A UCLA-led study has found that after leaving the hospital, nearly two-thirds of Medicare beneficiaries hospitalized for acute ischemic stroke either died or were rehospitalized within a year.
The findings point to an opportunity for more quality-of-care initiatives to improve stroke care, especially in transitioning to home, stroke rehabilitation and outpatient care.
The study, which appears online Dec. 16 in Stroke, a journal of the American Heart Association, also found that hospital mortality and readmission rates varied widely nationwide, indicating there may be substantial opportunities to improve stroke care and reduce variations in clinical outcomes, the researchers said.
"The findings show that ischemic stroke patients may be at substantial risk once leaving the hospital," said Dr. Gregg C. Fonarow, the study's first author and associate chief of the division of cardiology at the David Geffen School of Medicine at UCLA. "This is one of the first studies to take a look at mortality and rehospitalization rates for Medicare stroke patients across the country, and the findings are quite alarming."
An academic team analyzed data on outcomes for more than 90,000 Medicare patients admitted between 2003 and 2006 to 625 hospitals participating in the Get With the Guidelines-Stroke Program, a national registry for stroke hospitalizations.
All the patients had fee-for-service Medicare insurance. The average patient was 79 years old, 58 percent were female and 82 percent were white. Patients were hospitalized for the most common type of stroke -- an acute ischemic event, which occurs due to an obstruction within a blood vessel that supplies blood to the brain.
The team found that the total unadjusted in-patient hospital mortality rate was 6.1 percent, the mortality rate 30 days after hospital admission was 14.1 percent and the mortality rate one-year from admission was 31.1 percent.
Within the first year after hospital discharge among stroke patients who survived and were released from the hospital, the death rate was 26.7 percent, and the readmission rate was 56.2 percent. The overall rate of death or readmission was 61.9 percent.
"We need to better understand the patterns and causes of mortality and readmission after acute stroke to help avoid the hospitalizations and deaths that are preventable," said Fonarow, UCLA's Eliot Corday Professor of Cardiovascular Medicine and Science and director of the Ahmanson-UCLA Cardiomyopathy Center.
In addition, the study found wide variations between hospitals for both 30-day mortality rates and readmission rates after hospital discharge. The average 30-day unadjusted rate of death or readmission after hospital discharge was 21.4 percent, with the best hospitals performing at 14.4 percent and worst at 28.6 percent.
"There is a two-fold difference between the best and worst performing hospitals," Fonarow said. "We may be able to standardize treatment programs to help close this gap."
Even when risk-adjusting for hospital differences such as bed size; the region of the country; the type of facility, such as an academic or community hospital; and whether or not the hospital had a Joint Commission primary stroke center designation, there was very little difference in outcomes. Academic hospitals and those in the Northeast and West had just slightly more favorable outcomes.
Researchers also found that there were no improvements in mortality or rehospitalization rates in this population for the entire time period studied, 2003 to 2006.
Fonarow noted that the rates may even be conservative, given that the participating hospitals were already part of an in-hospital quality-improvement program for stroke.
The study also highlighted clinical variables that may provide target areas for improvement. Many of the hospital readmissions were for non-cardiovascular conditions like pneumonia, so additional prevention protocols in these areas may be helpful.
Numerous patients arrived at the hospital by private transport, which reinforces the importance for further patient and public education about calling 911 immediately if stroke is suspected, since time is critical for effective treatment.
The researchers noted that these results were only for fee-for-service Medicare beneficiaries. The clinical outcomes for younger stroke patients and those with other types of insurance may be different.
Further studies will take a closer look at in-hospital and out-patient factors that may influence stroke care.
The study was funded by Get With the Guidelines (GWTG), an American Heart Association/American Stroke Association program. The GWTG program is also supported in part by unrestricted educational grants to the American Heart Association by Pfizer Inc., the Merck-Schering Plough Partnership and the Pharmaceutical Roundtable. Additional disclosures are listed in the full study.
Other authors include Dr. Eric E. Smith, department of clinical neurosciences, University of Calgary; Mathew J. Reeves, department of epidemiology, Michigan State University; Wenqin Pan, DaiWai Olson, Dr. Adrian F. Hernandez and Dr. Eric D. Peterson, Duke Clinical Research Center; and Dr. Lee H. Schwamm, division of neurology, Massachusetts General Hospital.
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