Length of stay, prior hospitalization foreshadow 30-day stroke readmissions

Clinicians with stroke patients, take note: A history of repeated hospitalizations before, a long stay in the hospital after and a higher National Institutes of Health Stroke Score (NIHSS) may increase the risk of a patient returning within 30 days.

For stroke victims, the initial 30 days post incident is crucial to long-term health and survival. Rehospitalization costs an estimated $17.4 billion, annually. Several studies have explored interventions to reduce readmissions in the longer term; however, the crucial 30-day window remains largely unexplored.

Researchers with Wake Forest School of Medicine in Winston Salem, N.C. and Mercy Hospital in Oklahoma City, Okla., studied the medical histories of a cluster of patients to attempt to determine why some patients require repeated return visits following an initial admission for ischemic or hemorrhagic stroke.

The team led by Roy E. Strowd, MD, noticed that readmitted patients were more likely to have had comorbid conditions, such as cancer, coronary artery disease and congestive heart failure while still having an absence of hyperlipidemia, and were more likely to have been hospitalized two or more times in the year prior to their stroke. An increased risk of 7.2 percent was noted for each point increase in NIHSS.

Sixty-six percent of readmissions were unrelated to the initial stroke; while 34 percent of readmissions could be directly attributed to the initial admission, although the most common readmission diagnosis was noted as transient ischemic attack or ischemic stroke. Readmission risk was 2.2-fold higher with each prior hospitalization.

In discussing earlier investigations, Strowd et al noted that recent findings showed that NIHSS scores of 10 or more and discharge to nursing home or subacute rehabilitation had a direct correlation on readmission, as confirmed by this study. “It also may be that factors associated with a more severe incident admission may place these patients at an even higher risk of subsequent readmission,” they stated.

Tied with this, a concept called “post-hospital syndrome” linked factors such as sleep deprivation, psychological stress, deconditioning and other modifiable factors of acute hospitalization. This seemed to follow the high median length of stay in patients who ultimately returned in the 30-day window.

While they offer no interventional suggestions for reducing the risk of rehospitalization in the 30-day window, Strowd et al were confident that the two greatest indicators of risk of readmission came from NIHSS and two or more hospitalizations in the year before the inciting stroke.

This study was published online June 11 in the American Journal of Medical Quality.