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Leifheit EC, Wang Y, Goldstein LB, Lichtman JH. Trends in 1-Year Recurrent Ischemic Stroke in the US Medicare Fee-for-Service Population. Stroke 2022; 53:3338-3347. [PMID: 36214126 PMCID: PMC11059192 DOI: 10.1161/strokeaha.122.039438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/12/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND There have been important advances in secondary stroke prevention and a focus on healthcare delivery over the past decades. Yet, data on US trends in recurrent stroke are limited. We examined national and regional patterns in 1-year recurrence among Medicare beneficiaries hospitalized for ischemic stroke from 2001 to 2017. METHODS This cohort study included all fee-for-service Medicare beneficiaries aged ≥65 years who were discharged alive with a principal diagnosis of ischemic stroke from 2001 to 2017. Follow-up was up to 1 year through 2018. Cox models were used to assess temporal trends in 1-year recurrent ischemic stroke, adjusting for demographic and clinical characteristics. We mapped recurrence rates and identified persistently high-recurrence counties as those with rates in the highest sextile for stroke recurrence in ≥5 of the following periods: 2001-2003, 2004-2006, 2007-2009, 2010-2012, 2013-2015, and 2016-2017. RESULTS There were 3 638 346 unique beneficiaries discharged with stroke (mean age 79.0±8.1 years, 55.2% women, 85.3% White). The national 1-year recurrent stroke rate decreased from 11.3% in 2001-2003 to 7.6% in 2016-2017 (relative reduction, 33.5% [95% CI, 32.5%-34.5%]). There was a 2.3% (95% CI, 2.2%-2.4%) adjusted annual decrease in recurrence from 2001 to 2017 that included reductions in all age, sex, and race subgroups. County-level recurrence rates ranged from 5.5% to 14.0% in 2001-2003 and from 0.2% to 8.9% in 2016-2017. There were 76 counties, concentrated in the South-Central United States, that had the highest recurrence throughout the study. These counties had populations with a higher proportion of Black residents and uninsured adults, greater wealth inequity, poorer general health, and reduced preventive testing rates as compared with other counties. CONCLUSIONS Recurrent ischemic strokes decreased over time overall and across demographic subgroups; however, there were geographic areas with persistently higher recurrence rates. These findings can inform secondary prevention intervention opportunities for high-risk populations and communities.
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Affiliation(s)
- Erica C Leifheit
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (E.C.L., J.H.L.)
| | - Yun Wang
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (Y.W.)
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (Y.W.)
| | - Larry B Goldstein
- Department of Neurology, University of Kentucky College of Medicine and Kentucky Neuroscience Institute, Lexington (L.B.G.)
| | - Judith H Lichtman
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (E.C.L., J.H.L.)
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Bacellar A, Pedreira BB, Costa G, Assis T, Lobo C, Nascimento O. Predictors of readmission and long length of stay in elders admitted with neurological disorders in a tertiary center: a real-world investigation. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:321-329. [DOI: 10.1590/0004-282x20190041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 02/01/2019] [Indexed: 01/27/2023]
Abstract
ABSTRACT Hospital readmission and long length of stay (LOS) increase morbidity and hospital mortality and are associated with excessive costs to health systems. Objective: This study aimed to identify predictors of hospital readmission and long LOS among elders with neurological disorders (NDs). Methods: Patients ≥ 60 years of age admitted to the hospital between January 1, 2009, and December 31, 2010, with acute NDs, chronic NDs as underpinnings of acute clinical disorders, and neurological complications of other diseases were studied. We analyzed demographic factors, NDs, and comorbidities as independent predictors of readmission and long LOS (≥ 9 days). Logistic regression was performed for multivariate analysis. Results: Overall, 1,154 NDs and 2,679 comorbidities were identified among 798 inpatients aged ≥ 60 years (mean 75.8 ± 9.1). Of the patients, 54.5% were female. Patient readmissions were 251(31%) and 409 patients (51%) had an LOS ≥ 9 days (95% confidence interval 48%–55%). We found no predictors for readmission. Low socioeconomic class (p = 0.001), respiratory disorder (p < 0.001), infection (p < 0.001), genitourinary disorder (p < 0.033), and arterial hypertension (p = 0.002) were predictors of long LOS. Identified risks of long LOS explained 22% of predictors. Conclusions: Identifying risk factors for patient readmission are challenges for neurology teams and health system stakeholders. As low socioeconomic class and four comorbidities, but no NDs, were identified as predictors for long LOS, we recommend studying patient multimorbidity as well as functional and cognitive scores to determine whether they improve the risk model of long LOS in this population.
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Affiliation(s)
- Aroldo Bacellar
- D’Or Institute for Research and Education, Brasil; Universidade Federal Fluminense, Brasil
| | | | | | - Telma Assis
- D’Or Institute for Research and Education, Brasil
| | - Camila Lobo
- D’Or Institute for Research and Education, Brasil
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Westley-Wise V, Lago L, Mullan J, Facci F, Zingel R, Eagar K. Trends in unplanned readmissions over 15 years: a regional Australian perspective. AUST HEALTH REV 2019; 44:241-247. [PMID: 30827332 DOI: 10.1071/ah18072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 11/19/2018] [Indexed: 11/23/2022]
Abstract
Objective The aim of this study was to assess 15-year trends in unplanned readmissions in an Australian regional health service. Methods Drawing on data held in the Illawarra Health Information Platform (IHIP), this longitudinal retrospective study of adults admitted to hospital between 2001-02 and 2015-16 assessed rates of unplanned all-cause readmissions within 30 days ('early') and 1-6 months ('late') following discharge. Rates were compared over time and between patient groups. Results Age-adjusted early readmission rates declined over the 15 years by an average of 1.3% per annum, whereas late readmission rates increased by an average of 0.6% per annum. Together, there was an overall decline in readmission rates. The entire decline in early readmission rates and a reversal of the increasing trend in late readmission rates occurred since 2010-11. Similar trends occurred across age groups, but were most pronounced among those aged ≥75 years. Conclusions The decline in readmissions since 2010-11 suggests that the region has achieved improvements in discharge planning and in continuity between hospitals and community-based care. These improvements have occurred across broad patient groups. The longitudinal and linked data held in the IHIP provides a unique opportunity to examine patterns of service utilisation at a regional level. What is known about the topic? Published reports of longitudinal trends in readmissions are typically limited by short study periods and narrow criteria used to define study populations and readmissions. Australian longitudinal data suggest rates of early readmission have remained relatively unchanged in recent years, despite the focus on readmission rates as a metric to assess the quality and continuity of care. What does this paper add? This unique longitudinal study reports on long-term readmission trends over 15 years to hospitals within a single geographic area, with trends reported for both early (30-day) and late (1- to 6-month) readmissions by age group and major diagnostic categories. The findings reflect more complex patterns than are typically reported in cross-sectional and more limited longitudinal studies. What are the implications for practitioners? The results suggest improvements at a regional level that may be associated with care during the initial hospitalisation and discharge (reflected particularly in early readmissions) and in the community (reflected particularly in late readmissions). Future investigations will explore specific patient groups and the effects of specific initiatives, services and models of care to better predict those at risk of readmission and to inform translation locally and further afield. The relationship between readmissions and the use of ambulatory services (primary care, emergency department and out-patient) also warrants further investigation.
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Affiliation(s)
- Victoria Westley-Wise
- Illawarra Shoalhaven Local Health District, Level 1, 67-71 King Street, Warrawong, NSW 2502, Australia. ; ; and Centre for Health Services Research Illawarra Shoalhaven Population, University of Wollongong, Building 234, Innovation Campus, Wollongong, NSW 2522, Australia. , ; and Corresponding author.
| | - Luise Lago
- Centre for Health Services Research Illawarra Shoalhaven Population, University of Wollongong, Building 234, Innovation Campus, Wollongong, NSW 2522, Australia. ,
| | - Judy Mullan
- Centre for Health Services Research Illawarra Shoalhaven Population, University of Wollongong, Building 234, Innovation Campus, Wollongong, NSW 2522, Australia. ,
| | - Franca Facci
- Illawarra Shoalhaven Local Health District, Level 1, 67-71 King Street, Warrawong, NSW 2502, Australia. ;
| | - Rebekah Zingel
- Illawarra Shoalhaven Local Health District, Level 1, 67-71 King Street, Warrawong, NSW 2502, Australia. ;
| | - Kathy Eagar
- Australian Health Services Research Institute, University of Wollongong, Building 234, Innovation Campus, Wollongong, NSW 2522, Australia.
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Wen T, Liu B, Wan X, Zhang X, Zhang J, Zhou X, Lau AYL, Zhang Y. Risk factors associated with 31-day unplanned readmission in 50,912 discharged patients after stroke in China. BMC Neurol 2018; 18:218. [PMID: 30587162 PMCID: PMC6306006 DOI: 10.1186/s12883-018-1209-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 11/29/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Unplanned readmission within 31 days of discharge after stroke is a useful indicator for monitoring quality of hospital care. We evaluated the risk factors associated with 31-day unplanned readmission of stroke patients in China. METHODS We identified 50,912 patients from 375 hospitals in 29 provinces, municipalities or autonomous districts across China who experienced an unplanned readmission after stroke between 2015 and 2016, and extracted data from the inpatients' cover sheet data from the Medical Record Monitoring Database. Patients were grouped into readmission within 31 days or beyond for analysis. Chi-squared test was used to analyze demographic information, health system and clinical process-related factors according to the data type. Multilevel logistic modeling was used to examine the effects of patient (level 1) and hospital (level 2) characteristics on an unplanned readmission ≤31 days. RESULTS Among 50,912 patients, 14,664 (28.8%) were readmitted within 31 days after discharge. The commonest cause of readmissions were recurrent stroke (34.8%), hypertension (22.94%), cardio/cerebrovascular disease (13.26%) and diabetes/diabetic complications (7.34%). Higher risks of unplanned readmissions were associated with diabetes (OR = 1.089, P = 0.001), use of clinical pathways (OR = 1.174, P < 0.001), and being discharged without doctor's advice (OR = 1.485, P < 0.001). Lower risks were associated with basic medical insurances (OR ranging from 0.225 to 0.716, P < 0.001) and commercial medical insurance (OR = 0.636, P = 0.021), compared to self-paying for medical services. And patients aged 50 years old and above (OR ranging from 0.650 to 0.985, P < 0.05), with haemorrhagic stroke (OR = 0.467, P < 0.001), with length of stay more than 7 days in hospital (OR ranging from 0.082 to 0.566, P < 0.001), also had lower risks. CONCLUSIONS Age, type of stroke, medical insurance status, type of discharge, use of clinical pathways, length of hospital stay and comorbidities were the most influential factors for readmission within 31 days.
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Affiliation(s)
- Tiancai Wen
- School of Computer Science, Northwestern Polytechnical University Xi’an, Shangxi Province, 710129 China
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, 100700 China
- Data Center of Traditional Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing, 100700 China
| | - Baoyan Liu
- Data Center of Traditional Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing, 100700 China
| | - Xia Wan
- Institute of Basic Medical Sciences at Chinese Academy of Medical Sciences / School of Basic Medicine at Peking Union Medical College, Beijing, 100005 China
| | - Xiaoping Zhang
- Data Center of Traditional Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing, 100700 China
| | - Jin Zhang
- Data Center of Traditional Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing, 100700 China
| | - Xuezhong Zhou
- School of Computer and Information Technology, Beijing Jiaotong University, Beijing, 100044 China
| | | | - Yanning Zhang
- School of Computer Science, Northwestern Polytechnical University Xi’an, Shangxi Province, 710129 China
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Rohweder G, Salvesen Ø, Ellekjær H, Indredavik B. Hospital readmission within 10 years post stroke: frequency, type and timing. BMC Neurol 2017. [PMID: 28629340 PMCID: PMC5477341 DOI: 10.1186/s12883-017-0897-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was to examine the hospital readmissions in a 10 year follow-up of a stroke cohort previously studied for acute and subacute complications and to focus on their frequency, their causes and their timing. METHODS The hospital records of 243 patients, 50% of a cohort of 489 patients acutely and consecutively admitted to our stroke unit in 2002/3, were subjected to review 10 years after the incidental stroke and all acute admissions were examined. The main admitting diagnoses were attributed to one of 18 predefined categories of illness. Additionally, the occurrence of death was registered. RESULTS After 10 years 68.9% of patients had died and 72.4% had been readmitted to the hospital with a mean number of readmissions of 3.4 (+15.1 SD). 20% of the readmissions were due to a vascular cause, 17.3% were caused by infection, 9.3% by falls with (6.1%) and without fracture, 5.7% by a hemorrhagic event. The readmission rate was highest in the first 6 months post stroke with a rate of 116.2 admissions/100 live patient-years. Falls with fractures occurred maximally 3-5 years post stroke. CONCLUSIONS Hospital readmissions over the 10 years following stroke are caused by vascular events, infections, falls and hemorrhagic events, where the first 6 months are a period of particular vulnerability. The magnitude and the spectrum of these long-term complications suggest the need for a more comprehensive approach to post stroke prophylaxis.
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Affiliation(s)
- Gitta Rohweder
- From the Stroke Unit, Department of Internal Medicine, St Olav's Hospital, University Hospital of Trondheim, Harald Hardraades gate 5, 7030, Trondheim, Norway. .,The Institute for Neuromedicine (INM), Faculty of Medicine and Health Sciences, Norwegian University of Science And Technology (NTNU), Trondheim, Norway.
| | - Øyvind Salvesen
- The Unit of Applied Clinical Research, Faculty of Medicine and Health Sciences, Norwegian University of Science And Technology (NTNU), Trondheim, Norway
| | - Hanne Ellekjær
- From the Stroke Unit, Department of Internal Medicine, St Olav's Hospital, University Hospital of Trondheim, Harald Hardraades gate 5, 7030, Trondheim, Norway.,The Institute for Neuromedicine (INM), Faculty of Medicine and Health Sciences, Norwegian University of Science And Technology (NTNU), Trondheim, Norway
| | - Bent Indredavik
- From the Stroke Unit, Department of Internal Medicine, St Olav's Hospital, University Hospital of Trondheim, Harald Hardraades gate 5, 7030, Trondheim, Norway.,The Institute for Neuromedicine (INM), Faculty of Medicine and Health Sciences, Norwegian University of Science And Technology (NTNU), Trondheim, Norway
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Stroke severity may predict causes of readmission within one year in patients with first ischemic stroke event. J Neurol Sci 2016; 372:21-27. [PMID: 28017214 DOI: 10.1016/j.jns.2016.11.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 10/25/2016] [Accepted: 11/13/2016] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Readmissions after stroke are costly. Risk assessment using information available upon admission could identify high-risk patients for potential interventions to reduce readmissions. Baseline stroke severity has been suspected to be a factor in readmission; however, the exact nature of the impact has not been adequately understood. METHODS Hospitalized adult patients with first-ever ischemic stroke were identified from a nationwide administrative database. Stroke severity was assessed using a validated claims-based stroke severity index. Cox proportional hazards models were used to investigate the relationship between stroke severity and first readmission within one year. RESULTS Of the 10,877 patients, 4295 (39.5%) were readmitted in one year. The cumulative risk of readmission was 34.1%, 44.7%, and 62.9% in patients with mild, moderate, and severe stroke, respectively. Patients with greater stroke severity had a significantly higher adjusted risk of first readmission for infection, metabolic disorders, neurological sequelae, and pulmonary diseases, whereas those with lesser stroke severity were prone to first readmission due to accidents. Stroke severity did not affect the risk of first readmission for recurrent stroke/transient ischemic attack, other cardiovascular events, malignancy, ulcers/upper gastrointestinal bleeding, kidney diseases, and others. CONCLUSIONS Stroke severity in patients with first-ever ischemic stroke not only predicts readmission but also relates to the cause of readmission. Our results might provide important information for tailoring discharge planning to prevent readmissions.
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