Stroke is the second leading cause of hospital admissions among older adults in the United States, according to American Heart Association/American Stroke Association statistics. Ischemic stroke, which occurs as a result of an obstruction within a blood vessel supplying blood to the brain, accounts for 87 percent of all strokes.
Only a few contemporary studies have examined the full burden of hospital readmission and death after ischemic stroke, said Gregg C. Fonarow, M.D., study lead author and professor of cardiovascular medicine at the University of California-Los Angeles.
Fonarow and colleagues studied ischemic stroke mortality and re-hospitalization rates at 30 days and one year for Medicare beneficiaries and examined how those varied by hospital.
"We looked at readmission in addition to mortality because it is expensive to the healthcare system and may represent a potentially preventable, adverse event for patients," Fonarow said.
They analyzed outcome data from 91,134 Medicare beneficiaries treated at 625 hospitals participating in the American Heart Association/American Stroke Association's Get With The Guidelines®-Stroke initiative between April 2003 and December 2006.
"The Get With The Guidelines-Stroke database linked to Medicare data provided a very valuable opportunity to analyze outcomes for ischemic stroke patients from all regions of the country and from a broad group of acute care hospitals," said Fonarow, immediate past chair of the Get With The Guidelines Steering Committee. "Clinical data, coupled with long-term outcome data, was not previously available for Medicare beneficiaries at the national level."
The researchers found:
In-hospital death rates for ischemic stroke patients are nearly 15 percent within 30 days of admission and more than 30 percent within one year of admission.
The post discharge death or readmission rates are 61.9 percent within one year after discharge.
When ranked according to outcome - by death or re-hospitalization rates - the 30-day death rate after admission for hospitals that were in the top performing was 9.8 percent, compared with 17.8 percent for the worst performing.
No improvements in death or re-hospitalization rates for Medicare beneficiaries with acute stroke occurred from 2003 to 2006.
"These findings underscore the need for quality improvement interventions and systems of care that will improve early, intermediate, and long-term outcomes of patients with acute ischemic stroke," Fonarow said. "Standardizing evidence-based practices that focus on reducing the risks of preventable deaths or readmissions for ischemic stroke patients may be critical."
Findings from Get With The Guidelines-Stroke help define the frequency, timing and variation for hospital readmission. This should help clinicians, investigators and policymakers identify opportunities to apply targeted quality improvement and preventive strategies after ischemic stroke, Fonarow said. Participation in Get With The Guidelines-Stroke can assist hospitals with their stroke performance improvement efforts.
"Most of the variation in outcomes was unexplained by patient and hospital characteristics," Fonarow said. "This suggests that other factors, including treatment provided, systems of care, care transitions and outpatient follow-up, may explain much of the variation in outcomes."
A limitation of the study is that it includes only patients in fee-for-service Medicare and doesn't include patients enrolled in managed care, the uninsured and patients younger than 65.
Co-authors are: Eric E. Smith, M.D., M.P.H.; Mathew J. Reeves, Ph.D.; Wenqin Pan,
Ph.D.; DaiWai Olson, Ph.D.; Adrian F. Hernandez, M.D., M.H.S.; Eric D. Peterson, M.D., M.P.H.; and Lee H. Schwamm, M.D. Author disclosures are on the manuscript.
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