Discharge Against Medical Advice in Acute Ischemic Stroke: the Risk of 30-Day Unplanned Readmission

Enhancing readmission prediction model in older stroke patients by integrating insight from readiness for hospital discharge: Prospective cohort study

BACKGROUND

The 30-day hospital readmission rate is a key indicator of healthcare quality and system efficiency. This study aimed to develop machine-learning (ML) models to predict unplanned 30-day readmissions in older patients with ischemic stroke (IS) using a prospective cohort design.

METHODS

Patients were divided into two datasets: dataset I (January 2020-December 2021) for model development and dataset II (January 2022-December 2023) for validation. A diffusion model was applied to address data imbalance. Eleven machine-learning methods, including Random Forest (RF), Logistic Regression, CatBoost, eXtreme Gradient Boosting Light Gradient Boosting Machine, K-Nearest Neighbors Support Vector Machine, Multi-Layer Perceptron, and Gaussian Naive Bayes, and 2 ensemble learning models, were constructed to predict readmissions. Bayesian optimization was used to fine-tune the hyperparameters of these models. Model performance was primarily evaluated using the area under the receiver operating characteristic curve (AUC). Shapley Additive Explanations (SHAP) were utilized to identify and interpret the significance of predictive variables.

RESULTS

Dataset I included 489 patients, while dataset II comprised 418 patients, with readmission rates of 15.3 % and 16.0 %, respectively. The RF model achieved the highest predictive performance (AUC = 0.9116, sensitivity = 0.8806, specificity = 0.7806). SHAP analysis identified readiness for hospital discharge as the most significant predictor of readmission.

CONCLUSION

The RF model shows promise for predicting unplanned 30-day readmissions in older patients with IS. Multi-center studies with larger sample sizes are needed to validate these findings.

Patient-Physician Sex Discordance and "Before Medically Advised" Discharge from Hospital: A Population-Based Retrospective Cohort Study

BACKGROUND

Patient-physician sex discordance (when patient sex does not match physician sex) has been associated with reduced clinical rapport and adverse outcomes including post-operative mortality and unplanned hospital readmission. It remains unknown whether patient-physician sex discordance is associated with "before medically advised" hospital discharge (BMA discharge; commonly known as discharge "against medical advice").

OBJECTIVE

To evaluate whether patient-physician sex discordance is associated with BMA discharge.

DESIGN

Retrospective cohort study using 15 years (2002-2017) of linked population-based administrative health data for all non-elective, non-obstetrical acute care hospitalizations from British Columbia, Canada.

PARTICIPANTS

All individuals with eligible hospitalizations during study interval.

MAIN MEASURES

Exposure: patient-physician sex discordance.

OUTCOMES

BMA discharge (primary), 30-day hospital readmission or death (secondary).

RESULTS

We identified 1,926,118 eligible index hospitalizations, 2.6% of which ended in BMA discharge. Among male patients, sex discordance was associated with BMA discharge (crude rate, 4.0% vs 2.9%; adjusted odds ratio [aOR] 1.08; 95%CI 1.03-1.14; p = 0.003). Among female patients, sex discordance was not associated with BMA discharge (crude rate, 2.0% vs 2.3%; aOR 1.02; 95%CI 0.96-1.08; p = 0.557). Compared to patient-physician sex discordance, younger patient age, prior substance use, and prior BMA discharge all had stronger associations with BMA discharge.

CONCLUSIONS

Patient-physician sex discordance was associated with a small increase in BMA discharge among male patients. This finding may reflect communication gaps, differences in the care provided by male and female physicians, discriminatory attitudes among male patients, or residual confounding. Improved communication and better treatment of pain and opioid withdrawal may reduce BMA discharge.

Factors Associated with Discharge against Medical Advice among Acute Stroke Patients: Analysis of the Nationwide Emergency Department Sample

INTRODUCTION

Patients discharged against medical advice have been shown to have worse outcomes across a host of different conditions. However, risk factors related to increased odds of discharge against medical advice remain understudied in patients who suffer from acute cerebral infarction.

METHODS

We retrospectively examined the 2019 National Emergency Department Sample Database for stroke patients. Multivariable logistic regression was used to estimate associations between patient- and hospital-level factors and the outcome of discharge against medical advice.

RESULTS

Of the 603,623 encounters for acute ischemic stroke, 8,858 (1.5%) were discharged against medical advice. Predictors of discharge against medical advice were lower income quartile and having either Medicaid insurance (odds ratio [OR] 1.32, 95% confidence interval [CI]: 1.10-1.58) or being uninsured (OR 1.28, 95% CI: 1.03-1.58). Vascular comorbidities associated with discharge against medical advice included prior tobacco use (OR 1.60, 95% CI: 1.45-1.78) and coronary artery disease (OR 1.19, 95% CI: 1.04-1.35). Treatment with thrombectomy (OR 0.33, 95% CI: 0.13-0.78) or systemic thrombolysis (OR 0.39, 95% CI: 0.23-0.66) was inversely associated with discharge against medical advice. A high modified Charlson comorbidity index (3+ vs. 0, OR 0.49, 95% CI: 0.42-0.56) was also associated with a lower odds of discharge against medical advice. Presenting to a Northeastern hospital had the highest rate of discharge against medical advice, when compared to other regions (p < 0.05).

CONCLUSIONS

Certain patient-level, socioeconomic, and regional factors were associated with discharge against medical advice following acute stroke. These patient- and systems-level factors warrant heightened attention in order to optimize acute care and secondary prevention strategies.

Comparison between healthcare quality in primary stroke centers and comprehensive stroke centers for acute stroke patients: evidence from the Chinese Stroke Center Alliance

Background

To improve stroke care quality, the guidelines for stroke center construction in China recommended establishing primary stroke centers (PSCs) and comprehensive stroke centers (CSCs). We aimed to compare stroke care quality between the two types of centers.

Methods

Data were collected from acute stroke patients admitted to PSCs or CSCs in the China Stroke Center Alliance program. Twenty-one individual guideline-recommended performance measures and two summary measures were compared between the two groups. Multivariable logistic regression models were used to examine the association between stroke center status (CSC vs. PSC) and healthcare quality.

Findings

Data from 750,594 stroke patients from 1474 stroke centers (252 CSCs and 1222 PSCs) were analyzed. For many components of healthcare performance in stroke patients, comparable levels of performance were observed between CSCs and PCSs. Nonetheless, CSCs outperformed PSCs in the areas of administering intravenous recombinant tissue plasminogen activator within 4.5 h (aOR = 1.31 [95% CI: 1.07-1.60]), rehabilitation for acute ischaemic stroke (AIS) (aOR = 1.19 [95% CI: 1.01-1.40]), and the provision of hypoglycemic medication and statin therapy upon discharge for AIS (aOR = 1.26 [95% CI: 1.00-1.59] and aOR = 1.28 [95% CI: 1.04-1.59], respectively). More patients with intracerebral haemorrhage and subarachnoid haemorrhage received neurosurgery in CSCs (14.4% vs. 10.6% and 51.0% vs. 33.9%, respectively). Additionally, CSCs had higher in-hospital mortality than PSCs (aOR = 1.33 [95% CI: 1.01-1.73]).

Interpretation

Overall PSCs provided equivalent care for many quality measures to CSCs in China with the exception of thrombolysis, rehabilitation access, and medication at discharge for AIS, whereby improvements should be directed. Nevertheless, PSCs have demonstrated lower risk-adjusted in-hospital mortality rates.

Funding

The National Key Research and Development Projects of China.

Effect of leaving against medical advice on 30-day infective endocarditis readmissions

BACKGROUND

: The burden of against medical advice (AMA) discharges on the readmission rate of infective endocarditis (IE) patients has been largely ignored.

METHODS

We used the National Readmissions Database, years 2016 to 2019, to identify IE patients and categorized them into those who left AMA (IE AMA) and those who were discharged to home or skilled nursing facility (SNF)/other facility (IE non-AMA). The primary outcome was 30-day all-cause readmissions difference per AMA status.

RESULTS

Of 26,481 patients with IE who met the inclusion criteria, 4,310 (16.3%) left the hospital AMA. IE AMA patients were younger (mean years; 43.7 vs 34.2; p < 0.01) and had a higher prevalence of injection drug use (IDU) (89.4% vs 45.2%; p < 0.01) but fewer comorbidities compared to IE non-AMA. In adjusted analyses, IE AMA had higher hazards for 30-day readmissions compared to IE non-AMA [hazards ratio (HR): 3.1 (2.9 - 3.5); p < 0.01].

CONCLUSION

IE AMA are at increased risk of 30-day readmissions and higher resource utilization at the time of readmission compared to IE non-AMA. Considering the high prevalence of IDU in IE AMA, the role of mental health to curb the burden of IE readmissions is an area of further research.

Dysphagia Management and Outcomes in Elderly Stroke Patients with Malnutrition Risk: Results from Chinese Stroke Center Alliance

Purpose

To investigate the effectiveness of dysphagia screening and subsequent swallowing rehabilitation in elderly stroke patients with malnutrition risk.

Patients and Methods

Based on the Chinese Stroke Center Alliance (CSCA) from August 1, 2015 to July 21, 2019, we compared the in-hospital adverse outcomes among stroke patients (including ischemic stroke, intracranial hemorrhage, and subarachnoid hemorrhage) over 70 years old with and without dysphagia screening. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were the composite endpoint of discharge against medical advice (DAMA) or in-hospital death.

Results

Among 365,530 stroke patients ≥ 70 years old with malnutrition risk in the CSCA, documented dysphagia screening was performed for 288,764 (79.0%) participants. Of these, 41,482 (14.37%) patients had dysphagia, and 33,548 (80.87%) patients received swallowing rehabilitation. A total of 1,694 (0.46%) patients experienced in-hospital death. After adjustment for traditional risk factors, dysphagia screening was associated with a low risk of all-cause mortality in stroke patients [adjusted odds ratio (aOR): 0.75, 95% confidence interval (CI):0.65–0.87]. Compared to patients with dysphagia who did not receive swallowing rehabilitation, patients reveiving swallowing rehabilitation had a reduced risk of in-hospital death (aOR:0.39, 95% CI: 0.33–0.46). Additionally, dysphagia screening had a lower risk for the composite endpoint of DAMA or in-hospital death (aOR:0.83,95% CI: 0.80–0.87), as did subsequent swallowing rehabilitation (aOR:0.43,95% CI: 0.40–0.47). Similar results were observed in the sensitivity analysis through inverse probability of treatment weighting, propensity score matching, and excluding patients without National Institutes of Health Stroke Scale scores. A similar association was observed between dysphagia management and adverse clinical outcomes in ischemic stroke and intracranial hemorrhage patients.

Conclusion

Dysphagia screening and swallowing rehabilitation were associated with a reduced risk of in-hospital death and composite outcome of DAMA or in-hospital death for stroke patients with malnutrition risk. Future research should concentrate on improving the quality of medical care for dysphagia management to improve patients’ outcomes.