Stroke Feature: High stroke death, readmissions require multi-pronged solution

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Gregg C. Fonarow, MD, UCLA

Two-thirds of discharged ischemic stroke patients died or were rehospitalized within one year, suggesting a need for multidisciplinary strategies to improve outcomes, according to a study published online Dec. 16 in Stroke.

Gregg C. Fonarow, MD,  of the University of California, Los Angeles, and his colleagues used Get with the Guidelines-Stroke registry data to assess the trends and rates of ischemic stroke deaths and rehospitalization rates of 91,134 Medicare fee-for-service beneficiaries treated between April 2003 and December 2006 at 625 U.S. sites.

The mean age of patients was 79.3, 58 percent were female and 82 percent were white.

The in-hospital, 30-day and one-year unadjusted mortality rates from admission were 6.1, 14.1 and 31.1 percent, respectively. The rate of median hospital-level 30-day unadjusted death or readmission after discharge was 21.4 percent and the overall rate of death or readmissions within one year of a hospital discharge was 61.9 percent.

Fonarow and colleagues found that there was no improvement in either death or hospital readmission rates from 2003 to 2006 and that hospital-level performance in risk-adjusted outcomes did not significantly differ by hospital size or whether it was classified as a primary stroke center; however, hospitals in the Northeast and West showed more favorable outcomes.

While the researchers found that almost one-third of all patients died within the first year after discharge, they also found a substantial variation between hospitals, even after they risk-adjusted for differences in patient characteristics.

“Between the better or worse performing hospitals, there was almost a two-fold difference in the event rates,” Fonarow told Cardiovascular Business News in an interview.

“There were very striking and concerning rates of clinical events after an ischemic stroke even among those patients surviving the discharge,” said Fonarow. “The study highlights that these patients face a substantial burden and that there is a great opportunity to potentially improve the care for these patients both in the hospital and as they are transitioning to an outpatient."

As for the reasons for the rehospitalizations, Fonarow said that while some were due to incidence of recurrent stroke, others were due to cardiovascular events or comorbid conditions such as pneumonia, pulmonary infection, urinary tract infection or bleeding.

He offered that the study results outline that in the future, a multidisciplinary approach to care that goes beyond just preventing recurrent stroke will be necessary to help cut down the high rates of readmissions.

And while the researchers found a variation in outcomes between hospitals, Fonarow said that the outcomes didn’t differ significantly among large hospitals or stroke centers. However, he did say that academic hospitals fared slightly better than non-academic hospitals and hospitals located in the Northeast and West saw more favorable stroke outcomes. When asked why, he said that it may be due to differences in patterns of care and follow-up and other factors such as differences in referral rates for stroke rehabilitation may have also played a role

He noted that factors such as patterns of care, the frequency of follow-up and who performed follow-up were not studied, but could explain at least some of the variations in outcomes.

Focusing on quality improvement measures, stroke systems of care and improving follow-up could help close this gap of care and help to improve outcomes.

While further studies are needed, one strategy of improvement could be educating patients on the importance of being transported to the hospital via EMS rather than self-transport. This, he said, could increase the timeliness of care and improve outcomes.

“We think that the study results underscore a need for quality improvement interventions and systems of care to improve the early, intermediate and long-term outcomes of patients with ischemic stroke," he concluded. "This study highlights the extent of the problem and shows that there is a desperate need to improve the outcomes for these patients."