ARTICLE IN BRIEF
An analysis of data on stroke patients at a medical center in Taiwan found that 31 percent returned to the hospital during the first year after discharge; more than 25 percent of them were readmitted for an infection.
More than three of every ten stroke patients land back in the hospital within a year, often returning rather quickly with an infection that might have been preventable, according to a new study that tracked approximately 2,600 patients at a hospital in Taiwan.
“To provide the most appropriate intervention, and to use limited health care resources efficiently, it is essential to fully understand what causes readmission,” Huey-Juan Lin, MD, the study's lead author told Neurology Today. “It is notable that recurrent stroke may not be the main reason for readmission. Infections, especially in the earlier phase (after hospitalization), resulted in many readmissions.”
The study, published online before the Feb.1 print edition of Neurology, found that 31 percent of stroke patients returned to the hospital during the first year after discharge; more than 25 percent of them were readmitted for an infection. That finding might surprise patients and families who often focus their worries mostly on the possibility of another stroke.
Dr. Lin, an assistant professor of neurology at Taipei Medical University in Taiwan, told Neurology Today that more research is needed to predict which subgroups of stroke patients are most at risk for problems after discharge and what more can be done during the initial stay and in discharge planning to lower the likelihood of rehospitalization.
“We did find more infection in the early phase after stroke,” Dr. Lin said. “Some infections, such as aspiration pneumonia, could be prevented with appropriate management during hospitalization.”
The issue of readmission after stroke is getting more attention in the US as Medicare and other health insurers look for ways to slow down spending while also boosting quality of care. A 2007 study in Stroke of more than 2,600 Medicare patients in Connecticut found that more than half of the patients who survived hospitalization for acute ischemic stroke either died or were readmitted in the year after discharge. Another report published in the January edition of Stroke of 90,000 Medicare beneficiaries put the number even higher — two-thirds of patients treated for ischemic stroke died or were readmitted within a year. Previous research out of Taiwan pointed to a readmission rate around 50 percent.
MORE FOCUS NEEDED
“I'm glad this study draws more attention to this problem,” S. Claiborne Johnston, MD, PhD, professor of neurology and epidemiology and director of the Stroke Service at the University of California-San Francisco, told Neurology Today. He said there is a surprisingly small amount of research to drawn upon when looking at the issue of preventing readmission after stroke.
“This study is revealing a problem of high readmission rates that has probably gone unrecognized but is a reality across the world,” said Dr. Johnston, who was not involved with the study.
In their report, the Tawainese researchers noted that “stroke survivors carry a high risk of new illness, aggravation of known diseases, and functional decline, which subject them to rehospitalization. Readmission after stroke has significant impact on the physical and psychological well-being of the patients, and accounts for a considerable portion of total healthcare resources in many countries. However, we have limited information on the magnitude of the burden, and on whether there exists potentially preventable rehospitalization.”
The researchers began with 3,191 adult patients who were hospitalized for stroke between August 2006 and December 2008 at Chi-Mei Medical Center, a 1,200-bed community hospital in southern Taiwan that participates in the nationwide Taiwan Stroke Registry.
Of the initial study group, 233 patients, or 7.3 percent died during hospitalization. The researchers tracked the status of the remaining 2,657 patients at 1, 3, 6, and 12 months after discharge, using information gathered from outpatient clinic visits, telephone interviews, and chart reviews of records for readmission to the study hospital. The average age of the patients was 66 and 60 percent of them were men.
Rehospitalization occurred in 31 percent of patients within a year. Six percent of the patients died during that time.
“The risk was substantially high during the first 30 days,” the investigators wrote. The probability of readmission at 30 days was 10 percent, 17 percent by 90 days, 24 percent at 180 days. and 36 percent at 360 days, the researchers reported. “Increasing age, previous stroke/TIA, atrial fibrillation, coronary artery disease, having complications at the index hospitalization, longer length of stay, and dependency at discharge were the independent predictors for readmission.”
The most common reasons for rehospitalization were infection (28 percent), recurrent stroke (18 percent) and other cardiovascular events (10 percent). The researchers found that infections were a particular problem during the early period after discharge, but as time went on the incidence of recurring stroke and other cardiovascular events increased.
“The two most frequent infections, pneumonia and urinary tract infections, might relate to neurological deficits such as dysphagia, sphincter dysfunction, and limited motor function, as well as the quality of care and nutritional status after discharge.” They noted that some such infections could be prevented, but that it is premature to predict how much improvement can be achieved.
“The high rate of rehospitalization due to recurrent stroke and other cardiovascular events might reflect the natural history of disease, or on the other hand highlight the importance of figuring out the unrecognized gap in post-stoke care,” they continued. “Other manageable or preventable causes of readmission such as seizures and gastrointestinal ulcer disease, though not at an alarming proportion, would alert clinicians in caring (for) stroke survivors with potential risks.”
The study made one particularly interesting finding. Patients who were sent home rather to a follow-up care facility were no more at risk for readmission.
“Most of our patients (90 percent) were discharged to home. We had expected less skillful care and more readmission for patients discharged home if they had significant disabilities,” the researchers wrote. But that didn't turn out to be the case, even after adjusting for level of dependency at discharge.
In the Taiwanese culture, families assume primary responsibility for caring for their disabled members, the investigators noted, but there are an inadequate number of quality nursing and rehabilitation facilities and as the population ages, “the government is initiating strategies to meet the increasing demands.”
APPLYING THE FINDINGS
Douglas Lanska, MD, a staff neurologist at the Thomah Veterans Affairs Medical Center in Wisconsin, said he thought it would be difficult for US clinicians to draw any broad conclusions from the study because it involved a single hospital in a health care system that is different from this country. He noted in particular the tendency in Taiwan is to not rely on nursing homes or rehabilitation facilities for post-discharge care. “How we would generalize these results to somewhere else is not so clear,” he told Neurology Today.
Dr. Johnston said that in his experience, about one quarter to one third of stroke patients are sent to a nursing home or rehabilitation facility — much high than the 10 percent in the study done in Taiwan. Nonetheless, Dr. Johnston said a better understanding of the experience of stroke patients both here and in other countries should help lead to improvements in care and in turn fewer readmissions.
“Any hospitalization is destructive to patients and no admission can be taken lightly,” Dr. Johnston said.
Dr. Lin's team is now looking into ways to better prevent infection-related readmissions, such as urinary tract infections and aspiration pneumonia. The team also hopes to develop a prediction model that could be used by clinicians to identify patients at high risk for readmission.
Lin HJ, Chang WL, Tseng MC. Readmission after stroke in a hospital-based registry: Risk, etiologies, and risk factors. Neurology 2011; E-pub 2011 Jan 5.
Fonarow GC, Smith EE, Schwamm LH, et al, for the Get With The Guidelines Steering Committee and Hospitals. Hospital-level variation in mortality and rehospitalization for Medicare beneficiaries with acute ischemic stroke. Stroke 2011;42(1):159-166. E-pub 2010 Dec. 16.
Bravata DM, Ho SY, Concato J, et al. Readmission and death after hospitalization for acute ischemic stroke: 5-year follow-up in the Medicare population. Stroke 2007;38(6):1899-904. E-pub 2007 May 17.