are the most essential requirements.

Discharge Patterns for Ischemic and Hemorrhagic Stroke Patients Going From Acute Care Hospitals to Inpatient and Skilled Nursing Rehabilitation

OBJECTIVE

The aim of the study was to explore variation in acute care use of inpatient rehabilitation facilities and skilled nursing facilities rehabilitation after ischemic and hemorrhagic stroke.

DESIGN

A secondary analysis of Medicare claims data linked to inpatient rehabilitation facilities and skilled nursing facilities assessment files (2013-2014) was performed.

RESULTS

The sample included 122,084 stroke patients discharged to inpatient or skilled nursing facilities from 3677 acute hospitals. Of the acute hospitals, 3649 discharged patients with an ischemic stroke (range = 1-402 patients/hospital, median = 15) compared with 1832 acute hospitals that discharged patients with hemorrhagic events (range = 1-73 patients/hospital, median = 4). The intraclass correlation coefficient examined variation in discharge settings attributed to acute hospitals (ischemic intraclass correlation coefficient = 0.318, hemorrhagic intraclass correlation coefficient = 0.176). Patients older than 85 yrs and those with greater numbers of co-morbid conditions were more likely to discharge to skilled nursing facilities. Comparison of self-care and mobility across stroke type suggests that patients with ischemic stroke have higher functional abilities at admission.

CONCLUSIONS

This study suggests demographic and clinical differences among stroke patients admitted for postacute rehabilitation at inpatient rehabilitation facilities and skilled nursing facilities settings. Furthermore, examination of variation in ischemic and hemorrhagic stroke discharges suggests acute facility-level differences and indicates a need for careful consideration of patient and facility factors when comparing the effectiveness of inpatient rehabilitation facilities and skilled nursing facilities rehabilitation.

Frequency, predictors, and outcomes of readmission to index versus non-index hospitals after mechanical thrombectomy in patients with ischemic stroke

Background

Stroke systems of care employ a hub-and-spoke model, with fewer centers performing mechanical thrombectomy (MT) compared with stroke-receiving centers, where a higher number offer high-level, centralized treatment to a large number of patients.

Objective

To characterize rates and outcomes of readmission to index and non-index hospitals for patients with ischemic stroke who underwent MT.

Methods

This study leveraged a population-based, nationally representative sample of patients with stroke undergoing MT from the Nationwide Readmissions Database between 2010 and 2014. Descriptive, logistic regression analyses, and univariate and multivariate logistic regression models were carried out to determine patient- and hospital-level factors, mortality, complications, and subsequent readmissions associated with index and non-index hospitals' 90-day readmissions.

Results

In the study, 2111 patients with a stroke were treated with MT, of whom 534 were readmitted within 90 days. The most common reasons for readmission were: septicemia (5.9%), atrial fibrillation (4.8%), and cerebral artery occlusion with infarct (4.8%). Among readmitted patients, 387 (74%) were readmitted to index and 136 (26%) to non-index hospitals. On multivariable logistic regression analysis, non-index hospital readmission was not independently associated with major complications (p=0.09), mortality (p=0.34), neurological complications (p=0.47), or second readmission (p=0.92).

Conclusion

One-quarter of patients with a stroke treated with MT were readmitted within 90 days, and one quarter of these patients were readmitted to non-index hospitals. Readmission to a non-index hospital was not associated with mortality or increased complication rates. In a hub-and-spoke model it is important that follow-up care for a specialized procedure can be performed effectively at a vast number of non-index hospitals covering a large geographic area.

Recurrent stroke in midlife is associated with not having a primary care physician

OBJECTIVE

To determine using a population-based study whether midlife stroke patients having a primary care physician (PCP) at the time of first stroke have a lower risk of stroke recurrence and mortality than those who do not have a PCP.

METHODS

First-ever ischemic stroke patients 45 to 64 years of age at stroke onset were ascertained through the Brain Attack Surveillance in Corpus Christi (BASIC) project from 2000 to 2013 in Texas. Cox proportional hazards models were used to examine the association between not having a PCP and stroke recurrence or all-cause mortality in separate models. Cases were followed up for up to 5 years or until December 31, 2013, whichever came first. Cases were censored for recurrence if they died before experiencing a recurrent event. We adjusted for clinical risk factors that could be associated with having a PCP and recurrence or mortality.

RESULTS

There were 663 first-occurrence ischemic stroke cases. Of these, 77% had a PCP, 43% were female, and average age was 55.6 years. Five-year recurrence risk was 14.6%, and mortality risk was 19.2%. Not having a PCP was associated with higher recurrence risk (adjusted hazard ratio 1.75, 95% confidence interval 1.02-3.02). Having a PCP was not associated with mortality. Sensitivity analyses showed that results were robust to different ways to adjust for chronic conditions.

CONCLUSION

This study found lower rates of stroke recurrence among those with a PCP at the time of first stroke. Future studies could determine the value of establishing a PCP before stroke hospital discharge for secondary stroke prevention.

Variation in outcomes among 24/7 percutaneous coronary intervention centres for patients resuscitated from out-of-hospital cardiac arrest

BACKGROUND

Patients treated at 24/7 percutaneous coronary intervention (PCI) centres following out-of-hospital cardiac arrest (OHCA) have better outcomes than those treated at non-24/7 PCI centres. However, variation in outcomes between 24/7 PCI centres is not well studied.

OBJECTIVES

To evaluate variation in outcomes among 24/7 PCI centres and to assess stability of 24/7 PCI centre performance.

METHODS

Adult patients in the California Office of Statewide Health Planning and Development Patient Discharge Database with a "present on admission" diagnosis of cardiac arrest admitted to a 24/7 PCI centre from 2011 to 2015 were included. Primary outcome was good neurologic recovery at hospital discharge. Secondary outcomes were survival to hospital discharge, cardiac catheterisation, and DNR orders within 24 h. Data were analysed using mixed effects logistic regression models. Hospitals were ranked each year and overall.

RESULTS

Of 27,122 patients admitted to 128 24/7 PCI centres, 41% (11,184) survived and 27% (7188) had good neurologic recovery. Adjusted rates of good neurologic recovery (18%-39%; p,0.001), survival (32%-51%; p < 0.0001), cardiac catheterisation (11%-49%; p < 0.0001) and DNR orders within 24 h (4.8%-49%; p < 0.0001) varied between 24/7 PCI centres. For the 26 hospitals with mean good neurologic rankings in the top or bottom tenth during 2011-2013, 14 (54%) remained in their respective tenth for 2014-2015.

CONCLUSION

Significant variation exists between 24/7 PCI centres in good neurologic recovery following OHCA and persists over time. Future studies should evaluate hospital-level factors that contribute to these differences in outcomes between 24/7 PCI centres.

Health Services Research in Rehabilitation and Disability-The Time is Now

Policy drives practice, and health services research (HSR) is at the intersection of policy, practice, and patient outcomes. HSR specific to rehabilitation and disability is particularly needed. As rehabilitation researchers and providers, we are uniquely positioned to provide the evidence that guides reforms targeting rehabilitative care. We have the expertise to define the value of rehabilitation in a policy-relevant context. HSR is a powerful tool for providing this evidence. We need to continue building capacity for conducting rigorous, timely rehabilitation-related HSR. Fostering stakeholder engagement in these research efforts will ensure we maintain a patient-centered focus as we address the "Triple Aim" of better care, better health, and better value. In this Special Communication we discuss the role of rehabilitation researchers in HSR. We also provide information on current resources available in our field for conducting HSR and identify gaps for capacity building and future research. Health care reforms are a reality, and through HSR we can give rehabilitation a strong voice during these transformative times.

Hospital Discharge Disposition of Stroke Patients in Tennessee

OBJECTIVES

Early determination of hospital discharge disposition status at an acute admission is extremely important for stroke management and the eventual outcomes of patients with stroke. We investigated the hospital discharge disposition of patients with stroke residing in Tennessee and developed a predictive tool for clinical adoption. Our investigational aims were to evaluate the association of selected patient characteristics with hospital discharge disposition status and predict such status at the time of an acute stroke admission.

METHODS

We analyzed 127,581 records of patients with stroke hospitalized between 2010 and 2014. Logistic regression was used to generate odds ratios with 95% confidence intervals to examine the factor outcome association. An easy-to-use clinical predictive tool was built by using integer-based risk scores derived from coefficients of multivariable logistic regression.

RESULTS

Among the 127,581 records of patients with stroke, 86,114 (67.5%) indicated home discharge and 41,467 (32.5%) corresponded to facility discharge. All considered patient characteristics had significant correlations with hospital discharge disposition status. Patients were at greater odds of being discharged to another facility if they were women; older; black; patients with a subarachnoid or intracerebral hemorrhage; those with the comorbidities of diabetes mellitus, heart disease, hypertension, chronic kidney disease, arrhythmia, or depression; those transferred from another hospital; or patients with Medicare as the primary payer. A predictive tool had a discriminatory capability with area under the curve estimates of 0.737 and 0.724 for derivation and validation cohorts, respectively.

CONCLUSIONS

Our investigation revealed that the hospital discharge disposition pattern of patients with stroke in Tennessee was associated with the key patient characteristics of selected demographics, clinical indicators, and insurance status. These analyses resulted in the development of an easy-to-use predictive tool for early determination of hospital discharge disposition status.

The American Heart Association's Get With the Guidelines (GWTG)-Stroke development and impact on stroke care

The American Heart Association’s Get With the Guidelines (GWTG)-Stroke programme has changed stroke care delivery in the USA since its establishment in 2003. GWTG is a voluntary registry and continuous quality improvement initiative that collects data on patient characteristics, hospital adherence to guidelines and inpatient outcomes. Implementation of the programme saw increased provision of evidence-based care and improved patient outcomes. This review will describe the development of the programme and discuss the impact on stroke outcomes and transformation of stroke care delivery that followed its implementation.