30-day mortality and readmission after hemorrhagic stroke among Medicare beneficiaries in Joint Commission primary stroke center-certified and noncertified hospitals

Perioperative stroke

Ischaemic or haemorrhagic perioperative stroke (that is, stroke occurring during or within 30 days following surgery) can be a devastating complication following surgery. Incidence is reported in the 0.1-0.7% range in adults undergoing non-cardiac and non-neurological surgery, in the 1-5% range in patients undergoing cardiac surgery and in the 1-10% range following neurological surgery. However, higher rates have been reported when patients are actively assessed and in high-risk populations. Prognosis is significantly worse than stroke occurring in the community, with double the 30-day mortality, greater disability and diminished quality of life among survivors. Considering the annual volume of surgeries performed worldwide, perioperative stroke represents a substantial burden. Despite notable differences in aetiology, patient populations and clinical settings, existing clinical recommendations for perioperative stroke are extrapolated mainly from stroke in the community. Perioperative in-hospital stroke is unique with respect to the stroke occurring in other settings, and it is essential to apply evidence from other settings with caution and to identify existing knowledge gaps in order to effectively guide patient care and future research.

Stroke epidemiology and incidence in regional Queensland: findings of the Regional Queensland Stroke (REQUEST) study

BACKGROUND

Stroke rates globally have been declining, but a majority of the studies on strokes have been in urban populations. Regional populations have been understudied, bgeographic health differentials can impact stroke presentations and outcomes.

AIM

To determine the incidence, risk factors for and survivability of stroke in patients presenting to a large rural stroke referral centre.

METHODS

Data were collected from one major regional stroke referral centre in Queensland, Australia, over 12 months with follow-up at 3.75 years for survival analysis. Patients were retrospectively enrolled based on a diagnosis made by a stroke physician. ICD-10 codes at separation and postcode of residence were applied for case ascertainment. Trial of ORG10172 in Acute Stroke Treatment (TOAST) classification and the World Health Organization  standardised definition of stroke were applied.

RESULTS

There were 105 strokes in a population of 106 760 persons over 12 months, giving a crude rate of 98 per 100 000 and standardised rate of 52/100 000 per year. Cardioembolism (n = 33, 31.4%) was the most common cause out of all ischaemic strokes (n = 87, 82.9%), followed by large vessel atherosclerosis (n = 26, 24.8%). Hypertension was the most prevalent risk factor in all stroke types, and atrial arrhythmia was the most prevalent factor in cardioembolic strokes. Overall survival at 3.75 years was 61%.

CONCLUSIONS

Incidence of stroke in a regional Queensland population is similar to other regional populations and when compared with larger cities. Despite a global trend in stroke reduction, modifiable risk factors like hypertension and atrial arrhythmias continue to be over-represented in the stroke population. All-cause mortality after stroke is high, especially during the initial period.

Structural Inequities for Historically Underserved Communities in the Adoption of Stroke Certification in the United States

Importance

Stroke centers are associated with better outcomes. There is substantial literature surrounding disparities in stroke outcomes for underserved populations. However, the existing literature has focused primarily on discrimination at the individual or institutional level, and studies of structural discrimination in stroke care are scant.

Objective

To examine differences in hospitals' likelihood of adopting stroke care certification between historically underserved and general communities.

Design, Setting, and Participants

This study combined a data set of hospital stroke certification from all general acute nonfederal hospitals in the continental US from January 1, 2009, to December 31, 2019, with national, hospital, and census data to define historically underserved communities by racial and ethnic composition, income distribution, and rurality. For all categories except rurality, communities were categorized by the composition and degree of segregation of each characteristic. Cox proportional hazard models were then estimated to compare the hazard of adopting stroke care certification between historically underserved and general communities, adjusting for population size and hospital bed capacity. Data were analyzed from June 2021 to April 2022.

Main Outcomes and Measures

Hospitals' likelihood of adopting stroke care certification.

Results

A total of 4984 hospitals were included. From 2009 to 2019, the total number of hospitals with stroke certification grew from 961 to 1763. Hospitals serving Black, racially segregated communities had the highest hazard of adopting stroke care certification (hazard ratio [HR], 1.67; 95% CI, 1.41-1.97) in models not accounting for population size, but their hazard was 26% lower than among those serving non-Black, racially segregated communities (HR, 0.74; 95% CI, 0.62-0.89) in models controlling for population and hospital size. Adoption hazard was lower in low-income communities compared with high-income communities, regardless of their level of economic segregation, and rural hospitals were much less likely to adopt any level of stroke care certification relative to urban hospitals (HR, 0.43; 95% CI, 0.35-0.51).

Conclusions and Relevance

In this analysis of stroke certification adoption across acute care hospitals in the US from 2009 to 2019, hospitals in low-income and rural communities had a lower likelihood of receiving stroke certification than hospitals in general communities. Hospitals operating in Black, racially segregated communities had the highest likelihood of adopting stroke care, but because these communities had the largest population, patients in these communities had the lowest likelihood of access to stroke-certified hospitals when the model controlled for population size. These findings provide empirical evidence that the provision of acute neurological services is structurally inequitable across historically underserved communities.

Association Between Hospital Volumes and Clinical Outcomes for Patients With Nontraumatic Subarachnoid Hemorrhage

Background

Previous studies of patients with nontraumatic subarachnoid hemorrhage (SAH) suggest better outcomes at hospitals with higher case and procedural volumes, but the shape of the volume‐outcome curve has not been defined. We sought to establish minimum volume criteria for SAH and aneurysm obliteration procedures that could be used for comprehensive stroke center certification.

Methods and Results

Data from 8512 discharges in the National Inpatient Sample (NIS) from 2010 to 2011 were analyzed using logistic regression models to evaluate the association between clinical outcomes (in‐hospital mortality and the NIS‐SAH Outcome Measure [NIS‐SOM]) and measures of hospital annual case volume (nontraumatic SAH discharges, coiling, and clipping procedures). Sensitivity and specificity analyses for the association of desirable outcomes with different volume thresholds were performed. During 8512 SAH hospitalizations, 28.7% of cases underwent clipping and 20.1% underwent coiling with rates of 21.2% for in‐hospital mortality and 38.6% for poor outcome on the NIS‐SOM. The mean (range) of SAH, coiling, and clipping annual case volumes were 30.9 (1–195), 8.7 (0–94), and 6.1 (0–69), respectively. Logistic regression demonstrated improved outcomes with increasing annual case volumes of SAH discharges and procedures for aneurysm obliteration, with attenuation of the benefit beyond 35 SAH cases/year. Analysis of sensitivity and specificity using different volume thresholds confirmed these results. Analysis of previously proposed volume thresholds, including those utilized as minimum standards for comprehensive stroke center certification, showed that hospitals with more than 35 SAH cases annually had consistently superior outcomes compared with hospitals with fewer cases, although some hospitals below this threshold had similar outcomes. The adjusted odds ratio demonstrating lower risk of poor outcomes with SAH annual case volume ≥35 compared with 20 to 34 was 0.82 for the NIS‐SOM (95% CI, 0.71–094; P=0.0054) and 0.80 (95% CI, 0.68–0.93; P=0.0055) for in‐hospital mortality.

Conclusions

Outcomes for patients with SAH improve with increasing hospital case volumes and procedure volumes, with consistently better outcomes for hospitals with more than 35 SAH cases per year.

Comorbidities and Medical Complications in Hospitalized Subarachnoid Hemorrhage Patients

BACKGROUND

Aneurysmal subarachnoid hemorrhage (SAH) remains a devastating condition with a case fatality of 36% at 30 days. Risk factors for mortality in SAH patients include patient demographics and the severity of the neurological injury. Pre-existing conditions and non-neurological medical complications occurring during the index hospitalization are also risk factors for mortality in SAH. The magnitude of the effect on mortality of pre-existing conditions and medical complications, however, is less well understood. In this study, we aim to determine the effect of pre-existing conditions and medical complications on SAH mortality.

METHODS

For a 25% random sample of the Greater Montreal Region, we used discharge abstracts, physician billings, and death certificate records, to identify adult patients with a new diagnosis of non-traumatic SAH who underwent cerebral angiography or surgical clipping of an aneurysm between 1997 and 2014.

RESULTS

The one-year mortality rate was 14.76% (94/637). Having ≥3 pre-existing conditions was associated with increased one-year mortality OR 3.74, 95% CI [1.25, 9.57]. Having 2, or ≥3 medical complications was associated with increased one-year mortality OR, 2.42 [95% CI 1.25-4.69] and OR, 2.69 [95% CI 1.43-5.07], respectively. Sepsis, respiratory failure, and cardiac arrhythmias were associated with increased one-year mortality. Having 1, 2, or ≥3 pre-existing conditions was associated with increased odds of having medical complications in hospital.

CONCLUSIONS

Pre-existing conditions and in-hospital non-neurological medical complications are associated with increased one-year mortality in SAH. Pre-existing conditions are associated with increased medical complications.

Rural-Urban Disparities in Intracerebral Hemorrhage Mortality in the USA: Preliminary Findings from the National Inpatient Sample

Objectives

To compare in-hospital mortality between intracerebral hemorrhage (ICH) patients in rural hospitals to those in urban hospitals of the USA.

Methods

We used the National Inpatient Sample to retrospectively identify all cases of ICH in the USA over the period 2004–2014. We used multivariable-adjusted models to compare odds of mortality between rural and urban hospitals. Joinpoint regression was used to evaluate trends in age- and sex-adjusted mortality in rural and urban hospitals over time.

Results

From 2004 to 2014, 5.8% of ICH patients were admitted in rural hospitals. Rural patients were older (mean [SE] 76.0 [0.44] years vs. 68.8 [0.11] years in urban), more likely to be white and have Medicare insurance. Age- and sex-adjusted mortality was greater in rural hospitals (32.2%) compared to urban patients (26.5%) (p value < 0.001). After multivariable adjustment, patients hospitalized in rural hospitals had two times the odds of in-hospital death compared to patients in urban hospitals (OR 2.07, 95% CI 1.77–2.41. p value < 0.001). After joinpoint regression, mortality declined in urban hospitals by an average of 2.8% per year (average annual percentage change, [AAPC] − 2.8%, 95% CI − 3.7 to − 1.8%), but rates in rural hospitals remained unchanged (AAPC − 0.54%, 95% CI − 1.66 to 0.58%).

Conclusions

Despite current efforts to reduce disparity in stroke care, ICH patients hospitalized in rural hospitals had two times the odds of dying compared to those in urban hospitals. In addition, the ICH mortality gap between rural and urban centers is increasing. Further studies are needed to identify and reverse the causes of this disparity.

Electronic supplementary material

The online version of this article (10.1007/s12028-020-00950-2) contains supplementary material, which is available to authorized users.

Predictors of Mortality in Older Adults With Epilepsy: Implications for Learning Health Systems

OBJECTIVE

To determine the incidence of epilepsy and subsequent 5-year mortality among older adults, as well as characteristics associated with mortality.

METHODS

This was a retrospective cohort study of Medicare beneficiaries age 65 or above with at least 2 years enrollment before January 2009. Incident epilepsy cases were identified in 2009 using ICD-9-CM code-based algorithms; death was assessed through 2014. Cox regression models examined the association between 5-year mortality and incident epilepsy, and whether mortality differed by sociodemographic characteristics or comorbid disorders.

RESULTS

Among the 99,990 of 33,615,037 beneficiaries who developed epilepsy, most were White (79.7%), female (57.3%), urban (80.5%), and without Medicaid (71.3%). The 5-year mortality rate for incident epilepsy was 62.8% (62,838 deaths). In multivariable models, lower mortality was associated with female sex (adjusted hazards ratio [AHR] 0.85, 95% confidence interval [CI] 0.84-0.87), Asian race (AHR 0.82, 95% CI 0.76-0.88), and Hispanic ethnicity (AHR 0.81, 95% CI 0.76-0.84). Hazard of death increased with comorbid disease burden (per 1-point increase: AHR 1.27, 95% CI 1.26-1.27) and Medicaid coinsurance (AHR 1.17, 95% CI 1.14-1.19). Incident epilepsy was particularly associated with higher mortality when diagnosed after another neurologic condition: Parkinson disease (AHR 1.29, 95% CI 1.21-1.38), multiple sclerosis (AHR 2.13, 95% CI 1.79-2.59), dementia (AHR 1.33, 95% CI 1.31-1.36), traumatic brain injury (AHR 1.55, 95% CI 1.45-1.66), and stroke/TIA (AHR 1.20, 95% CI 1.18-1.21).

CONCLUSIONS

Newly diagnosed epilepsy is associated with high 5-year mortality among Medicare beneficiaries. Future studies that parse the interplay of effects from underlying disease, race, sex, and poverty on mortality will be critical in the design of learning health care systems to reduce premature deaths.

Patterns of Admission and Outcomes for Patients with Intracranial Hemorrhage in Catalonia, Spain

BACKGROUND

Limited information is available about the hospital types to which patients with intracerebral hemorrhage (ICH) are admitted and treated. This could be important because some effective therapeutic measures can only be administered at comprehensive stroke centers (CSCs).

METHODS

Using the Acute Hospitals Discharge database, which provides population-based information, we identified ICH patients admitted to 7 CSCs and 53 non-CSCs (from January 2015 to December 2016) in Catalonia. CSCs were defined as centers with an emergency department ready to assess and treat code stroke patients around the clock, 24-hour availability of neurology, neurosurgery, and neuroradiology services, and admission to the stroke unit and/or intensive care unit. The database provided the demographics, admitting hospital, and interhospital transfers. Vital status was retrieved from the Central Registry of the Catalan Public Health Insurance.

RESULTS

A total of 3339 ICH patients were identified (mean age, 72.2 ± 14.6 years; 56.8% men). Of the 3339 patients, 45.7% were admitted to a CSC and 54.3% to a non-CSC. Transfer from a non-CSC to a CSC occurred for 1.97% of the patients. In-hospital mortality was similar between the CSCs and non-CSCs (30.2% vs. 27.5%; P = 0.09). The long-term mortality was also comparable between the CSC and non-CSC groups (45.4% vs. 47%; P = 0.34).

CONCLUSIONS

Despite a considerable proportion of ICH patients remaining at a non-CSC for their entire hospitalization, the short- and long-term mortality were comparable between the 2 hospital types. More studies are required to determine whether outcomes other than mortality might be related to the admitting hospital type and whether the routing protocols for ICH patients should be modified.

Measuring stroke outcomes for 74 501 patients using linked administrative data: System-wide estimates and validation of 'home-time' as a surrogate measure of functional status

AIMS

Administrative data offer cost-effective, whole-of-population stroke surveillance yet the lack of validated measures of functional status is a shortcoming. The number of days spent living at home after stroke ('home-time') is a patient-centred outcome that can be objectively ascertained from administrative data. Population-based validation against both severity and outcome measures and for all subtypes is lacking. We aimed to report representative 'home-time' estimates and validate 'home-time' as a surrogate measure of functional status after stroke.

METHODS

Stroke hospitalisations from a state-wide census in New South Wales, Australia, from January 1, 2005 to March 31, 2014 were linked to prehospital data, poststroke admissions and deaths. We correlated 90-day 'home-time' with Glasgow Coma Scale (GCS) scores, measured upon a patient's initial contact with paramedics and Functional Independence Measure (FIM) scores, measured upon entry to rehabilitation after the acute hospital stroke admission. Negative binomial regressions identified predictors of 'home-time'.

RESULTS

Patients with stroke (N = 74 501) spent a median of 53 days living at home 90 days after the event. Median 'home-time' was 60 days after ischaemic stroke, 49 days after subarachnoid haemorrhage and 0 days after intracerebral haemorrhage. GCS and FIM scores significantly correlated with 'home-time' (P < .001). Women spent significantly less time at home compared with men after stroke, although being married increased 'home-time' after ischaemic stroke and subarachnoid haemorrhage.

CONCLUSIONS

These findings underscore the immediate and adverse impact of stroke. 'Home-time' measured using administrative data is a robust, replicable and valid patient-centred outcome enabling inexpensive population-based surveillance and system-wide quality assessment.

Impact of disease-specific care certification on clinical outcome and healthcare performance of myocardial infarction in Taiwan

BACKGROUND

The relationship between certification for specific disease care and clinical outcome was not well known. Previous studies regarding the effect of certification for acute stroke centers were limited by their cross-sectional design. This study aimed to investigate the effect of disease-specific care (DSC) certification on healthcare performance and clinical outcome of acute myocardial infarction (AMI).

METHODS

This retrospective, longitudinal, controlled study was performed by analyzing the nationwide Taiwan Clinical Performance Indicators dataset from 2011 to 2018. Hospitals undergoing DSC certification for coronary care and reporting AMI indicators 1 year before, during, and 1 year after certification were included in group C, whereas hospitals not seeking DSC certification but reporting AMI indicators during the same period were included in group U. The primary endpoint was in-hospital mortality of AMI.

RESULTS

In total, 20 hospitals (9 in group C and 11 in group U) and up to 16 173 AMI cases were included for analysis. In-hospital mortality was similar between both groups at baseline. However, the in-hospital mortality was significantly improved during and after certification periods in comparison with that at baseline in group C (6.8% vs 8.4%, p = 0.04; 6.7% vs 8.4%, p = 0.02), whereas there was no significant change in group U, resulting in a statistically significant difference between both groups during and after certification periods (odds ratio = 0.74 [95% CI = 0.60-0.91] and 0.78 [95% CI = 0.64-0.96]). Compared with group U, the improvement in healthcare performance indicators, such as door-to-electrocardiography time <10 minutes, blood testing for low-density lipoprotein cholesterol level, prescribing a beta-blockade or a P2Y12 receptor inhibitor during hospitalization, prescribing a statin on discharge, and consultation for cardiac rehabilitation, was significant in group C.

CONCLUSION

The current study demonstrated the beneficial effect of DSC certification on clinical outcome of AMI probably mediated through quality improvement during the healthcare process.

Annual incidences and predictors of 30-day readmissions following spontaneous intracerebral hemorrhage from 2010 to 2014 in the United States: A retrospective Nationwide analysis

Objective

30-day readmission rate is a quality metric often employed to represent hospital and provider performance. Currently, little is known regarding 30-day readmissions (30dRA) following spontaneous intracerebral hemorrhage (sICH). The purpose of this study was to use a national database to identify risk factors and trends in 30dRAs following sICH.

Patients and methods

64,909 cases with a primary diagnosis of sICH were identified within the Nationwide Readmission Database (NRD) from 2010 through 2014. Charlson Comorbidity Index (CCI) was used to adjust for the severity of each patient's comorbidities. A binary logistic regression model was constructed to identify predictors of 30-day readmission. Cochran-Mantel-Haenszel test was used to generate a pooled odd ratio (OR) describing the likelihood of experiencing a 30dRA according to year.

Results

The 30dRA rate following sICH decreased from 13.9% in 2010 to 12.5% in 2014 (pooled OR = 0.90, 95% CI 0.87–0.94). Cerebrovascular and cardiovascular etiologies accounted for the greatest number of admissions (36.1%). Sodium abnormality, healthcare-associated infection, gastrostomy, venous thromboembolism, and ischemic stroke during the index admission were associated with 30-day readmission. Furthermore, patients who underwent ventriculostomy (OR = 1.20, 95% CI 1.03–1.38) and craniotomy (OR = 1.20, 95% CI 1.09–1.31) were more likely to be readmitted within 30 days. Hospital volume, hospital teaching status, mechanical ventilation, and tracheostomy did not affect 30dRAs. Median readmission costs increased from $9,875 in 2012 to $11,028 in 2014 (p = 0.040).

Conclusion

The overall U.S. 30dRA rate after sICH from 2010 to 2014 was 12.9% and decreased slightly during this time period, but associated costs increased. Prospective studies are required to confirm the risk factors described in this study and to identify methods for preventing readmissions.

Readmission after neurosurgical intervention in epilepsy: A nationwide cohort analysis

OBJECTIVE

Hospital readmissions result in increased health care costs and are associated with worse outcomes after neurosurgical intervention. Understanding factors associated with readmissions will inform future studies aimed at improving quality of care in those with epilepsy.

METHODS

Patients of all ages with epilepsy who underwent a neurosurgical intervention were identified in the 2014 Nationwide Readmissions Database, a nationally representative dataset containing data from roughly 17 million US hospital discharges. Diagnosis of epilepsy was based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)-based case definitions. Neurosurgical interventions for epilepsy: resective/disconnective surgery, responsive neurostimulation/deep brain stimulation, vagus nerve stimulation, radiosurgery, and intracranial electroencephalography were identified using ICD-9-CM procedure codes. Primary outcome was all-cause 30-day readmission following discharge from the index hospitalization.

RESULTS

There were a total of 2284 index surgical admissions. Overall, 10.83% (n = 251) of patients following an index epilepsy surgery admission were readmitted within 30 days. Factors independently associated with 30-day readmission for all epilepsy surgery admissions were: Medicare insurance (P < .01), discharge disposition that was not home (P < .01), higher Elixhauser comorbidity indexes (P < .01), longer length of stay (P < .01), and adverse events of surgical and medical care during index stay (P = .04). In the multivariate model, Medicare insurance (hazard ratio [HR] 1.81 [1.29-2.53], P < .01) and length of stay (HR 1.02 [1.01-1.04], P < .01) remained significant independent predictors for 30-day readmission. The most common primary reason for readmissions was epilepsy/convulsions accounting for 22.85%.

SIGNIFICANCE

Our results suggest that careful management of postoperative seizures and discharge planning after epilepsy surgery may be important to optimize outcomes and reduce the risk of readmission, particularly for patients on Medicare.

Preventable Readmissions and Predictors of Readmission After Subarachnoid Hemorrhage

OBJECTIVE

To estimate rates of all-cause and potentially preventable readmissions up to 90 days after discharge for aneurysmal subarachnoid hemorrhage (SAH) and medical comorbidities associated with readmissions BACKGROUND: Readmission rate is a common metric linked to compensation and used as a proxy to quality of care. Prior studies in SAH have reported 30-day readmission rates of 7-17% with a higher readmission risk among those with the higher SAH severity, ≥ 3 comorbidities, and non-home discharge. Intermediate-term rates, up to 90-days, and the proportion of these readmissions that are potentially preventable are unknown. Furthermore, the specific medical comorbidities associated with readmissions are unknown.

METHODS

Index SAH admissions were identified from the 2013 Nationwide Readmissions Database. All-cause readmissions were defined as any readmission during the 30-, 60-, and 90-day post-discharge period. Potentially preventable readmissions were identified using Prevention Quality Indicators developed by the US Agency for Healthcare Research and Quality. Unadjusted and adjusted Poisson models were used to identify factors associated with increased readmission rates.

RESULTS

Out of 9987 index admissions for SAH, 7949 (79%) survived to discharge. The percentage of 30-, 60-, and 90-day all-cause readmissions were 7.8, 16.6, and 26%, respectively. Up to 14% of readmissions in the first 30 days were considered potentially preventable and acute conditions (dehydration, bacterial pneumonia, and urinary tract infections) accounted for over half, whereas acute cerebrovascular disease was the most common cause for neurological return. In multivariable analysis, significant predictors of a higher readmission rate included diabetes (rate ratio [RR] 1.09, 95% confidence interval [CI] 1.03-1.15), congestive heart failure (RR 1.09, 1.003-1.18), and renal impairment (RR 1.35, 1.13-1.61). Only discharge home was associated with a lower readmission rate (RR 0.89, 0.85-0.93).

CONCLUSIONS

SAH has a 30-day readmission rate of 7.8% which continues to rise into the intermediate-term. A low but constant proportion of readmissions are potentially preventable. Several chronic medical comorbidities were associated with readmissions. Prospective studies are warranted to clarify causal relationships.

Stroke Center Care and Outcome: Results from the CSPPC Stroke Program

The aim of this study was to assess the association between admission to stroke centers for acute ischemic stroke and complications and mortality during hospitalization in a Chinese population by means of an observational study using data from the China Stroke Center Data-Sharing Platform. We compared in-hospital complications and mortality for patients admitted with acute ischemic stroke (N = 13,236) between November 1, 2018 and December 31, 2018 at stroke center (SH) and non-stroke center (CH) hospitals using distance to hospitals as an instrumental variable to adjust for potential prehospital selection bias. The results showed that complication rates during hospitalization among ischemic stroke patients who received thrombolytic therapy (n = 11,203) were lower in the SH group than in the CH group: 11.1% vs 15.7% (absolute difference, - 5.11% [95% CI, - 6.05 to - 3.99%], odds ratio [OR] 0.85 [95% CI, 0.74 to 0.92]). The incidence of intracranial hemorrhage was reduced from 4.2 to 3.2%: SH group vs CH group, 3.2% vs 4.2% (absolute difference, - 1.24% [95% CI, - 1.65 to - 0.82%], OR 0.83 [95% CI, 0.69 to 0.0.98]). Furthermore, the total mortality rate in the SH group was also lower than in the CH group: SH group vs CH group, 2.2% vs 3.0% (absolute difference, - 0.92% [95% CI, - 1.48 to - 0.53%], OR 0.85 [95% CI, 0.73 to 0.96]). The data showed that admission to SH hospitals was associated with a lower risk of treatment complications and death for patients with an acute ischemic stroke receiving thrombolytic therapy.

Nonindex Readmission After Ruptured Brain Aneurysm Treatment Is Associated with Higher Morbidity and Repeat Readmission

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) requires complex multidisciplinary care. After initial treatment (index hospital), readmission to a different hospital (nonindex) can compromise quality of care, resulting in increased morbidity. We aimed to evaluate factors associated with nonindex readmission and evaluate association of nonindex hospital readmission on outcomes in patients with ruptured aneurysm.

METHODS

Readmissions within 90 days after aSAH treatment were identified in the 2010-2014 Nationwide Readmissions Database. Multivariable logistic regression identified patient and hospital characteristics associated with nonindex readmission. Separate multivariable models determined increased morbidity or risk of second readmission for nonindex readmissions.

RESULTS

A total of 9254 patients who underwent treatment of ruptured aneurysms from 2010 to 2014 were identified. Of these, 1985 (21.5%) were readmitted within 90 days. Three hundred and fifty-five of these readmissions (17.9%) occurred to nonindex hospitals. Patients that were discharged to a skilled nursing or other facility (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.27-2.28]) had higher odds of nonindex readmission, whereas patients with private insurance were associated with lower odds of nonindex readmission (OR, 0.65; 95% CI, 0.46-0.92). Patients readmitted to a nonindex (vs. index) hospital were associated with increased likelihood of major complications (OR, 1.71; 95% CI, 1.18-2.48) and second readmissions (OR, 1.51; 95% CI, 1.17-1.96).

CONCLUSIONS

After treatment of a ruptured cerebral aneurysm, 17.9% of readmissions occurred at a nonindex hospital. These patients were at increased risk for major complications or subsequent readmissions, which may be because of care fragmentation. Interventions aimed at improving continuity of care may reduce higher morbidity associated with nonindex readmission.

Mortality and functional outcomes after a spontaneous subarachnoid haemorrhage: A retrospective multicentre cross-sectional study in Kenya

INTRODUCTION

Despite a reduction in poor outcomes in recent decades, spontaneous subarachnoid haemorrhage (SAH) remains associated with severe disability and high mortality rates. The exact extent of these outcomes is however unknown in Africa. This study aimed to determine the mortality and functional outcomes of patients with SAH in Kenya.

METHODS

We conducted a retrospective multicentre cross-sectional study involving patients admitted with SAH to three referral hospitals in Nairobi. All patients with a confirmed (primary) discharge diagnosis of first-time SAH between January 2009 and November 2017 were included (n = 158). Patients who had prior head trauma or cerebrovascular disease (n = 53) were excluded. Telephone interviews were conducted with surviving patients or their next of kin to assess out-of-hospital outcomes (including functional outcomes) based on modified Rankin Scale (mRS) scores. Chi-square and Fisher's exact tests were used to assess associations between mortality and functional outcomes and sample characteristics.

RESULTS

Of the 158 patients sampled, 38 (24.1%) died in hospital and 42 (26.6%) died within 1 month. In total, 87 patients were discharged home and followed-up in this study, of which 72 reported favourable functional outcomes (mRS ≤2). This represented 45.6% of all patients who presented alive, pointing to high numbers of unfavourable outcomes post SAH in Kenya.

CONCLUSIONS

Mortality following SAH remains high in Kenya. Patients who survive the initial ictus tend to do well after treatment, despite resource constraints.

LIMITATIONS

The study findings should be interpreted with caution because of unavoidable limitations in the primary data. These include its retrospective nature, the high number of patients lost to follow up, missing records and diagnoses, and/or possible miscoding of cases.

The impact of disease severity adjustment on hospital standardised mortality ratios: Results from a service-wide analysis of ischaemic stroke admissions using linked pre-hospital, admissions and mortality data

Background

Administrative data are used to examine variation in thirty-day mortality across health services in several jurisdictions. Hospital performance measurement may be error-prone as information about disease severity is not typically available in routinely collected data to incorporate into case-mix adjusted analyses. Using ischaemic stroke as a case study, we tested the extent to which accounting for disease severity impacts on hospital performance assessment.

Methods

We linked all recorded ischaemic stroke admissions between July, 2011 and June, 2014 to death registrations and a measure of stroke severity obtained at first point of patient contact with health services, across New South Wales, Australia’s largest health service jurisdiction. Thirty-day hospital standardised mortality ratios were adjusted for either comorbidities, as is typically done, or for both comorbidities and stroke severity. The impact of stroke severity adjustment on mortality ratios was determined using 95% and 99% control limits applied to funnel plots and by calculating the change in rank order of hospital risk adjusted mortality rates.

Results

The performance of the stroke severity adjusted model was superior to incorporating comorbidity burden alone (c-statistic = 0.82 versus 0.75; N = 17,700 patients, 176 hospitals). Concordance in outlier classification was 89% and 97% when applying 95% or 99% control limits to funnel plots, respectively. The sensitivity rates of outlier detection using comorbidity adjustment compared with gold-standard severity and comorbidity adjustment was 74% and 83% with 95% and 99% control limits, respectively. Corresponding positive predictive values were 74% and 91%. Hospital rank order of risk adjusted mortality rates shifted between 0 to 22 places with severity adjustment (Median = 4.0, Inter-quartile Range = 2–7).

Conclusions

Rankings of mortality rates varied widely depending on whether stroke severity was taken into account. Funnel plots yielded largely concordant results irrespective of severity adjustment and may be sufficiently accurate as a screening tool for assessing hospital performance.

Association between patient outcomes and accreditation in US hospitals: observational study

OBJECTIVES

To determine whether patients admitted to US hospitals that are accredited have better outcomes than those admitted to hospitals reviewed through state surveys, and whether accreditation by The Joint Commission (the largest and most well known accrediting body with an international presence) confers any additional benefits for patients compared with other independent accrediting organizations.

DESIGN

Observational study.

SETTING

4400 hospitals in the United States, of which 3337 were accredited (2847 by The Joint Commission) and 1063 underwent state based review between 2014 and 2017.

PARTICIPANTS

4 242 684 patients aged 65 years and older admitted for 15 common medical and six common surgical conditions and survey respondents of the Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS).

MAIN OUTCOME MEASURES

Risk adjusted mortality and readmission rates at 30 days and HCAHPS patient experience scores. Hospital admissions were identified from Medicare inpatient files for 2014, and accreditation information was obtained from the Centers for Medicare and Medicaid Services and The Joint Commission.

RESULTS

Patients treated at accredited hospitals had lower 30 day mortality rates (although not statistically significant lower rates, based on the prespecified P value threshold) than those at hospitals that were reviewed by a state survey agency (10.2% v 10.6%, difference 0.4% (95% confidence interval 0.1% to 0.8%), P=0.03), but nearly identical rates of mortality for the six surgical conditions (2.4% v 2.4%, 0.0% (-0.3% to 0.3%), P=0.99). Readmissions for the 15 medical conditions at 30 days were significantly lower at accredited hospitals than at state survey hospitals (22.4% v 23.2%, 0.8% (0.4% to 1.3%), P<0.001) but did not differ for the surgical conditions (15.9% v 15.6%, 0.3% (-1.2% to 1.6%), P=0.75). No statistically significant differences were seen in 30 day mortality or readmission rates (for both the medical or surgical conditions) between hospitals accredited by The Joint Commission and those accredited by other independent organizations. Patient experience scores were modestly better at state survey hospitals than at accredited hospitals (summary star rating 3.4 v 3.2, 0.2 (0.1 to 0.3), P<0.001). Among accredited hospitals, The Joint Commission did not have significantly different patient experience scores compared to other independent organizations (3.1 v 3.2, 0.1 (-0.003 to 0.2), P=0.06).

CONCLUSIONS

US hospital accreditation by independent organizations is not associated with lower mortality, and is only slightly associated with reduced readmission rates for the 15 common medical conditions selected in this study. There was no evidence in this study to indicate that patients choosing a hospital accredited by The Joint Commission confer any healthcare benefits over choosing a hospital accredited by another independent accrediting organization.

Factors associated with 1-year mortality after discharge for acute stroke: what matters?

OBJECTIVE

To evaluate factors associated with 1-year mortality after discharge for acute stroke.

METHODS

In this retrospective cohort study, we studied 305 patients with ischemic stroke or intracerebral hemorrhage discharged in 2010/2011. We linked Get With The Guidelines®-Stroke clinical data with New York State administrative data and used multivariate regression models to examine variables related to 1-year all-cause mortality poststroke.

RESULTS

The mean age was 68.6 ± 14.8 years and 51.1% were women. A total of 146 (47.9%) were discharged directly home, 96 (31.5%) to inpatient rehabilitation facilities (IRFs), and 63 (20.7%) to skilled nursing facilities (SNFs). Overall, 24 (7.9%) patients died within 1-year post-discharge. Older age (adjusted odds ratio [OR] 1.05, 95% confidence interval [CI] 1.00-1.10), higher National Institutes of Health Stroke Scale (NIHSS) on admission (OR 1.10, 95% CI 1.03-1.17), and discharge destination (IRF vs. home, OR 0.10, 95% CI 0.01-0.94; and SNF vs. home, OR 2.22, 95% CI 0.71-6.95) were factors associated with 1-year all-cause mortality. When ambulation status at discharge was added to the model, ambulation with assistance and non-ambulation were significantly associated with mortality (ambulatory with assistance vs. ambulatory, OR 9.42, 95% CI 1.87-47.61; nonambulatory vs. ambulatory, OR 12.65, 95% CI 1.89-84.89).

CONCLUSIONS

While age and NIHSS on admission are important predictors of long-term outcomes, factors at discharge - ambulation status at discharge and discharge destination - are associated with 1-year mortality post-discharge for acute stroke and therefore could represent therapeutic targets to improve long-term survival in future studies.

Estimates and Temporal Trend for US Nationwide 30-Day Hospital Readmission Among Patients With Ischemic and Hemorrhagic Stroke

IMPORTANCE

Readmission reduction is linked to improved quality of care, saves cost, and is a desirable patient-centered outcome. Nationally representative readmission metrics for patients with stroke are unavailable to date. Such estimates are necessary for benchmarking performance.

OBJECTIVES

To provide US nationwide estimates and a temporal trend for overall, planned, and potentially preventable 30-day hospital readmission among patients with ischemic and hemorrhagic stroke; to investigate the association between hospitals' stroke discharge volume, teaching status, and 30-day readmission; and to highlight reasons for 30-day readmission and explore the association of 30-day readmission in terms of mortality, length of stay, and cost of care among patients with stroke.

DESIGN, SETTING, AND PARTICIPANTS

Cohort, year-wise analysis of the Nationwide Readmissions Database between January 1, 2010, and September 30, 2015. The setting was a population-based cohort study providing national estimates of 30-day readmission. The database represents 50% of all US hospitalizations from 22 geographically dispersed states. Participants were adult (≥18 years) patients with a primary discharge diagnosis of intracerebral hemorrhage, acute ischemic stroke, or subarachnoid hemorrhage. Hospitals were categorized by their annual stroke discharge volume and were classified as teaching hospitals if they had an American Medical Association-approved residency program or had a ratio of full-time equivalent interns and residents to beds of 0.25 or higher.

MAIN OUTCOMES AND MEASURES

Readmission was defined as any admission within 30 days of index hospitalization discharge. Using Centers for Medicare & Medicaid Services-defined algorithms, events were classified as planned or unplanned and as potentially preventable.

RESULTS

Based on study criteria, 2 078 854 eligible patients were included (mean [SE] age, 70.02 [0.07] years; 51.9% female). Thirty-day readmission was highest for patients with intracerebral hemorrhage (13.70%; 95% CI, 13.40%-13.99%), followed by patients with acute ischemic stroke (12.44%; 95% CI, 12.33%-12.55%) and patients with subarachnoid hemorrhage (11.48%; 95% CI, 11.01%-11.96%). On average, there was a 3.3% annual decline in readmission between 2010 and 2014, which was statistically significant for the period of investigation (odds ratio, 0.96; 95% CI, 0.95-0.97). Patients discharged from nonteaching hospitals with high stroke discharge volume were at a significantly higher risk of 30-day readmission, and the top 2 reasons for readmission were acute cerebrovascular disease and septicemia.

CONCLUSIONS AND RELEVANCE

This study suggests that nationally representative readmission metrics can be used to benchmark hospitals' performance, and a temporal trend of 3.3% may be used to evaluate the effectiveness of readmission reduction strategies.

Relationship between patient safety indicator events and comprehensive stroke center volume status in the treatment of unruptured cerebral aneurysms

OBJECTIVE

The Agency of Healthcare Research and Quality (AHRQ) has defined Patient Safety Indicators (PSIs) for assessments in quality of inpatient care. The hypothesis of this study is that, in the treatment of unruptured cerebral aneurysms (UCAs), PSI events are less likely to occur in hospitals meeting the volume thresholds defined by The Joint Commission for Comprehensive Stroke Center (CSC) certification.

METHODS

Using the 2002–2011 National (Nationwide) Inpatient Sample, patients treated electively for a nonruptured cerebral aneurysm were selected. Patients were evaluated for PSI events (e.g., pressure ulcers, retained surgical item, perioperative hemorrhage, pulmonary embolism, sepsis) defined by AHRQ-specified ICD-9 codes. Hospitals were categorized by treatment volume into CSC or non-CSC volume status based on The Joint Commission’s annual volume thresholds of at least 20 patients with subarachnoid hemorrhage and performance of 15 or more endovascular coiling or surgical clipping procedures for aneurysms.

RESULTS

A total of 65,824 patients underwent treatment for an unruptured cerebral aneurysm. There were 4818 patients (7.3%) in whom at least 1 PSI event occurred. The overall inpatient mortality rate was 0.7%. In patients with a PSI event, this rate increased to 7% compared with 0.2% in patients without a PSI event (p < 0.0001). The overall rate of poor outcome was 3.8%. In patients with a PSI event, this rate increased to 23.3% compared with 2.3% in patients without a PSI event (p < 0.0001). There were significant differences in PSI event, poor outcome, and mortality rates between non-CSC and CSC volume-status hospitals (PSI event, 8.4% vs 7.2%; poor outcome, 5.1% vs 3.6%; and mortality, 1% vs 0.6%). In multivariate analysis, all patients treated at a non-CSC volume-status hospital were more likely to suffer a PSI event with an OR of 1.2 (1.1–1.3). In patients who underwent surgery, this relationship was more substantial, with an OR of 1.4 (1.2–1.6). The relationship was not significant in the endovascularly treated patients.

CONCLUSIONS

In the treatment of unruptured cerebral aneurysms, PSI events occur relatively frequently and are associated with significant increases in morbidity and mortality. In patients treated at institutions achieving the volume thresholds for CSC certification, the likelihood of having a PSI event, and therefore the likelihood of poor outcome and mortality, was significantly decreased. These improvements are being driven by the improved outcomes in surgical patients, whereas outcomes and mortality in patients treated endovascularly were not sensitive to the CSC volume status of the hospital and showed no significant relationship with treatment volumes.

Thirty-day readmission rate as a surrogate marker for quality of care in neurosurgical patients: a single-center Canadian experience

OBJECTIVE

Readmission to the hospital within 30 days of discharge is used as a surrogate marker for quality and value of care in the United States (US) healthcare system. Concern exists regarding the value of 30-day readmission as a quality of care metric in neurosurgical patients. Few studies have assessed 30-day readmission rates in neurosurgical patients outside the US. The authors performed a retrospective review of all adult neurosurgical patients admitted to a single Canadian neurosurgical academic center and who were discharged to home to assess for the all-cause 30-day readmission rate, unplanned 30-day readmission rate, and avoidable 30-day readmission rate.

METHODS

A retrospective review was performed assessing 30-day readmission rates after discharge to home in all neurosurgical patients admitted to a single academic neurosurgical center from January 1, 2011, to December 31, 2011. The primary outcomes included rates of all-cause, unplanned, and avoidable readmissions within 30 days of discharge. Secondary outcomes included factors associated with unplanned and avoidable 30-day readmissions.

RESULTS

A total of 184 of 950 patients (19.4%) were readmitted to the hospital within 30 days of discharge. One-hundred three patients (10.8%) were readmitted for an unplanned reason and 81 (8.5%) were readmitted for a planned or rescheduled operation. Only 19 readmissions (10%) were for a potentially avoidable reason. Univariate analysis identified factors associated with readmission for a complication or persistent/worsening symptom, including age (p = 0.009), length of stay (p = 0.007), general neurosurgery diagnosis (p < 0.001), cranial pathology (p < 0.001), intensive care unit (ICU) admission (p < 0.001), number of initial admission operations (p = 0.01), and shunt procedures (p < 0.001). Multivariate analysis identified predictive factors of readmission, including diagnosis (p = 0.002, OR 2.4, 95% CI 1.4-5.3), cranial pathology (p = 0.002, OR 2.7, 95% CI 1.4-5.3), ICU admission (p = 0.004, OR 2.4, 95% CI 1.3-4.2), and number of first admission operations (p = 0.01, OR 0.51, 95% CI 0.3-0.87). Univariate analysis performed to identify factors associated with potentially avoidable readmissions included length of stay (p = 0.03), diagnosis (p < 0.001), cranial pathology (p = 0.02), and shunt procedures (p < 0.001). Multivariate analysis identified only shunt procedures as a predictive factor for avoidable readmission (p = 0.02, OR 5.6, 95% CI 1.4-22.8).

CONCLUSIONS

Almost one-fifth of neurosurgical patients were readmitted within 30 days of discharge. However, only about half of these patients were admitted for an unplanned reason, and only 10% of all readmissions were potentially avoidable. This study demonstrates unique challenges encountered in a publicly funded healthcare setting and supports the growing literature suggesting 30-day readmission rates may serve as an inappropriate quality of care metric in neurosurgical patients. Potentially avoidable readmissions can be predicted, and further research assessing predictors of avoidable readmissions is warranted.

Hospital readmissions after spontaneous intracerebral hemorrhage in Southern Portugal

OBJECTIVES

Spontaneous intracerebral hemorrhage (SICH) survivors are at risk of hospital readmissions. Data on readmissions after SICH is scarce. We aimed to study the frequency and predictors of readmissions after SICH in Algarve, Portugal.

PATIENTS AND METHODS

Retrospective study of a community representative cohort of SICH survivors (2009-2015). The first unplanned readmission in the first year after discharge was the outcome. Cox regression analysis was performed to identify predictors of 1-year readmission.

RESULTS

Of the 357 SICH survivors followed, 116 (32.5%) were readmitted within the first-year. Sixty-seven (18.8%) of the survivors were early readmitted (<90 days), corresponding to 57.8% or all readmissions. Common causes were pneumonia, endocrine/nutritional/metabolic and cardiovascular complications. The risk of readmission was increased by prior to index SICH history of ≥ 3 previous emergency department visits (hazards ratio (HR) = 2.663 (1.770-4.007); P < 0.001), pneumonia during index hospitalization (HR = 2.910 (1.844-4.592); P < 0.001) and reduced in patients discharge home (HR = 0.681 (0.366-0.976); P = 0.048).

CONCLUSIONS

The rate of readmissions after SICH is high, predictors are identifiable and causes are potentially preventable. Improvement of care can potentially reduce this burden.

Rationale and Design of a Statewide Cohort to examine efficient resource utilization for patients with Intracerebral hemorrhage (EnRICH)

Background

Intracerebral hemorrhage is a devastating disease with no specific treatment modalities. A significant proportion of patients with intracerebral hemorrhage are transferred to large stroke treatment centers, such as Comprehensive Stroke Centers, because of perceived need for higher level of care. However, evidence of improvement in patient-centered outcomes for these patients treated at larger stroke treatment centers as compared to community hospitals is lacking.

Methods / design

“Efficient Resource Utilization for Patients with Intracerebral Hemorrhage (EnRICH)” is a prospective, multisite, state-wide, cohort study designed to assess the impact of level of care on long-term patient-centered outcomes for patients with primary / non-traumatic intracerebral hemorrhage. The study is funded by the Texas state legislature via the Lone Star Stroke Research Consortium. It is being implemented via major hub hospitals in large metropolitan cities across the state of Texas. Each hub has an extensive network of “spoke” hospitals, which are connected to the hub via traditional clinical and administrative arrangements, or by telemedicine technologies. This infrastructure provides a unique opportunity to track outcomes for intracerebral hemorrhage patients managed across a health system at various levels of care. Eligible patients are enrolled during hospitalization and are followed for functional, quality of life, cognitive, resource utilization, and dependency outcomes at 30 and 90 days post discharge. As a secondary aim, an economic analysis of the incremental cost-effectiveness of treating intracerebral hemorrhage patients at higher levels of care will be conducted.

Discussion

Findings from EnRICH will provide much needed evidence of the effectiveness and efficiency of regionalized care for intracerebral hemorrhage patients. Such evidence is required to inform policy and streamline clinical decision-making.

Thirty-day readmission after spontaneous intracerebral hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) is the most severe form of stroke, but data on readmission after ICH are sparse. We aimed to determine frequency, causes, and predictors of 30-day readmission after ICH.

MATERIALS AND METHODS

This retrospective cohort study includes all spontaneous ICH survivors admitted to the stroke unit at Haukeland University Hospital in Bergen in Norway from July 2007 to December 2013. Patients were followed by review of electronic medical charts, and the first unplanned readmission within 30 days after discharge was used as final outcome. Cox regression analysis was performed to identify predictors of 30-day readmission.

RESULTS

We identified 226 patients with spontaneous ICH, 70 (31.0%) of whom died before discharge or were discharged to palliative care. Of the remaining 156 ICH survivors, 28 (18.0%) were readmitted within 30 days. Median time to readmission was 12 days (IQR 4.5 - 18.5). Most patients were readmitted due to infections (N = 13). None of the patients were readmitted with recurrent stroke. Pneumonia and enteral feeding during the index hospitalization were associated with readmission for infections (both p < .01). Age was the only independent predictor of readmission (HR 1.06, 95% CI 1.02 - 1.11, p = .006).

CONCLUSIONS

Almost one in five of our spontaneous ICH survivors was readmitted within 30 days, and most readmissions were caused by infections.

Causes and Timing of Unplanned Early Readmission After Neurosurgery

BACKGROUND

Reducing the rate of 30-day hospital readmission has become a priority in healthcare quality improvement policy, with a focus on better characterizing the reasons for unplanned readmission. In neurosurgery, however, peer-reviewed analyses describing the patterns of readmission have been limited in their number and generalizability.

OBJECTIVE

To determine the incidence, timing, and causes of 30-day readmission after neurosurgical procedures.

METHODS

We conducted a retrospective longitudinal study from 2009 to 2012 using the Statewide Planning And Research Cooperative System, which collects patient-level details for all admissions and discharges within New York. We identified patients readmitted within 30 days of initial discharge. The rate of, reasons for, and time to readmission were determined overall and within 4 subgroups: craniotomies, cranial surgery without craniotomy, spine, and neuroendovascular procedures.

RESULTS

There were 163 743 index admissions, of whom 14 791 (9.03%) were readmitted. The most common reasons for unplanned readmission were infection (29.52%) and medical complications (19.22%). Median time to readmission was 11 days, with hemorrhagic strokes and seizures occurring earlier, and medical complications and infections occurring later. Readmission rates were highest among patients undergoing cerebrospinal fluid shunt revision and malignant tumor resection (15.57%-22.60%). Spinal decompressions, however, accounted for the largest volume of readmissions (33.13%).

CONCLUSION

Many readmissions may be preventable and occur at predictable time intervals. The causes and timing of readmission vary significantly across neurosurgical subgroups. Future studies should focus on detecting specific complications in select cohorts at predefined time points, which may allow for interventions to lower costs and reduce patient morbidity.

ABBREVIATIONS

CSF, cerebrospinal fluidIQR, interquartile rangeSPARCS, Statewide Planning And Research Cooperative System.

Hospital-Based Study of the Frequency and Risk Factors of Stroke Recurrence in Two Years in China

BACKGROUND

Stroke causes death and disability throughout the world and recurrent stroke events are more likely to be disabling or fatal. We conducted a hospital-based study to investigate the frequency and influence factors of stroke recurrence in China.

METHODS

Data from patients hospitalized with stroke between January 2007 and December 2010 of 109 tertiary hospitals in China were used. Stroke recurrence and associated factors were ascertained. The zero-inflated model was used to evaluate the factors of recurrence.

RESULTS

Of 101,926 discharged patients, the cumulative 2-year stroke recurrence rate was 3.80% for subarachnoid hemorrhage (SAH), 5.31% for intracerebral hemorrhage (ICH), and 8.71% for ischemic stroke (IS), respectively. Among patients with stroke recurrence, 54.11% with SAH, 60.42% with ICH, and 92.92% with IS relapsed for the same type of the first-onset stroke. For discharged patients with SAH with middle cerebral artery aneurysm clipping or artery aneurysm embolization, it was less likely to stroke relapse, but the times of recurrence would increase if 1 recurrence appeared. Cerebral artery aneurysms and hypertension were risk factors for recurrence frequency. For ICH, protective factors for recurrence were trepanation and drainage of intracranial hematoma, cerebral angiography, puncture and drainage of intracranial hematoma, and length of stay (LOS). But rheumatic heart disease and atrial fibrillation would further the relapse frequency. For IS, age and LOS were protective factors, but recurrence frequency would increase if the first recurrence happened. Cervical spondylopathy, male gender, and diabetes were risk factors for frequency of relapse.

CONCLUSIONS

Associated factors were different for recurrence frequency among different stroke types.

A retrospective cohort study of high-impact users among patients with cerebrovascular conditions

OBJECTIVE

To apply group-based trajectory modelling (GBTM) to the hospital administrative data to evaluate, model and visualise trends and changes in the frequency of long-term hospital care use of the subgroups of patients with cerebrovascular conditions.

DESIGN

A retrospective cohort study of patients with cerebrovascular conditions.

SETTINGS

Secondary care of all patients with cerebrovascular conditions admitted to English National Hospital Service hospitals.

PARTICIPANTS

All patients with cerebrovascular conditions identified through national administrative data (Hospital Episode Statistics) and subsequent emergency hospital admissions followed up for 4 years.

MAIN OUTCOME MEASURE

Annual number of emergency hospital readmissions.

RESULTS

GBTM model classified patients with intracranial haemorrhage (n=2605) into five subgroups, whereas ischaemic stroke (n=34 208) and transient ischaemic attack (TIA) (n=20 549) patients were shown to have two conventional groups, low and high impact. The covariates with significant association with high-impact users (17.1%) among ischaemic stroke were epilepsy (OR 2.29), previous stroke (OR 2.18), anxiety/depression (OR 1.63), procedural complication (OR 1.43), admission to intensive therapy unit (ITU) or high dependency unit (HDU) (OR 1.42), comorbidity score (OR 1.36), urinary tract infections (OR 1.32), vision loss (OR 1.32), chest infections (OR 1.25), living alone (OR 1.25), diabetes (OR 1.23), socioeconomic index (OR 1.20), older age (OR 1.03) and prolonged length of stay (OR 1.00). The covariates associated with high-impact users among TIA (20.0%) were thromboembolic event (OR 3.67), previous stroke (OR 2.51), epilepsy (OR 2.25), hypotension (OR 1.86), anxiety/depression (OR 1.63), amnesia (OR 1.62), diabetes (OR 1.58), anaemia (OR 1.55), comorbidity score (OR 1.39), atrial fibrillation (OR 1.27), living alone (OR 1.25), socioeconomic index (OR 1.13), older age (OR 1.04) and prolonged length of stay (OR 1.02). The high-impact users (0.5%) among intracranial haemorrhage were strongly associated with thromboembolic event (OR 20.3) and inversely related to older age (OR 0.58).

CONCLUSION

GBTM effectively assessed trends in the use of hospital care by the subgroups of patients with cerebrovascular conditions. High-impact users persistently had higher annual readmission during the follow-up period.

Differentiating Incident from Recurrent Stroke Using Administrative Data: The Impact of Varying Lengths of Look-Back Periods on the Risk of Misclassification

BACKGROUND/AIMS

Administrative data are widely used to monitor epidemiological trends in stroke and outcomes; yet there is scant empirical guidance on how to best differentiate incident from recurrent stroke.

METHODS

We identified all hospital admissions in New South Wales, Australia, with a principal stroke diagnosis from July 1, 2013 to June 30, 2014, linked to 12 years of previous admissions. We calculated the proportion of cases identified with a prior stroke to determine the number of years of look-back required to minimise misclassification of incident and recurrent strokes.

RESULTS

Using the maximum available look-back period of 12 years, 1,171 out of 8,364 eligible stroke cases (14.0%) had a stroke history. A 1-year look-back period identified only 25.1% of these patients and 1 in 10 stroke cases were misclassified as incident. With a 10-year clearance period, less than 1 in 100 stroke cases were misclassified as incident. The risk of misclassification was lower in patients younger than 65 years and in those with haemorrhagic stroke.

CONCLUSION

Hospital administrative data sets linked to prior admissions can be used to distinguish recurrent from incident stroke. The risk of misclassifying recurrent stroke cases as incident events is negligible with a look-back period of 10 years.

Access disparities to Magnet hospitals for ischemic stroke patients

Access disparities to centers of excellence can have detrimental consequences for population health. We investigated the presence of racial disparities in the access of stroke patients to hospitals recognized by the Magnet Recognition Program of the American Nurses Credentialing Center (ANCC). We performed a cohort study of all ischemic stroke patients who were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2009 to 2013. We examined the association of African-American race with Magnet status hospitalization after ischemic stroke. A mixed effects propensity adjusted multivariable regression analysis was used to control for confounding. During the study period, 176,557 patients presented with ischemic stroke, and met the inclusion criteria. Overall, 4,624 (13.7%) African-Americans, and 27,468 (19.2%) non African-Americans with ischemic stroke were admitted to Magnet hospitals. Using a multivariable logistic regression, we demonstrate that African-Americans were associated with lower admission rates to Magnet institutions (OR 0.70; 95% CI, 0.68-0.73) (Table 2). This persisted in a mixed effects logistic regression model (OR 0.75; 95% CI, 0.71-0.78) to adjust for clustering at the county level, and a propensity score adjusted logistic regression model (OR 0.87; 95% CI, 0.83-0.90). Using a comprehensive all-payer cohort of ischemic stroke patients in New York State we identified an association of African-American race with lower rates of admission to Magnet hospitals.

Sequence Analysis of Long-Term Readmissions among High-Impact Users of Cerebrovascular Patients

Objective

Understanding the chronological order of the causes of readmissions may help us assess any repeated chain of events among high-impact users, those with high readmission rate. We aim to perform sequence analysis of administrative data to identify distinct sequences of emergency readmissions among the high-impact users.

Methods

A retrospective cohort of all cerebrovascular patients identified through national administrative data and followed for 4 years.

Results

Common discriminating subsequences in chronic high-impact users (n = 2863) of ischaemic stroke (n = 34208) were “urological conditions-chest infection,” “chest infection-urological conditions,” “injury-urological conditions,” “chest infection-ambulatory condition,” and “ambulatory condition-chest infection” (p < 0.01). Among TIA patients (n = 20549), common discriminating (p < 0.01) subsequences among chronic high-impact users were “injury-urological conditions,” “urological conditions-chest infection,” “urological conditions-injury,” “ambulatory condition-urological conditions,” and “ambulatory condition-chest infection.” Among the chronic high-impact group of intracranial haemorrhage (n = 2605) common discriminating subsequences (p < 0.01) were “dementia-injury,” “chest infection-dementia,” “dementia-dementia-injury,” “dementia-urine infection,” and “injury-urine infection.” Conclusion. Although common causes of readmission are the same in different subgroups, the high-impact users had a higher proportion of patients with distinct common sequences of multiple readmissions as identified by the sequence analysis. Most of these causes are potentially preventable and can be avoided in the community.

Conclusion

Although common causes of readmission are the same in different subgroups, the high-impact users had a higher proportion of patients with distinct common sequences of multiple readmissions as identified by the sequence analysis. Most of these causes are potentially preventable and can be avoided in the community.

Many Neurology Readmissions Are Nonpreventable

INTRODUCTION

Reducing unplanned hospital readmissions has become a national focus due to the Centers for Medicare and Medicaid Services' (CMS) penalties for hospitals with high rates. A first step in reducing unplanned readmission is to understand which patients are at high risk for readmission, which readmissions are planned, and how well planned readmissions are currently captured in comparison to patient-level chart review.

METHODS

We examined all 5455 inpatient neurology admissions over a 2-year period to University of California San Francisco Medical Center and Johns Hopkins Hospital via chart review. We collected information such as patient age, procedure codes, diagnosis codes, all-payer diagnosis-related group, observed length of stay (oLOS), and expected length of stay. We performed multivariate logistic modeling to determine predictors of readmission. Discharge summaries were reviewed for evidence that a subsequent readmission was planned.

RESULTS

A total of 353 (6.5%) discharges were readmitted within 30 days. Fifty-five (15.6%) of the 353 readmissions were planned, most often for a neurosurgical procedure (41.8%) or immunotherapy (23.6%). Only 8 of these readmissions would have been classified as planned using current CMS methodology. Patient age (odds ratio [OR] = 1.01 for each 10-year increase, P < .001) and estimated length of stay (OR = 1.04, P = .002) were associated with a greater likelihood of readmission, whereas index admission oLOS was not.

CONCLUSIONS

Many neurologic readmissions are planned; however, these are often classified by current CMS methodology as unplanned and penalized accordingly. Modifications of the CMS lists for potentially planned neurological and neurosurgical procedures and for acute discharge neurologic diagnoses should be considered.

Systematic Review of Hospital Readmissions in Stroke Patients

Background. Previous evidence on factors and causes of readmissions associated with high-impact users of stroke is scanty. The aim of the study was to investigate common causes and pattern of short- and long-term readmissions stroke patients by conducting a systematic review of studies using hospital administrative data. Common risk factors associated with the change of readmission rate were also examined. Methods. The literature search was conducted from 15 February to 15 March 2016 using various databases, such as Medline, Embase, and Web of Science. Results. There were a total of 24 studies (n = 2,126,617) included in the review. Only 4 studies assessed causes of readmissions in stroke patients with the follow-up duration from 30 days to 5 years. Common causes of readmissions in majority of the studies were recurrent stroke, infections, and cardiac conditions. Common patient-related risk factors associated with increased readmission rate were age and history of coronary heart disease, heart failure, renal disease, respiratory disease, peripheral arterial disease, and diabetes. Among stroke-related factors, length of stay of index stroke admission was associated with increased readmission rate, followed by bowel incontinence, feeding tube, and urinary catheter. Conclusion. Although risk factors and common causes of readmission were identified, none of the previous studies investigated causes and their sequence of readmissions among high-impact stroke users.

Primary Stroke Center Hospitalization for Elderly Patients With Stroke: Implications for Case Fatality and Travel Times

IMPORTANCE

Physicians often must decide whether to treat patients with acute stroke locally or refer them to a more distant Primary Stroke Center (PSC). There is little evidence on how much the increased risk of prolonged travel time offsets benefits of a specialized PSC care.

OBJECTIVES

To examine the association of case fatality with receiving care in PSCs vs other hospitals for patients with stroke and to identify whether prolonged travel time offsets the effect of PSCs.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of Medicare beneficiaries with stroke admitted to a hospital between January 1, 2010, and December 31, 2013. Drive times were calculated based on zip code centroids and street-level road network data. We used an instrumental variable analysis based on the differential travel time to PSCs to control for unmeasured confounding. The setting was a 100% sample of Medicare fee-for-service claims.

EXPOSURES

Admission to a PSC.

MAIN OUTCOMES AND MEASURES

Seven-day and 30-day postadmission case-fatality rates.

RESULTS

Among 865 184 elderly patients with stroke (mean age, 78.9 years; 55.5% female), 53.9% were treated in PSCs. We found that admission to PSCs was associated with 1.8% (95% CI, -2.1% to -1.4%) lower 7-day and 1.8% (95% CI, -2.3% to -1.4%) lower 30-day case fatality. Fifty-six patients with stroke needed to be treated in PSCs to save one life at 30 days. Receiving treatment in PSCs was associated with a 30-day survival benefit for patients traveling less than 90 minutes, but traveling at least 90 minutes offset any benefit of PSC care.

CONCLUSIONS AND RELEVANCE

Hospitalization of patients with stroke in PSCs was associated with decreased 7-day and 30-day case fatality compared with noncertified hospitals. Traveling at least 90 minutes to receive care offset the 30-day survival benefit of PSC admission.

Predictors of 30-day readmission after aneurysmal subarachnoid hemorrhage: a case-control study

OBJECTIVE Despite persisting questions regarding its appropriateness, 30-day readmission is an increasingly common quality metric used to influence hospital compensation in the United States. However, there is currently insufficient evidence to identify which patients are at highest risk for readmission after aneurysmal subarachnoid hemorrhage (SAH). The objective of this study was to identify predictors of 30-day readmission after SAH, to focus preventative efforts, and to provide guidance to funding agencies seeking to risk-adjust comparisons among hospitals. METHODS The authors performed a case-control study of 30-day readmission among aneurysmal SAH patients treated at a single center between 2003 and 2013. To control for geographic distance from the hospital and year of treatment, the authors randomly matched each case (30-day readmission) with approximately 2 SAH controls (no readmission) based on home ZIP code and treatment year. They evaluated variables related to patient demographics, socioeconomic characteristics, comorbidities, presentation severity (e.g., Hunt and Hess grade), and clinical course (e.g., need for gastrostomy or tracheostomy, length of stay). Conditional logistic regression was used to identify significant predictors, accounting for the matched design of the study. RESULTS Among 82 SAH patients with unplanned 30-day readmission, the authors matched 78 patients with 153 nonreadmitted controls. Age, demographics, and socioeconomic factors were not associated with readmission. In univariate analysis, multiple variables were significantly associated with readmission, including Hunt and Hess grade (OR 3.0 for Grade IV/V vs I/II), need for gastrostomy placement (OR 2.0), length of hospital stay (OR 1.03 per day), discharge disposition (OR 3.2 for skilled nursing vs other disposition), and Charlson Comorbidity Index (OR 2.3 for score ≥ 2 vs 0). However, the only significant predictor in the multivariate analysis was discharge to a skilled nursing facility (OR 3.2), and the final model was sensitive to criteria used to enter and retain variables. Furthermore, despite the significant association between discharge disposition and readmission, less than 25% of readmitted patients were discharged to a skilled nursing facility. CONCLUSIONS Although discharge disposition remained significant in multivariate analysis, most routinely collected variables appeared to be weak independent predictors of 30-day readmission after SAH. Consequently, hospitals interested in decreasing readmission rates may consider multifaceted, cost-efficient interventions that can be broadly applied to most if not all SAH patients.

Majority of 30-Day Readmissions After Intracerebral Hemorrhage Are Related to Infections

BACKGROUND AND PURPOSE

Infections are common after intracerebral hemorrhage, but little is known about the risk of serious infection requiring readmission after hospital discharge.

METHODS

To determine if infections are prevalent in patients readmitted within 30 days of discharge, we performed a retrospective cohort study of patients discharged from nonfederal acute care hospitals in California with a primary diagnosis of intracerebral hemorrhage between 2006 and 2010. We excluded patients who died during the index admission, were discharged against medical advice, or were not California residents. Our main outcome was 30-day unplanned readmission with primary infection-related International Classification of Diseases, Ninth Revision, Clinical Modification code.

RESULTS

There were 24 540 index intracerebral hemorrhage visits from 2006 to 2010. Unplanned readmissions occurred in 14.5% (n=3550) of index patients. Of 3550 readmissions, 777 (22%) had an infection-related primary diagnosis code. When evaluating primary and all secondary diagnosis codes, infection was associated with 1826 (51%) of readmissions. Other common diagnoses associated with readmission included stroke-related codes (n=840, 23.7%) and aspiration pneumonitis (n=154, 4.3%). The most common infection-related primary diagnosis codes were septicemia (n=420, 11.8%), pneumonia (n=124, 3.5%), urinary tract infection (n=141, 4.0%), and gastrointestinal infection (n=42, 1.2%). Patients with a primary infection-related International Classification of Diseases, Ninth Revision, Clinical Modification code on readmission had higher in-hospital mortality compared with other types of readmission (15.6% versus 8.0%, P<0.001). After controlling for other predictors of mortality, primary infection-related readmissions remained associated with in-hospital mortality (relative risk, 1.7; 95% confidence interval, 1.3-2.2).

CONCLUSIONS

Infections are associated with a majority of 30-day readmissions after intracerebral hemorrhage and increased mortality. Efforts should be made to reduce infection-related complications after hospital discharge.

Effectiveness of regionalized systems for stroke and myocardial infarction

BACKGROUND

Acute ischemic stroke (AIS) and ST-segment elevation myocardial infarction (STEMI) are ischemic emergencies. Guidelines recommend care delivery within formally regionalized systems of care at designated centers, with bypass of nearby centers of lesser or no designation. We review the evidence of the effectiveness of regionalized systems in AIS and STEMI.

METHODS

Literature was searched using terms corresponding to designation of AIS and STEMI systems and from 2010 to the present. Inclusion criteria included report of an outcome on any dependent variable mentioned in the rationale for regionalization in the guidelines and an independent variable comparing care to a non- or pre-regionalized system. Designation was defined in the AIS case as certification by the Joint Commission as either a primary (PSC) or comprehensive (CSC) stroke center. In the STEMI case, the search was conducted linking "regionalization" and "myocardial infarction" or citation as a model system by any American Heart Association statement.

RESULTS

For AIS, 17 publications met these criteria and were selected for review. In the STEMI case, four publications met these criteria; the search was therefore expanded by relaxing the criteria to include any historical or anecdotal comparison to a pre- or nonregionalized state. The final yield was nine papers from six systems.

CONCLUSION

Although regionalized care results in enhanced process and reduced unadjusted rates of disparity in access and adverse outcomes, these differences tend to become nonsignificant when adjusted for delayed presentation and hospital arrival by means other than emergency medical services. The benefits of regionalized care occur along with a temporal trend of improvement due to uptake of quality initiatives and guideline recommendations by all systems regardless of designation. Further research is justified with a randomized registry or cluster randomized design to support or refute recommendations that regionalization should be the standard of care.

Post-Acute Care Data for Predicting Readmission After Ischemic Stroke: A Nationwide Cohort Analysis Using the Minimum Data Set

BACKGROUND

Reducing hospital readmissions is a key component of reforms for stroke care. Current readmission prediction models lack accuracy and are limited by data being from only acute hospitalizations. We hypothesized that patient-level factors from a nationwide post-acute care database would improve prediction modeling.

METHODS AND RESULTS

Medicare inpatient claims for the year 2008 that used International Classification of Diseases, Ninth Revision codes were used to identify ischemic stroke patients older than age 65. Unique individuals were linked to comprehensive post-acute care assessments through use of the Minimum Data Set (MDS). Logistic regression was used to construct risk-adjusted readmission models. Covariates were derived from MDS variables. Among 39 178 patients directly admitted to nursing homes after hospitalization due to acute stroke, there were 29 338 (75%) with complete MDS assessments. Crude rates of readmission and death at 30 days were 8448 (21%) and 2791 (7%), respectively. Risk-adjusted models identified multiple independent predictors of all-cause 30-day readmission. Model performance of the readmission model using MDS data had a c-statistic of 0.65 (95% CI 0.64 to 0.66). Higher levels of social engagement, a marker of nursing home quality, were associated with progressively lower odds of readmission (odds ratio 0.71, 95% CI 0.55 to 0.92).

CONCLUSIONS

Individual clinical characteristics from the post-acute care setting resulted in only modest improvement in the c-statistic relative to previous models that used only Medicare Part A data. Individual-level characteristics do not sufficiently account for the risk of acute hospital readmission.

Causes of 30-day readmission after aneurysmal subarachnoid hemorrhage

OBJECTIVE

Hospital readmission is a common but controversial quality measure increasingly used to influence hospital compensation in the US. The objective of this study was to evaluate the causes for 30-day hospital readmission following aneurysmal subarachnoid hemorrhage (SAH) to determine the appropriateness of this performance metric and to identify potential avenues for improved patient care.

METHODS

The authors retrospectively reviewed the medical records of all patients who received surgical or endovascular treatment for aneurysmal SAH at Barnes-Jewish Hospital between 2003 and 2013. Two senior faculty identified by consensus the primary medical/surgical diagnosis associated with readmission as well as the underlying causes of rehospitalization.

RESULTS

Among 778 patients treated for aneurysmal SAH, 89 experienced a total of 97 readmission events, yielding a readmission rate of 11.4%. The median time from discharge to readmission was 9 days (interquartile range 3-17.5 days). Actual hydrocephalus or potential concern for hydrocephalus (e.g., headache) was the most frequent diagnosis (26/97, 26.8%), followed by infections (e.g., wound infection [5/97, 5.2%], urinary tract infection [3/97, 3.1%], and pneumonia [3/97, 3.1%]) and thromboembolic events (8/97, 8.2%). In most cases (75/97, 77.3%), we did not identify any treatment lapses contributing to readmission. The most common underlying causes for readmission were unavoidable development of SAH-related pathology (e.g., hydrocephalus; 36/97, 37.1%) and complications related to neurological impairment and immobility (e.g., thromboembolic event despite high-dose chemoprophylaxis; 21/97, 21.6%). The authors determined that 22/97 (22.7%) of the readmissions were likely preventable with alternative management. In these cases, insufficient outpatient medical care (for example, for hyponatremia; 16/97, 16.5%) was the most common shortcoming.

CONCLUSIONS

Most readmissions after aneurysmal SAH relate to late consequences of hemorrhage, such as hydrocephalus, or medical complications secondary to severe neurological injury. Although a minority of readmissions may potentially be avoided with closer medical follow-up in the transitional care environment, readmission after SAH is an insensitive and likely inappropriate hospital performance metric.

Vascular Neurologists as Directors of Stroke Centers in the United States

BACKGROUND AND PURPOSE

Hospital certification as primary and comprehensive stroke center is associated with improvement in care. We aimed to characterize the leadership at stroke centers nationwide to determine the proportion led by vascular neurologists, a board-recognized subspecialty focusing on stroke care.

METHODS

We identified hospitals in the United States holding primary and comprehensive stroke center designation as of September 2013. We contacted each hospital to identify the medical director and used data from relevant medical boards to determine specialization. Sex and date of medical school graduation were obtained from an online physician database.

RESULTS

Of the 1167 primary and 50 comprehensive stroke center hospitals certified by the Joint Commission (n=1114), Det Norske Veritas (n=68), and Healthcare Facilities Accreditation Program (n=35), we identified the director in 940 (77%). Leadership was most often by a neurologist (n=745; 79%) followed by physicians in emergency medicine (n=58; 6%) and internal medicine (n=17; 2%). Vascular neurologists (n=319) led about one-third of stroke centers. Directors were mostly men (n=764; 81%), with a median number of years after medical school graduation of 25 (interquartile range, 18-34). Comprehensive stroke centers were more likely than primary stroke centers to have leadership by vascular neurologist (77%, n=37 versus 32%, n=282; P<0.001).

CONCLUSIONS

Vascular neurologist led about one-third of stroke centers. There is opportunity for vascular neurologists to increase their role in stroke center directorship.