Bouncing-back: rehospitalization in patients with complicated transitions in the first thirty days after hospital discharge for acute stroke

Care Transition Interventions to Improve Stroke Outcomes: Evidence Gaps in Underserved and Minority Populations

In many countries hospital length of stay after an acute stroke admission is typically just a few days, therefore, most of a person's recovery from stroke occurs in the community. Care transitions, which occur when there is a change in, or handoff between 2 different care settings or providers, represent an especially vulnerable period for patients and caregivers. For some patients with stroke the return home is associated with substantial practical, psychosocial, and health-related challenges leading to substantial burden for the individual and caregiver. Underserved and minority populations, because of their exposure to poor environmental, social, and economic conditions, as well as structural racism and discrimination, are especially vulnerable to the problems of complicated care transitions which in turn, can negatively impact stroke recovery. Overall, there remain significant unanswered questions about how to promote optimal recovery in the post-acute care period, particularly for those from underserved communities. Evidence is limited on how best to support patients after they have returned home where they are required to navigate the chronic stages of stroke with little direct support from health professionals.

The Association of Socioeconomic Status and Discharge Destination with 30-Day Readmission after Ischemic Stroke

OBJECTIVES

This study aimed to explore the association of socioeconomic status and discharge destination with 30-day readmission after ischemic stroke.

MATERIALS AND METHODS

We examined 30-day all-cause readmission among patients hospitalized for ischemic stroke in states of Arkansas, Iowa, and Wisconsin in 2016 and 2017 and New York in 2016 using Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases.

RESULTS

Among the 52301 patients included, 51.1% were female. The 30-day readmission rates were 10.2%, 8.2%, 9.3%, 10.4%, 11.6%, and 11.2% for age group 18-34, 35-44, 45-54, 55-64, 65-74, and ≥75 years, respectively (p<0.001). In Generalized Estimating Equation analysis, patients with Medicare and Medicaid insurance were more likely to be readmitted, compared with private insurance, (adjusted Odds Ratio [aOR] 1.37, 95% CI 1.23-1.53; and aOR 1.26, 95% CI 1.09-1.45, respectively). Patients in the bottom quartile of zip code level median household income had higher 30-day readmission rate (12.4%) than those in the 2nd, 3rd and 4th quartile (10.3%, 10.1%, and 10.7%, respectively, p<0.001). Compared with those discharged home with self-care which had the lowest readmission rate (8.4%), patients who left against medical advice had the highest readmission rate (18.6%; aOR 2.23, 95% CI 1.75-2.83), followed by rehabilitation and skilled nursing facilities (13.2%; aOR 1.33, 95% CI 1.22-1.46), and home with home health care (11.3%, aOR 1.18, 95% CI 1.08-1.28).

CONCLUSIONS

Socioeconomic status and discharged destination affect readmission after stroke. These results provide evidence to inform vulnerable patient population as targets for readmission prevention.

Healthcare Utilization for Stroke Patients at the End of Life: Nationally Representative Data

Objectives Stroke and post-stroke complications are associated with high morbidity, mortality, and cost. Our objective was to examine healthcare utilization and hospice enrollment for stroke patients at the end of life. Materials and methods The 2014 Nationwide Readmissions Database is a national database of > 14 million admissions. We used validated ICD-9 codes to identify fatal ischemic stroke, summarized demographics and hospitalization characteristics, and examined healthcare use within 30 days before fatal stroke admission. We used de-identified 2014 Medicare hospice data to identify stroke and non-stroke patients admitted to hospice. Results Among IS admissions in 2014 (n = 472,969), 22652 (4.8%) had in-hospital death. 28.2% with fatal IS had two or more hospitalizations in 2014. Among those with fatal IS admission, 13.0% were admitted with cerebrovascular disease within 30 days of fatal IS admission. Half of stroke patients discharged to hospice from the Medicare dataset were hospitalized with cerebrovascular disease within the thirty days prior to hospice enrollment. Within the study year, 6.9% of hospice enrollees had one or more emergency room visits, 31.7% had one or more inpatient encounters, and 5.2% had one or more nursing facility encounters (compared to 21.4%, 70.6%, and 27.2% respectively in the 30-day period prior to enrollment). Conclusions High rates of readmission prior to fatal stroke may indicate opportunity for improvement in acute stroke management, secondary prevention, and palliative care involvement as encouraged by AHA/ASA guidelines. For patients who are expected to survive 6 months or less, hospice may offer goal-concordant services for patients and caregivers who desire comfort-focused care.

Movement Matters, and So Does Context: Lessons Learned From Multisite Implementation of the Movement Matters Activity Program for Stroke in the Comprehensive Postacute Stroke Services Study

The purpose of this Special Communication is to discuss the rationale and design of the Movement Matters Activity Program for Stroke (MMAP) and explore implementation successes and challenges in home health and outpatient therapy practices across the stroke belt state of North Carolina. MMAP is an interventional component of the Comprehensive Postacute Stroke Services Study, a randomized multicenter pragmatic trial of stroke transitional care. MMAP was designed to maximize survivor health, recovery, and functional independence in the community and to promote evidence-based rehabilitative care. MMAP provided training, tools, and resources to enable rehabilitation providers to (1) prescribe physical activity and exercise according to evidence-based guidelines and programs, (2) match service setting and parameters with survivor function and benefit coverage, and (3) align treatment with quality metric reporting to demonstrate value-based care. MMAP implementation strategies were aligned with the Expert Recommendations for Implementing Change project, and MMAP site champion and facilitator survey feedback were thematically organized into the Consolidated Framework for Implementation Research domains. MMAP implementation was challenging, required modification and was affected by provider- and system-level factors. Program and study participation were limited and affected by practice priorities, productivity standards, and stroke patient volume. Sites with successful implementation appeared to have empowered MMAP champions in vertically integrated systems that embraced innovation. Findings from this broad evaluation can serve as a road map for the design and implementation of other comprehensive, complex interventions that aim to bridge the currently disconnected realms of acute care, postacute care, and community resources.

Opiate Prescriptions at Discharge Are Not Associated with Early Readmissions in Acute Pancreatitis

BACKGROUND

Early readmissions in acute pancreatitis (AP) are common. The impact of opiate prescriptions on readmissions is unknown.

AIMS

To determine whether the prescription of opiates at hospital discharge and the dose prescribed are associated with early readmissions in AP.

METHODS

Direct admissions from the Emergency Department (ED) for AP from September 1, 2013, to August 31, 2016 were identified. Opiate prescription was defined as a new prescription at discharge in an opiate-naïve patient. Early readmission was ED visit or hospitalization within 30 days for an AP-related reason. Multivariable logistic regression was performed, adjusted for age, Charlson Comorbidity Index, pancreatic necrosis, baseline opiate use, non-opiate analgesics, and pain score at discharge.

RESULTS

A total of 318 AP patients were identified; the overall early readmission rate was 18%. One hundred and twenty-one (38%) were prescribed opiates at discharge, and 22% had an early readmission. One hundred and ninety-seven (62%) were not prescribed opiates, and 16% had an early readmission. Median opiate dose was 48 mg (24-h morphine equivalents). On multivariable analysis, neither the prescription of opiates (OR 1.2, 95% CI 0.6-2.4, p = 0.55) nor the dose of opiates (OR 0.99, 95% CI 0.99-1.00, p = 0.39) was associated with early readmission. In subset analysis of patients discharged with an opiate prescription, those on opiates at baseline were significantly more likely to have an early readmission (OR 4.19, 95% CI 1.04-16.94, p = 0.04).

CONCLUSIONS

In AP patients, neither prescription of opiates at discharge nor prescribed dose was associated with early readmission. Patients on opiates at baseline discharged with an opiate prescription were more likely to have an early readmission.

Swallowing progression during the acute phase of cortical and subcortical ischemic stroke and its association with the extension of brain damage and cognitive impairment

Objective: To assess swallowing progression and its association with the extension of brain damage and cognitive impairment during the acute phase of ischemic stroke. Methods: Cross-sectional, observational study with 50 patients, who were admitted to a Stroke Unit with cerebral ischemia, with a maximum stroke time of 24 h. The following clinical tools were used: National Institutes of Health Stroke Scale, Mini-Mental State Examination, Frontal Battery Assessment, and the Alberta Stroke Program Early CT Score for neuroimaging. The Gugging Swallowing Screen and the Functional Oral Intake Scale were used to assess swallowing. The patients were assessed at three different time-points: at hospital admission, after 72 h of hospitalization, and at hospital discharge. Results: The mean age of patients was 65.5 years. The frequency of dysphagic patients was 50.0%, 18.0%, and 12.0% at admission, after 72 h of hospitalization, and at discharge, respectively. Scores on the Frontal Battery Assessment and the Alberta Stroke Program Early CT Score were associated with dysphagia progression. Conclusion: Dysphagia is a common complication in the acute phase of stroke, and is associated with the extension of brain damage and cognitive impairment.

Improving stroke transitions: Development and implementation of a social work case management intervention

Strokes impact over 800,000 people every year. Stroke care typically begins with inpatient care and then continues across an array of healthcare settings. These transitions are difficult for patients and caregivers, with psychosocial needs going unmet. Our team developed a case management intervention for acute stroke patients and their caregivers aimed at improving stroke transitions. The intervention focusses on four aspects of a successful care transition: support, preparedness, identifying and addressing unmet needs, and stroke education. This paper describes the development and implementation of this program, and is an example of the synergy created between neuroscience and clinical practice.

Improving transitions in acute stroke patients discharged to home: the Michigan stroke transitions trial (MISTT) protocol

Background

For some stroke patients and caregivers, navigating the transition between hospital discharge and returning home is associated with substantial psychosocial and health-related challenges. Currently, no evidence-based standard of care exists that addresses the concerns of stroke patients and caregivers during the transition period. Objectives of the Michigan Stroke Transitions Trial (MISTT) are to test the impact of a social worker home-based case management program, as well as an online information and support resource, on patient and caregiver outcomes after returning home.

Methods

The Michigan Stroke Transitions Trial is a randomized, pragmatic, open (un-blinded), 3-group parallel designed superiority trial conducted in 3 Michigan hospitals. Eligible participants are adult acute stroke patients discharged home directly or within 4 weeks of being discharged to a rehabilitation facility. The patient’s primary caregiver is also invited to participate. Patients are randomized on the day they return home using a randomized block design. Consented patients discharged to a rehabilitation facility who do not go home within 4 weeks are dropped from the study.

The 2 study interventions begin within a week of returning home and conclude 3 months later. The 3-group design compares usual care to either a home-based social worker stroke case management (SWSCM) program, or a combination of the SWSCM program plus access to an online information and support resource (MISTT website). Outcomes data are collected at 7-days and 90-days by trained telephone interviewers. Primary patient outcomes include the PROMIS global 10 score (a generic Quality of Life scale), and the Patient Activation Measure (PAM). Caregiver outcomes include the Bakas Caregiving Outcomes Scale. Final analysis will be based on 214 randomized acute stroke patients. To accommodate subjects excluded due to prolonged rehabilitation stays, as well as those lost-to-follow-up, up to 315 patients will be consented.

Discussion

The MISTT study will determine if a home-based case management program designed around the needs and preferences of stroke patients and caregivers, alone or in combination with a patient-centered online information and support resource can improve stroke survivor and caregiver outcomes 3 months after returning home.

Trial registration

ClinicalTrials.gov: NCT02653170 (Protocol ID: 135457). Registered April 9, 2015.

Prospective correlates of early (30 day) readmissions on a Cardiothoracic Surgery Service

Known to vary widely among hospitals for unclear reasons, early readmissions are associated with higher mortality and are suspected to frequently be due to inadequate discharge preparation/planning. It has been previously documented that the strongest and most consistent predictor of early readmissions in CHF patients is chronic cognitive impairment, and compensatory assistance with adherence on discharge improves early readmission rates. Prospective observational study. The present investigation examined multiple putative perioperative predictors of early readmission in a hospitalized Cardiothoracic Surgery Service. A subtest of the Mini-Cog, Short Term Memory, was the strongestunivariate predictor of early readmissions (p < .001), but the overall Mini-Cog (p = .024), Age (p = .045), Number of Admissions over the Preceding Year (p = .036), an Anxiety Scale (p = .035), Years of Education (p = .055) and a Depression Scale (p = .056) also demonstrated covariation. In a Logistic Regression, only Short Term Memory survived as a predictor variable (p = .007), correctly classifying 76% of patients. Chronic cognitive impairment is a predictor of early readmissions in Cardiothoracic patients. A brief bedside exam interpreted in medical context may permit identification of patients requiring familial assistance for adherence on discharge.

Exploring the predictors of early readmission to psychiatric hospital

BACKGROUND

Aims of this study are to explore the associations of readmission to psychiatric hospital over time, to develop a statistical model for early readmission to psychiatric hospital and to assess the feasibility of predicting early readmission.

METHOD

The sample comprised 7891 general psychiatric discharges in South London, taken from a large anonymised repository of electronic patient records. We initially explored time to readmission using Cox regression - this included investigation of time-dependent effects. Subsequently, we used logistic regression to create a predictive model for 90-day readmission. We investigated the effect on readmission of a set of variables that included demographic variables, diagnosis and legal status during the index admission, previous service use, housing variables and individual item scores on the Health of the Nation Outcome Scales (HoNOS) at admission and at discharge.

RESULTS

Fifteen per cent of those discharged were readmitted within 90 days. Cox regression demonstrated that the estimated baseline hazard of readmission declined steeply after discharge and that the effects of several predictors, especially diagnosis, changed over time - most notably, personality disorder was associated with increased readmission relative to schizophrenia at the time of discharge, but did not significantly differ by 1-year postdischarge. In the logistic regression, increased readmission was associated with personality disorder diagnosis; shorter length of the index admission (excepting zero length admissions); number of discharges in the preceding 2 years; and having a high score at discharge on the HoNOS overactive and aggressive behaviour item, cognitive problems item or hallucinations and delusions items. Detention under Section 3 or a forensic section of the Mental Health Act during the index admission was associated with reduced readmission. The coefficient of discrimination for the logistic regression, which is equivalent to r 2, was 0.04 and the estimated area under the receiver operating curve was 0.65.

CONCLUSIONS

The association found between early readmission and personality disorder diagnosis merits further investigation, as does the possible trade-off between reduction in length of stay and increased readmission. Other novel findings such as the associations found with HoNOS item scores also merit replication. As with previous studies, we found that the rate of readmission declines steeply after hospital discharge, so that the period immediately subsequent to discharge is a period of comparatively high risk. However, prediction of early readmission within this high-risk group remains challenging - it seems most likely that many unmeasured influences operate subsequent to the time of discharge.

Care pathways and healthcare use of stroke survivors six months after admission to an acute-care hospital in France in 2012

INTRODUCTION

Care pathways and healthcare management are not well described for patients hospitalized for stroke.

METHODS

Among the 51 million beneficiaries of the French national health insurance general scheme (77% of the French population), patients hospitalized for a first stroke in 2012 and still alive six months after discharge were included using data from the national health insurance information system (Sniiram). Patient characteristics were described by discharge destination-home or rehabilitation center (for < 3 months)-and were followed during their first three months back home.

RESULTS

A total of 61,055 patients had a first admission to a public or private hospital for stroke (mean age; 72 years, 52% female), 13% died during their stay and 37% were admitted to a stroke management unit. Overall, 40,981 patients were still alive at six months: 33% of them were admitted to a rehabilitation center (mean age: 73 years) and 54% were discharged directly to their home (mean age 67 years). For each group, 45 and 62% had been previously admitted to a stroke unit. Patients discharged to rehabilitation centers had more often comorbidities, 39% were highly physically dependent and 44% were managed in specialized neurology centers. For patients with a cerebral infarction who were directly discharged to their home 76% received at least one antihypertensive drug, 96% an antithrombotic drug and 76% a lipid-lowering drug during the following month. For those with a cerebral hemorrhage, these frequencies were respectively 46, 33 and 28%. For those admitted to a rehabilitation center, more than half had at least one visit with a physiotherapist or a nurse, 15% a speech therapist, 10% a neurologist or a cardiologist and 15% a psychiatrist during the following three months back home (average numbers of visits for those with at least one visit: 23 for physiotherapists and 100 for nurses). Patients who returned directly back home had fewer physiotherapist (30%) or nurse (47%) visits but more medical consultations. The 3-month re-hospitalization rate for patients who were discharged directly to their home was 23% for those who had been admitted to a stroke unit and 25% for the others. In rehabilitation centers, this rate was 10% for patients who stayed < 3 months.

CONCLUSIONS

These results illustrate the value of administrative databases to study stroke management, care pathways and ambulatory care. These data should be used to improve care pathways, organization, discharge planning and treatments.

Associations between Depressive Symptoms and 30-day Hospital Readmission among Older Adults

BACKGROUND

Hospital readmissions are common and costly. Our goal was to determine the association between depressive symptoms and readmission within 30 days following hospital discharge in older adults.

METHODS

We analyzed data from a study of 789 persons aged 65 years or older admitted to a 20-bed acute care for elders (ACE) hospital unit from May 2009 to July 2011. Depressive symptoms were recorded within 24-hours of admission to the hospital unit, using the Center for Epidemiologic Studies -Depression (CES-D) Scale. The primary outcome was readmission to hospital within 30 days of discharge.

RESULTS

The mean age was 77 years; 66% were female, 72% were White, and 59% were unmarried. On average, older patients reported 2.6 comorbid conditions. Sixteen percent were classified with high depressive symptoms (CES-D ≥ 16). The readmission rate within 30 days was 15%. Older patients with high depressive symptoms had more than 1.6 times the odds (OR 1.66; 95% CI: 1.01-2.74) of being readmitted within 30-days, as compared to those with low depressive symptoms (CES-D < 16), after adjustment for age, race/ethnicity, sex, marital status and comorbid conditions.

CONCLUSION

High depressive symptoms increased the risk of hospital readmission within 30 days of discharge after adjusting for relevant covariates. In-hospital screening for depressive symptoms may identify older persons at risk for recurrent hospital admissions.

Restarting the cycle: incidence and predictors of first acute care use after nursing home discharge

OBJECTIVES

To describe the time to first acute care use (e.g., emergency department (ED) use without hospitalization or rehospitalization) for older adults discharged to home after receiving postacute care in skilled nursing facilities (SNFs); to identify predictors of first acute care use.

DESIGN

Retrospective cohort study using administrative claims data.

SETTING

SNFs providing postacute care for patients in North and South Carolina (N = 1,474).

PARTICIPANTS

A cohort of Medicare beneficiaries aged 65 and older (N = 55,980) who were hospitalized and then transferred to a SNF for postacute care and subsequently discharged home (January 1, 2010, to August 31, 2011).

MEASUREMENTS

Medicare institutional claims data (Parts A and B) and Medicare enrollment data were used; facility-level variables were obtained from CMS Nursing Home Compare. Survival from SNF discharge to first acute care use was explored. Cox proportional hazards regression models were used to describe individual-, home care-, and nursing facility-level predictors.

RESULTS

After discharge from SNF to home, 22.1% of older adults had an episode of acute care use within 30 days, including 7.2% with an ED visit without hospitalization and 14.8% with a rehospitalization; 37.5% of older adults had their first acute care use within 90 days. Male sex, dual eligibility status, higher Charlson comorbidity score, certain primary diagnoses at index hospitalization (neoplasms and respiratory disease), and care in SNFs with for-profit ownership or fewer licensed practical nurses hours per patient-day were associated with greater likelihood of acute care use.

CONCLUSION

Medicare beneficiaries have a high use of acute care services after discharge from SNFs, and several factors associated with acute care use are potentially modifiable. Findings suggest the need for interventions to support beneficiaries as they transition from SNFs to home.

Transient ischaemic attack and ischaemic stroke: constructing episodes of care using hospital claims data

Background

Stroke patients may have multiple hospital separations relating to the same stroke. Understanding the pattern of hospitalisations for these patients enables first and recurrent events to be distinguished to better understand care. The aim of this study was to investigate reasons for hospital separations after transient ischaemic attack (TIA) or ischaemic stroke and construct episode of care criteria.

Methods

A retrospective observational study was conducted using the Australian Government Department of Veterans’ Affairs administrative claims database. All patients hospitalised for TIA or ischaemic stroke in 2008–2009 were included. Reasons for hospital separations in the 60 days after TIA or ischaemic stroke were classified by a clinical panel as ‘probably’, ‘possibly’ or ‘unlikely’ to be related to the index separation. Based on panel assessment and time between separations, episode of care criteria for TIA and ischaemic stroke were constructed.

Results

Of the 4520 veterans alive after the index separation, 32% of TIA patients (n=782) and 63% of ischaemic stroke patients (n=1323) had another separation within 60 days. The clinical panel reviewed 460 unique reasons for readmission. Of the 3263 separations, 55% and 85% were classified as related to the index TIA and ischaemic stroke separation, respectively.

Conclusions

Patients hospitalised for ischaemic stroke are likely to have multiple hospital separations for treatment of the same event. Multiple separations for treatment of TIA were less frequent. Consideration of these related separations is recommended when assessing health service utilisation from claims databases.

Older adults' experiences of transitions between care settings at the end of life in England: a qualitative interview study

CONTEXT

Providing care that is shaped around the needs of patients, carers, and families is a challenge in the last months of life, as moves between home and institutions may be frequent. Despite this, there have been few studies of end-of-life transitions in the U.K.

OBJECTIVES

To explore older adults' experiences as they move between places of care at the end of life.

METHODS

In-depth qualitative interviews and thematic analysis of the data were performed. Thirty adults aged between 69 and 93 years took part. All were judged by their physicians to be in the last year of life, diagnosed with heart failure (13), lung cancer (14), and stroke (3). Sixteen participants were from the lowest socioeconomic groups.

RESULTS

Four themes were identified from the data relating to 1) the prioritization of institutional processes, 2) support across settings, 3) being heard, and 4) dignity. As they moved between different settings, much of the care received by older adults was characterized by inflexibility and a failure of professional carers to listen. Liaison between and within services was not always effective, and community support after a hospital admission was perceived to be, on occasions, absent, inappropriate, or excessive.

CONCLUSION

Qualitative study of transitions provides valuable insights into end-of-life care, even in countries where there are few financial barriers to services. This study has highlighted a need for continued attention to basic aspects of care and communication between professionals and with patients.

Factors predicting rehospitalization of elderly patients in a postacute skilled nursing facility rehabilitation program

OBJECTIVE

To examine potential risk factors for rehospitalization of skilled nursing facility (SNF) rehabilitation patients.

DESIGN

Retrospective review of rehabilitation charts.

SETTING

SNF rehabilitation beds (n=114) at a 514-bed urban, academic nursing home that receives patients from tertiary care hospitals.

PARTICIPANTS

Consecutive rehabilitation patients (n=50) who were rehospitalized during days 4 to 30 of rehabilitation, compared with a matched group of rehabilitation patients (n=50) who were discharged without rehospitalization.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Data on potential risk factors were collected: demographics, medical history, conditions associated with preceding hospitalization, and initial rehabilitation examination and laboratory values. The clinical conditions precipitating rehospitalizations were noted.

RESULTS

Sixty-two percent of rehospitalizations were related to complications or recurrence of the same medical condition that was treated during the preceding hospitalization. The rehospitalized group had significantly more comorbidities including anemia (P=.001) and malignant solid tumors (P<.001), index hospitalizations involving a gastrointestinal condition (P=.001), needed more assistance with eating (P=.001) and walking (P=.03), and had lower hemoglobin (P=.002) and albumin levels (P<.001). A logistic regression model found that the strongest predictors for rehospitalization are a history of a malignant solid tumor (odds ratio [OR]=10.10), a recent hospitalization involving gastrointestinal conditions (OR=4.62), and a low serum albumin level (with each unit decrease in albumin, the odds of rehospitalization are 4 times greater [OR=.24, P=.005]).

CONCLUSIONS

Comorbid conditions, reasons for index hospitalization, and laboratory values are associated with an increased risk for rehospitalization. Further studies are needed to identify high-risk elderly patients and target interventions to minimize rehospitalizations.

Hospital readmission in persons with stroke following postacute inpatient rehabilitation

BACKGROUND

Readmission is an important quality indicator following acute care hospitalization. We examined factors associated with hospital readmission in persons with stroke following postacute inpatient rehabilitation.

METHODS

Prospective cohort study including 674 persons with stroke who received rehabilitation at 11 facilities located in eight states and the District of Columbia. Measures included hospital readmission within 3 months of discharge, sociodemographic characteristics, length of stay, primary payment source, comorbidities, stroke type, standardized assessments of motor and cognitive function, depressive symptoms, and social support.

RESULTS

Mean age was 71.5 years (SD = 10.5). Twenty-five percent of patients reported high depressive symptoms. Overall, 18% (n = 122) of the sample was rehospitalized. Univariate analyses showed that people who were rehospitalized were more likely (p < .05) to be non-Hispanic white, married, demonstrate less functional independence at discharge, experience longer lengths of stay in rehabilitation, and report more depressive symptoms and lower social support. In the fully adjusted multivariable hierarchical generalized linear model, motor functional status (OR = 0.98, 95% CI 0.96-0.99), depressive symptoms (OR = 1.80, 95% CI 1.06-3.05), and social support (OR = 2.28, 95% CI 1.29-4.03) remained statistically significant. In addition, a minority-by-depressive symptoms interaction term also reached statistical significance.

CONCLUSION

Functional status, depressive symptoms, and social support were important predictors of hospital readmission. These variables are not included in most administrative data sets. Future research to develop useful risk-adjustment models for rehospitalization following postacute inpatient rehabilitation services should include large diverse samples and explore practical sources for additional meaningful information.

Association between mental health conditions and rehospitalization, mortality, and functional outcomes in patients with stroke following inpatient rehabilitation

BACKGROUND

Limited evidence exists regarding the association of pre-existing mental health conditions in patients with stroke and stroke outcomes such as rehospitalization, mortality, and function. We examined the association between mental health conditions and rehospitalization, mortality, and functional outcomes in patients with stroke following inpatient rehabilitation.

METHODS

Our observational study used the 2001 VA Integrated Stroke Outcomes database of 2162 patients with stroke who underwent rehabilitation at a Veterans Affairs Medical Center. Separate models were fit to our outcome measures that included 6-month rehospitalization or death, 6-month mortality post-discharge, and functional outcomes post inpatient rehabilitation as a function of number and type of mental health conditions. The models controlled for patient socio-demographics, length of stay, functional status, and rehabilitation setting.

RESULTS

Patients had an average age of 68 years. Patients with stroke and two or more mental health conditions were more likely to be readmitted or die compared to patients with no conditions (OR: 1.44, p = 0.04). Depression and anxiety were associated with a greater likelihood of rehospitalization or death (OR: 1.33, p = 0.04; OR:1.47, p = 0.03). Patients with anxiety were more likely to die at six months (OR: 2.49, p = 0.001).

CONCLUSIONS

Patients with stroke with pre-existing mental health conditions may need additional psychotherapy interventions, which may potentially improve stroke outcomes post-hospitalization.

Senescent swallowing: impact, strategies, and interventions

The risk for disordered oropharyngeal swallowing (dysphagia) increases with age. Loss of swallowing function can have devastating health implications, including dehydration, malnutrition, pneumonia, and reduced quality of life. Age-related changes increase risk for dysphagia. First, natural, healthy aging takes its toll on head and neck anatomy and physiologic and neural mechanisms underpinning swallowing function. This progression of change contributes to alterations in the swallowing in healthy older adults and is termed presbyphagia, naturally diminishing functional reserve. Second, disease prevalence increases with age, and dysphagia is a comorbidity of many age-related diseases and/or their treatments. Sensory changes, medication, sarcopenia, and age-related diseases are discussed herein. Recent findings that health complications are associated with dysphagia are presented. Nutrient requirements, fluid intake, and nutrition assessment for older adults are reviewed relative to dysphagia. Dysphagia screening and the pros and cons of tube feeding as a solution are discussed. Optimal intervention strategies for elders with dysphagia ranging from compensatory interventions to more rigorous exercise approaches are presented. Compelling evidence of improved functional swallowing and eating outcomes resulting from active rehabilitation focusing on increasing strength of head and neck musculature is provided. In summary, although oropharyngeal dysphagia may be life threatening, so are some of the traditional alternatives, particularly for frail, elderly patients. Although the state of the evidence calls for more research, this review indicates that the behavioral, dietary, and environmental modifications emerging in this past decade are compassionate, promising, and, in many cases, preferred alternatives to the always present option of tube feeding.

The price of bouncing back: one-year mortality and payments for acute stroke patients with 30-day bounce-backs

OBJECTIVES

To examine 1-year mortality and healthcare payments of stroke patients experiencing zero, one and two or more bounce-backs within 30 days of discharge.

DESIGN

Retrospective analysis of administrative data.

SETTING

Four hundred twenty-two hospitals in the southern and eastern United States.

PARTICIPANTS

Eleven thousand seven hundred twenty-nine Medicare beneficiaries aged 65 and older surviving at least 30 days with acute ischemic stroke in 2000.

MEASUREMENTS

One-year mortality and predicted total healthcare payments were calculated using log-normal parametric survival analysis and quantile regression, respectively. Models included sociodemographics, prior medical history, stroke severity, length of stay, and discharge site.

RESULTS

Crude survival at 1 year for the zero, one and two or more bounce-back groups was 83%, 67%, and 55%, respectively. The one bounce-back group had 49% shorter (time ratio (TR)=0.51, 95% confidence interval (CI)=0.46-0.56) and the two or more bounce-backs group had 68% shorter (TR=0.32, 95% CI=0.27-0.38) adjusted 1-year survival time than the zero bounce-back group. For high- and low-cost patients, adjusted predicted payments were greater with each additional bounce-back experienced.

CONCLUSION

Acute stroke patients experiencing bounce-backs within 30 days have strikingly poorer survival and higher healthcare payments over the subsequent year than their counterparts with no bounce-backs. Bounce-backs may serve as a simple predictor for identifying stroke patients at extremely high risk for poor outcomes.