The Impact Factors on the Cost and Length of Stay among Acute Ischemic Stroke

The relative cerebral blood volume (rCBV) <42% is independently associated with prolonged hospitalization in anterior circulation large vessel occlusion

BackgroundThe pretreatment rCBV <42% lesion volume on CT Perfusion (CTP) has recently been shown to predict 90-day functional outcomes in stroke patients. However, its association with length of stay (LOS) has not yet been explored. This study aims to assess the relationship between rCBV <42% and prolonged LOS, defined as 7 days or longer.MethodsIn this retrospective evaluation of our prospectively collected database, we analyzed patients with confirmed anterior circulation large vessel occlusion on CT angiography who also received CT perfusion between 9/1/2017 and 10/01/2023. We used Student's t-test, Mann-Whitney U test, and Chi-Square test to assess differences. Logistic regression and ROC analyses were employed to evaluate the relationship between rCBV <42% and length of stay (LOS). A p-value of ≤0.05 was considered statistically significant.ResultsA total of 268 patients met our inclusion criteria. Of these, 85 (31.7%) received intravenous thrombolysis (IVT), and 221 (82.5%) underwent mechanical thrombectomy (MT). After adjusting for several variables, logistic regression analysis revealed that an rCBV <42% lesion volume was independently associated with prolonged length of stay (LOS) (aOR = 0.98, p < .001). ROC analysis indicated an area under the curve (AUC) of 0.66 (p < .001) for predicting prolonged LOS.ConclusionrCBV <42% lesion volume is independently associated with prolonged LOS. This parameter may serve as a useful adjunct tool in prognostication of AIS-LVO patients.

Prolonged Hospital Length of Stay Does Not Improve Functional Outcome in Acute Ischemic Stroke

INTRODUCTION

Ischemic stroke is the second leading cause of mortality and a major contributor to disability worldwide. Hospital length of stay (LOS) is a marker of medical efficiency for stroke care. There is limited information on this issue in China. This study aimed to identify predictors of prolonged LOS and to assess whether a prolonged LOS benefits functional outcomes in patients with acute ischemic stroke (AIS) in China.

METHODS

This secondary analysis of the Chinese Acute Ischemic Stroke Treatment Outcome Registry, a multicenter, prospective, hospital-based registry study, included patients diagnosed as AIS and admitted to a hospital within 3 days after AIS onset from May 2015 to October 2017. Participants were dichotomized as the normal LOS group (LOS ≤ 14 days) and the prolonged LOS group (LOS > 14 days). The outcomes were the proportions of poor outcome at 3 months and 12 months after stroke onset. Poor outcome was defined as a mRS score of 3-6.

RESULTS

This study included 8171 patients (median age 64.0 years; 5367 male, 2804 female); 2968 (36.3%) patients had a prolonged LOS. Multivariable analysis identified independent predictors of prolonged LOS, including medical insurance, history of diabetes mellitus, stroke severity, use of anticoagulant agents, in-hospital infection complications, hemorrhagic events, and hospital region. A prolonged LOS was associated with a higher risk of poor outcome at 3 and 12 months after stroke, with this finding upheld in a propensity score-matched cohort as well as subgroup analyses stratified by stroke severity and age.

CONCLUSION

In this study, approximately one-third of patients with AIS experienced a prolonged LOS over 14 days. Independent predictors of prolonged LOS included medical insurance, history of diabetes mellitus, stroke severity, use of anticoagulant agents, in-hospital infection complications, hemorrhagic events, and hospital region. Extending the LOS beyond 14 days did not enhance the prognosis for patients with AIS. As an observational study, our research provided the foundation for further interventional studies. Graphical abstract available for this article.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02470624.

Effects of stroke nurse-led acute stroke management on treatment time benchmarks, intravenous thrombolysis rates, and patient outcomes: A systematic review and meta-analysis

INTRODUCTION

Multidisciplinary stroke teams, including a stroke nurse, prove effective in delivering optimal acute ischemic stroke (AIS) management. This systematic review and meta-analysis critically synthesize existing studies to assess the impact of stroke nurse involvement on treatment time benchmarks and patient outcomes.

METHOD

Data from various databases constituted the primary sources of literature, and the risk of bias and article quality were evaluated using relevant tools. Primary endpoints were door-to-needle (DTN) time, mortality, and good functional outcomes (mRS 0 - 2) at three months. Secondary endpoints included varied treatment time metrics, IVT rates, and length of hospital stay (LOS).

RESULTS

We screened 235 studies published up to September 2023 and ultimately included eight in our analysis. The stroke nurse intervention was significantly associated with a decrease in DTN time (Standard Mean Difference [SMD] = -19.71 min; 95 % CI = [-31.45, -7.97]), reduced three-month mortality rates (Odds Ratio [OR] = 0.56; 95 % CI = [0.37, 0.85]) and improved functional outcomes (OR = 1.33; 95 % CI = [1.03, 1.71]). The IVT rate significantly increased (OR = 1.52; 95 % CI = [1.01, 2.28]) with stroke nurse intervention. However, LOS was comparable (SMD = -0.45 days; 95 % CI = [-1.11, 0.21]) between scenarios with and without stroke nurse involvement.

CONCLUSIONS

Our study emphasizes the advantages of including stroke nurses in acute stroke teams, leading to reduced treatment times, increased IVT rates, and enhanced patient outcomes. It highlights the importance of inter-professional stroke teams and evidence-based nursing care to ensure equitable access to high-quality stroke care across diverse healthcare settings.

Larger Perfusion Mismatch Volume Is Associated With Longer Hospital Length of Stay in Medium Vessel Occlusion Stroke

BACKGROUND AND PURPOSE

Prolonged length of stay (LOS) following a stroke is associated with unfavorable clinical outcomes. Factors predicting LOS in medium vessel occlusion (MeVO), impacting up to 40% of acute ischemic stroke (AIS) cases, remain underexplored. This study aims to investigate the predictors of LOS in AIS-MeVO.

METHODS

We conducted a retrospective analysis of prospectively maintained stroke databases, comprising AIS cases with MeVO in the anterior circulation, assessed by adequate CT perfusion (CTP). Baseline and clinical data were obtained from electronic health records. Alberta Stroke Program Early CT Scores (ASPECTS) were calculated from non-contrast head CT. The perfusion mismatch volume (time to maximum > 6 s minus relative cerebral blood flow <30%) volume was reported from CTP. Multiple regression was employed to examine the relationship between baseline parameters and hospital LOS.

RESULTS

A total of 133 patients (median age 71 [interquartile range 63-80] years, 59.4% females) were included in the study cohort. The perfusion mismatch volume significantly positively correlated with LOS (r = 0.264, p = 0.004). After adjusting for age, sex, hypertension, diabetes, prior stroke or transient ischemic attack, admission NIHSS, ASPECTS, Tan score, intravenous thrombolysis, mechanical thrombectomy (MT), and hemorrhagic transformation, a larger mismatch volume remained independently associated with longer hospital stays (β = 0.209, 95% confidence interval [CI] 0.006-0.412, p = 0.045). Additional significant determinants of longer hospital stay included admission NIHSS (β = 0.250, 95% CI: 0.060-0.440, p = 0.010) and MT (β = 0.208, 95% CI: 0.006-0.410, p = 0.044). Among patients who underwent MT (n = 83), multiple regression analysis incorporating both perfusion mismatch volume and admission NIHSS revealed that perfusion mismatch volume remained independently associated with LOS (β = 0.248, 95% CI: 0.019-0.471, p = 0.033), while admission NIHSS did not retain significance (β = 0.208, 95% CI: 0.019-0.433, p = 0.071).

CONCLUSIONS

In our cohort of AIS patients with MeVO in the anterior circulation, and particularly in those who underwent MT, the perfusion mismatch volume serves as an independent predictor of LOS. These findings offer critical valuable insights in clinical assessments and decision-making protocols of MT in AIS-MeVO.

Diabetes mellitus in stroke unit: prevalence and outcomes-the Verona acute coronary syndrome and stroke in diabetes outcome (VASD-OUTCOME) study

BACKGROUND

Cerebrovascular accidents (CVA) represent a major complication in diabetes (DM). Real-life evidence as to whether modern management of CVA and DM have softened this relationship is limited. Therefore, we estimated prevalence and impact of DM on in-hospital survival and complications in a contemporary cohort of subjects with CVA.

METHODS

We retrospectively evaluated the records of 937 patients admitted for CVA at the Stroke Unit of Verona University Hospital during a 3-year period. Pre-existing or de novo DM was ascertained by prior diagnosis, glucose-lowering therapy at admission/discharge or admittance plasma glucose ≥ 200 mg/dL. Multiple regressions were applied to test DM as predictor of in-hospital mortality, complications (composite of infections, cardio- and cerebrovascular complications, major bleeding and pulmonary complications), duration and costs of hospitalization.

RESULTS

Diabetes prevalence was 21%, of which 22% de novo diagnoses. Compared to non-DM, diabetic individuals were older and carried an increased burden of cardiovascular risk factors. Compared to known DM, de novo DM individuals were younger, had higher admittance plasma glucose and poorer cardiovascular comorbidities. Overall, DM versus non-DM individuals did not show significantly increased risk of death (14.0 vs. 9.3%; crude-OR 1.59 95% CI 0.99-2.56). Controlling for confounders did not improve significance. DM resulted independent predictor for in-hospital complications (36.2% vs. 26.9%; adj-OR 1.49, 1.04-2.13), but not for duration and costs of hospitalization.

CONCLUSION

DM frequently occurs in patients admitted for stroke and carries an excess burden of adverse in-hospital complications, urgently calling for strategies to anticipate DM diagnosis and tailored treatment in high-risk individuals.

CT perfusion derived relative cerebral blood volume < 42 % is negatively associated with poor functional outcomes at discharge in anterior circulation large vessel occlusion stroke

BACKGROUND AND AIM

Recent studies have shown that the CT Perfusion (CTP) parameter of rCBV < 42 % lesion volume can predict 90-day functional outcomes in stroke patients. However, its correlation with discharge outcomes, including functional dependence, has not been investigated. Our study aims to evaluate the relationship between rCBV < 42 % and poor functional outcomes at discharge, defined as a modified Rankin score (mRS) of 3 or higher.

MATERIALS AND METHODS

This retrospective study analyzed patients with confirmed occlusion on CT angiography, who also received CT perfusion between 9/1/2017 and 10/01/2023. Statistical tests (Student's T, Mann-Whitney U, and Chi-Square) were used to assess differences. Univariable and multivariable logistic regression analyses were performed to evaluate the associations of rCBV < 42 % with discharge mRS. A p-value ≤ 0.05 was considered significant.

RESULTS

A total of 268 patients [median age: 68 years (IQR: 59-77), 56.3 % female] met the inclusion criteria. Among them, 85 patients (31.7 %) received intravenous thrombolysis (IVT), and 221 patients (82.5 %) underwent mechanical thrombectomy (MT). After adjusting for various variables, logistic regression analysis indicated that rCBV < 42 % lesion volume was associated with poor functional outcomes at discharge (aOR = 0.97, p < 0.05). T.

CONCLUSION

The rCBV < 42 % could be a valuable tool in prognosticating AIS-LVO patients.

Machine learning for early dynamic prediction of functional outcome after stroke

BACKGROUND

Prediction of outcome after stroke is critical for treatment planning and resource allocation but is complicated by fluctuations during the first days after onset. We propose a machine learning model that can provide hourly predictions based on the integration of continuous variables acquired within 72 h of hospital admission.

METHODS

We analyzed 2492 admissions for ischemic stroke in the Geneva University Hospital from 01.01.2018 to 31.12.2021, amounting to 2'131'752 unique data points. We developed a transformer model that continuously included clinical, physiological, imaging, and biological data recorded within 72 h of admission. This model was trained to generate hourly predictions of mortality and morbidity. Shapley additive explanations were used to identify the most relevant predictors to explain outcomes for each patient. The MIMIC-III database was used for external validation.

RESULTS

Our transformer model predicts mortality, with an area under the receiver operating characteristic curve of 0.830 (95% CI 0.763-0.885) on admission, reaching 0.893 (95% CI 0.839-0.933) 72 h later for a 3-month outcome. Validated in an independent cohort, it outperforms all static models. Based on their mean explanatory weights, the top predictors included continuous clinical evaluation, baseline patient characteristics, timing from admission to acute treatment, and markers of inflammation and organ dysfunction.

CONCLUSIONS

The performance of our transformer model demonstrates the potential of machine learning models integrating clinical, physiological, imaging, and biological variables over time after stroke. The clinical applicability of our model is further strengthened by access to hourly updated predictions along with accompanying explanations.

Dysphagia-related acute stroke complications: A retrospective observational cohort study

OBJECTIVES

Post-stroke dysphagia is associated with aspiration pneumonia, but strategies intended to mitigate this complication, such as oral intake modifications, may unintentionally lead to dehydration-related complications such as urinary tract infections (UTIs) and constipation. This study aimed to determine the rates of aspiration pneumonia, dehydration, UTI and constipation in a large cohort of acute stroke patients and the independent predictors of each complication.

MATERIALS AND METHODS

Data were extracted retrospectively for 31,953 acute stroke patients admitted to six hospitals in Adelaide, South Australia over a 20-year period. Tests of difference compared rates of complications between patients with and without dysphagia. Multiple logistic regression modelling explored variables that significantly predicted each complication.

RESULTS

In this consecutive cohort of acute stroke patients, with a mean (SD) age of 73.8 (13.8) years and 70.2% presenting with ischaemic stroke, rates of complications were: aspiration pneumonia (6.5%); dehydration (6.7%); UTI (10.1%); and constipation (4.4%). Each complication was significantly more prevalent for patients with dysphagia compared to those without. Controlling for demographic and other clinical variables, the presence of dysphagia independently predicted aspiration pneumonia (OR=2.61, 95% CI 2.21-3.07; p<.001), dehydration (OR=2.05, 95% CI 1.76-2.38; p<.001), UTI (OR=1.34, 95% CI 1.16-1.56; p<.001), and constipation (OR=1.30, 95% CI 1.07-1.59; p=.009). Additional predictive factors were increased age and prolonged hospitalisation.

CONCLUSIONS

Aspiration pneumonia, dehydration, UTI, and constipation are common acute sequelae of stroke and independently associated with dysphagia. Future dysphagia intervention initiatives may utilise these reported complication rates to evaluate their impact on all four adverse health complications.

A study on predicting the length of hospital stay for Chinese patients with ischemic stroke based on the XGBoost algorithm

BACKGROUND

The incidence of stroke is a challenge in China, as stroke imposes a heavy burden on families, national health services, social services, and the economy. The length of hospital stay (LOS) is an essential indicator of utilization of medical services and is usually used to assess the efficiency of hospital management and patient quality of care. This study established a prediction model based on a machine learning algorithm to predict ischemic stroke patients' LOS.

METHODS

A total of 18,195 ischemic stroke patients' electronic medical records and 28 attributes were extracted from electronic medical records in a large comprehensive hospital in China. The prediction of LOS was regarded as a multi classification problem, and LOS was divided into three categories: 1-7 days, 8-14 days and more than 14 days. After preprocessing the data and feature selection, the XGBoost algorithm was used to build a machine learning model. Ten fold cross-validation was used for model validation. The accuracy (ACC), recall rate (RE) and F1 measure were used to evaluate the performance of the prediction model of LOS of ischemic stroke patients. Finally, the XGBoost algorithm was used to identify and remove irrelevant features by ranking all attributes based on feature importance.

RESULTS

Compared with the naive Bayesian algorithm, logistic region algorithm, decision tree classifier algorithm and ADaBoost classifier algorithm, the XGBoot algorithm has higher ACC, RE and F1 measure. The average ACC, RE and F1 measure were 0.89, 0.89 and 0.89 under the 10-fold cross-validation. According to the analysis of the importance of features, the LOS of ischemic stroke patients was affected by demographic characteristics, past medical history, admission examination features, and operation characteristics. Finally, the features in terms of hemiplegia aphasia, MRS, NIHSS, TIA, Operation or not, coma index etc. were found to be the top features in importance in predicting the LOS of ischemic stroke patients.

CONCLUSIONS

The XGBoost algorithm was an appropriate machine learning method for predicting the LOS of patients with ischemic stroke. Based on the prediction model, an intelligent medical management prediction system could be developed to predict the LOS based on ischemic stroke patients' electronic medical records.

Risk factor identification and prediction models for prolonged length of stay in hospital after acute ischemic stroke using artificial neural networks

Background

Accurate estimation of prolonged length of hospital stay after acute ischemic stroke provides crucial information on medical expenditure and subsequent disposition. This study used artificial neural networks to identify risk factors and build prediction models for a prolonged length of stay based on parameters at the time of hospitalization.

Methods

We retrieved the medical records of patients who received acute ischemic stroke diagnoses and were treated at a stroke center between January 2016 and June 2020, and a retrospective analysis of these data was performed. Prolonged length of stay was defined as a hospital stay longer than the median number of days. We applied artificial neural networks to derive prediction models using parameters associated with the length of stay that was collected at admission, and a sensitivity analysis was performed to assess the effect of each predictor. We applied 5-fold cross-validation and used the validation set to evaluate the classification performance of the artificial neural network models.

Results

Overall, 2,240 patients were enrolled in this study. The median length of hospital stay was 9 days. A total of 1,101 patients (49.2%) had a prolonged hospital stay. A prolonged length of stay is associated with worse neurological outcomes at discharge. Univariate analysis identified 14 baseline parameters associated with prolonged length of stay, and with these parameters as input, the artificial neural network model achieved training and validation areas under the curve of 0.808 and 0.788, respectively. The mean accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of prediction models were 74.5, 74.9, 74.2, 75.2, and 73.9%, respectively. The key factors associated with prolonged length of stay were National Institutes of Health Stroke Scale scores at admission, atrial fibrillation, receiving thrombolytic therapy, history of hypertension, diabetes, and previous stroke.

Conclusion

The artificial neural network model achieved adequate discriminative power for predicting prolonged length of stay after acute ischemic stroke and identified crucial factors associated with a prolonged hospital stay. The proposed model can assist in clinically assessing the risk of prolonged hospitalization, informing decision-making, and developing individualized medical care plans for patients with acute ischemic stroke.

Impact of anemia on acute ischemic stroke outcomes: A systematic review of the literature

INTRODUCTION

Anemia has been reported in nearly 40% of acute ischemic stroke (AIS) patients and is linked to significant morbidity and disability. The presence of anemia is associated with worse outcomes in AIS, specifically in the presence of large vessel occlusion (LVO). An optimal hemoglobin (Hb) target specific to this pathology has not yet been established. The goal of this review is to systematically review literature that observes the association that exists between AIS outcomes and hemoglobin (Hb) levels.

METHODS

A systematic review was performed in accordance with guidelines for the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) to identify studies from 2008-2022. The following inclusion and exclusion criteria were used: studies of adult patients with AIS; must describe outcomes with regard to Hb levels in AIS (not limited to LVO); must be written in English. The clinical variables extracted included Length of Stay (LOS), modified rankin score (mRS), Hb levels, and mortality.

RESULTS

A total of 1,154 studies were gathered, with 116 undergoing full text review. 31 studies were included in this review. The age of patients ranged from 61.4 to 77.8. The presence of anemia in AIS increased LOS by 1.7 days on average and these patients also have a 15.2% higher rate of mortality at one year, on average.

DISCUSSION

This data suggests that the contemporary thresholds for treating anemia in AIS patients may be inadequate because anemia is strongly associated with poor outcomes (e.g., mRS>2 or mortality) and increased LOS in AIS patients. The current generalized Hb threshold for transfusion (7 g/dL) is also used in AIS patients, however, a more aggressive transfusion parameter should be further explored based on these findings. Further studies are required to confirm these findings and to determine if a more liberal RBCT threshold will result in clinical benefits.

Drivers of Ischemic Stroke Hospital Cost Trends Among Older Adults in the United States

PURPOSE

The increased use of neuroimaging and innovations in ischemic stroke (IS) treatment have improved outcomes, but the impact on median hospital costs is not well understood.

METHODS

A retrospective study was conducted using Medicare 5% claims data for 75,525 consecutive index IS hospitalizations for patients aged ≥65 years from 2012 to 2019 (values in 2019 dollars). IS episode cost was calculated in each year for trend analysis and stratified by cost components, including neuroimaging (CT angiography [CTA], CT perfusion [CTP], MRI, and MR angiography [MRA]), treatment (endovascular thrombectomy [EVT] and/or intravenous thrombolysis), and patient sociodemographic factors. Logistic regression was performed to analyze the drivers of high-cost episodes and median regression to assess drivers of median costs.

RESULTS

The median IS episode cost increased by 4.9% from $9,509 in 2012 to $9,973 in 2019 (P = .0021). Treatment with EVT resulted in the greatest odds of having a high-cost (>$20,000) hospitalization (odds ratio [OR], 71.86; 95% confidence interval [CI], 54.62-94.55), as did intravenous thrombolysis treatment (OR, 3.19; 95% CI, 2.90-3.52). Controlling for other factors, neuroimaging with CTA (OR, 1.72; 95% CI, 1.58-1.87), CTP (OR, 1.32; 95% CI, 1.14-1.52), and/or MRA (OR, 1.26; 95% CI, 1.15-1.38) had greater odds of having high-cost episodes than those without CTA, CTP, and MRA. Length of stay > 4 days (OR, 4.34; 95% CI, 3.99-4.72) and in-hospital mortality (OR, 1.85; 95% CI, 1.63-2.10) were also associated with high-cost episodes.

CONCLUSIONS

From 2012 to 2019, the median IS episode cost increased by 4.9%, with EVT as the main cost driver. However, the increasing treatment cost trends have been partially offset by decreases in median length of stay and in-hospital mortality.

Stroke epidemiology in southern Brazil: Investigating the relationship between stroke severity, hospitalization costs, and health-related quality of life

We aimed with the present study to fill the gap on the performance and safety of stroke management and the costs related to hospitalizations, the relevant comorbidities associated with stroke patients, and the stroke patient outcomes health-related quality of life (HRQOL) progress. Our study investigated the clinical, neurological, and social impact of stroke in 220 patients in a tertiary hospital located in the countryside of the state of Santa Catarina, Brazil. Description of clinical and neurological characteristics of stroke patients between 2015 to 2020 was analyzed using electronic medical records. The most affected age group was 61-80 years, being female the most affected sex. Almost 89.5% of the patients had some risk factor, with a higher prevalence of ischemic stroke. This type of stroke was the expensive, in terms of hospitalization, with an average cost of $74.10. Considering the stroke-specific quality of life scale (SSQOL) score, 88.3% of patients who demonstrated some comorbidity and 47.6% of women had lower quality of life levels post-stroke. Our data could be useful to substantiate a data-base with epidemiology statistics characterization of stroke hospitalizations, indicating the severity of stroke for the patient.

Clinical Outcomes and Costs of Recurrent Ischemic Stroke: A Systematic Review

OBJECTIVE

Recurrent stroke patients suffer significant morbidity and mortality, representing almost 30% of the stroke population. Our objective was to determine the clinical outcomes and costs of recurrent ischemic stroke (recurrent-IS).

METHODS

Our study protocol was registered with the International Prospective Register of Systematic Reviews (CRD42020192709). Following PRISMA guidelines, our medical librarian conducted a search in EMBASE, PubMed, Web-of-Science, Scopus, and CINAHL (last performed on August 25, 2020).

INCLUSION CRITERIA

(1) Studies reporting clinical outcomes and/or costs of recurrent-IS; (2) Original research published in English in year 2010 or later; (3) Study participants aged ≥18 years.

EXCLUSION CRITERIA

(1) Case reports/studies, abstracts/posters, Editorial letters/reviews; (2) Studies analyzing interventions other than intravenous thrombolysis and thrombectomy. Four independent reviewers selected studies with review of titles/abstracts and full-text, and performed data extraction. Discrepancies were resolved by a senior independent arbitrator. Risk-of-bias was assessed using the Mixed Methods Appraisal Tool.

RESULTS

Initial search yielded 20,428 studies. Based on inclusion/exclusion criteria, 9 studies were selected, consisting of 24,499 recurrent-IS patients. In 5 studies, recurrent-IS ranged from 4.4-56.8% of the ischemic stroke cohorts at 3 or 12 months, or undefined follow-up. Mean age was 60-80 years and female proportions were 38.5-61.1%. Clinical outcomes included mortality 11.6-25.9% for in-hospital, 30-days, or 4-years (3 studies). In one study from the U.S., mean in-hospital costs were $17,121(SD-$53,693) and 1-year disability costs were $34,639(SD-$76,586) per patient.

CONCLUSIONS

Our study highlights the paucity of data on clinical outcomes and costs of recurrent-IS and identifies gaps in existing literature to direct future research.

Characterizing social and policy determinants of hospital length of stay among paediatric inpatients with diabetes using linked population-based data

Background

Evidence is limited on the non-medical factors influencing hospital length of stay (LOS) among paediatric inpatients with diabetes, notably potential social and policy correlates. This study aimed to characterize the associations of socioeconomic status and health policy environment with diabetes-attributable LOS to help inform accountability monitoring of a provincial comprehensive diabetes strategy aiming to minimize time in hospital among this high-risk population.

Data and methods

This retrospective population-based study drew on multiple linked administrative and geospatial databases among all children aged 18 and under with a diabetes-related hospitalization in the province of New Brunswick, Canada, during the four-year period following implementation of an insulin pump funding program. Multiple linear regression was used to assess the role of access to the public insulin pump resourcing scheme and relative neighbourhood deprivation as predictors of days spent in acute care, controlling for age, sex, and place of residence.

Results

Among the paediatric inpatient population (N = 386), 21% had accessed social resources made available through the insulin pump funding policy and 42% resided in the most materially deprived neighbourhoods. Diabetes-related hospital stays averaged 3.87 days. Paediatric inpatients having accessed resources through the social insurance policy spent significantly fewer days in hospital (1.34 days less [95% CI: 0.63–2.05]) than those who had not, all else being equal. Observed differences in LOS by neighbourhood socioeconomic deprivation were not found to be statistically significant in the multivariate analysis.

Conclusion

Findings from this context of universal medical coverage suggested that public policy for supplemental financing of assistive technologies among children with diabetes may be associated with reduced burden to the hospital system. The causes of socioenvironmental disparities in LOS require further investigation to inform interventions to mitigate preventable patient-level variations in hospital-based health outcomes.

Regional Differences in Hospital Costs of Acute Ischemic Stroke in China: Analysis of Data From the Chinese Acute Ischemic Stroke Treatment Outcome Registry

Background and Purpose: Studies on the regional differences in hospital costs of acute ischemic stroke (AIS) are scarce in China. We aimed to explore the regional differences in hospital costs and identify the determinants of hospital costs in each region. Methods: Data were collected from the Chinese Acute Ischemic Stroke Treatment Outcome Registry (CASTOR), a multicenter prospective study on patients diagnosed with AIS and hospitalized from 2015 to 2017. Univariate and multivariate analyses were undertaken to identify the determinants of hospital costs of AIS. Results: A total of 8,547 patients were included in the study, of whom 3,700 were from the eastern area, 2,534 were from the northeastern area, 1,819 were from the central area, and 494 were from the western area. The median hospital costs presented a significant difference among each region, which were 2175.9, 2175.1, 2477.7, and 2282.4 dollars in each area, respectively. Each region showed a similar hospital cost proportion size order of cost components, which was Western medicine costs, other costs, diagnostic costs, and traditional medicine costs, in descending order. Male sex, diabetes mellitus, severe stroke symptoms, longer length of stay, admission to the intensive care unit, in-hospital complications of hemorrhage, and thrombectomy were independently associated with hospital costs in most regions. Conclusion: Hospital costs in different regions showed a similar proportion size order of components in China. Each region had different determinants of hospital costs, which reflected its current medical conditions and provided potential determinants for increasing medical efficiency according to each region's situation.

Medical complications and outcome after endovascular therapy for acute ischemic stroke

AIM

Endovascular therapy (EVT) in acute stroke is an effective but invasive treatment which is frequently followed by various complications. The aim of the present study was to examine the rate of medical complications and other adverse events following EVT.

METHODS

Retrospective single-center study of 380 consecutive stroke patients who received EVT between the years 2015-2019.

RESULTS

A total of 234 (61.6%) patients had at least one recorded medical complication. The most common complication was pneumonia in 154 (40.5%) patients, followed by acute cardiac insufficiency in 134 (35.3%), and myocardial infarction in 22 (5.8%) patients. In multivariate analysis, the need for general anesthesia (OR 3.8 (1.9-7.7)), Charlson Comorbidity Index >3 (OR 1.3 (1.1-1.5)), male gender (1.9 (1.1-1.3)) and high National Institutes of Health Stroke Scale (NIHSS) score at admission (1.1 (1.0-1.2)) were associated with medical complications.

CONCLUSION

Medical complications are common among unselected stroke patients undergoing EVT. Both comorbidity and stroke severity have an influence on medical complications. Early recognition of complications is essential, because vast majority of patients encountering medical complications have a poor short-term outcome.

Impact of Hospital Level on Stroke Outcomes in the Thrombolytic Therapy Era in Northeast Thailand: A Retrospective Study

INTRODUCTION

Stroke is a common neurological disease. Thrombolytic therapy has been shown to be beneficial in acute ischemic stroke. This treatment can be given in various hospital levels. This study aimed to evaluate the quality of acute ischemic stroke care among various hospital levels.

METHODS

Data were randomly selected from the medical records that were sent to the National Health Security Office (NHSO) for reimbursement purposes between October 2015 and August 2016. Patient demographics, risk factors, stroke subtypes, stroke severity, quality of care indicators, and complications were recorded. Paired comparisons between two groups were carried out using the Bonferroni correction.

RESULTS

A total of 947 patients, including 169 patients from community hospitals (CHs), 629 from regional hospitals (RHs), and 149 from tertiary hospitals (THs), were included in the final analysis. The CH group had a higher median age but lower median initial National Institutes of Health Stroke Scale (NIHSS) score than the RH and TH groups (median age = 70, 66, and 67 years, respectively, and initial NIHSS = 6, 8, and 9, respectively). The CH group had shorter onset-to-needle times for intravenous recombinant tissue plasminogen activator (rt-PA) treatment than the other two groups (147 vs. 178.5 and 180 min). After adjustment for baseline characteristics, stroke type, and stroke severity, the CH group was significantly associated with lower mortality and presence of complications. The adjusted odds ratios (95% confidence intervals) for the two factors were 0.13 (0.03, 0.67) and 0.59 (0.35, 0.99). None of the patients received endovascular therapy or non-thrombolytic interventional therapy.

CONCLUSION

CHs may have the potential for acute ischemic stroke care in the same way as RHs or THs, with faster rt-PA treatment, in northeast Thailand. However, further studies should be performed to evaluate appropriate patient characteristics for CHs.

Specialized Outpatient Clinic vs Stroke Unit for TIA and Minor Stroke: A Cohort Study

OBJECTIVE

To evaluate the effects of an outpatient clinic setup for minor stroke/TIA using subsequent admission of patients at high risk of recurrent stroke.

METHODS

We performed a cohort study of all patients with suspected minor stroke/TIA seen in an outpatient clinic at Aarhus University Hospital, Denmark, between September 2013 and August 2014. Patients with stroke were compared to historic (same hospital) and contemporary (another comparable hospital) matched, hospitalized controls on nonprioritized outcomes: length of stay, readmissions, care quality (10 process-performance measures), and mortality. Patients with TIA were compared to contemporary matched, hospitalized controls. Following complete diagnostic workup, patients with stroke/TIA were classified into low/high risk of recurrent stroke ≤7 days.

RESULTS

We analyzed 1,076 consecutive patients, of whom 253 (23.5%) were subsequently admitted to the stroke ward. Stroke/TIA was diagnosed in 215/171 patients, respectively. Fifty-six percent (121/215) of the patients with stroke were subsequently admitted to the stroke ward. Comparison with the historic stroke cohort (n = 191) showed a shorter acute hospital stay for the strokes (median 1 vs 3 days; adjusted length of stay ratio 0.49; 95% confidence interval 0.33-0.71). Thirty-day readmission rate was 3.2% vs 11.6% (adjusted hazard ratio 0.23 [0.09-0.59]), and care quality was higher, with a risk ratio of 1.30 (1.15-1.47). The comparison of stroke and TIAs to contemporary controls showed similar results. Only one patient in the low risk category and not admitted experienced stroke within 7 days (0.6%).

CONCLUSIONS

An outpatient clinic setup for patients with minor stroke/TIA yields shorter acute hospital stay, lower readmission rates, and better quality than hospitalization in stroke units.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that a neurovascular specialist-driven outpatient clinic for patients with minor stroke/TIA with the ability of subsequent admission is safe and yields shorter acute hospital stay, lower readmission rates, and better quality than hospitalization in stroke units.

Impaired Distal Perfusion Predicts Length of Hospital Stay in Patients with Symptomatic Middle Cerebral Artery Stenosis

BACKGROUND AND PURPOSE

Perfusion imaging can risk stratify patients with symptomatic intracranial stenosis. We aim to determine the association between perfusion delay and length of hospital stay (LOS) in symptomatic middle cerebral artery (MCA) stenosis patients.

METHODS

This is a retrospective study of consecutive patients admitted to a comprehensive stroke center over 5 years with ischemic stroke or transient ischemic attack (TIA) within 7 days of symptom onset due to MCA stenosis (50-99%) and underwent perfusion imaging. Patients were divided into three groups: mismatch volume ≥ 15 cc based on T max > 6 second delay, T max 4-6 second delay, and <4 second delay. The outcome was LOS, both as a continuous variable and categorical (≥7 days [prolonged LOS] vs. <7 days). We used adjusted regression analyses to determine the association between perfusion categories and LOS.

RESULTS

One hundred and seventy eight of 194 patients met the inclusion criteria. After adjusting for age and NIHSS, T max >6 second mismatch was associated with prolonged LOS (OR 2.94 95% CI 1.06-8.18; P = .039), but T max 4-6 second was not (OR 1.45 95% CI .46-4.58, P = .528). We found similar associations when LOS was a continuous variable for T max > 6 second (β coefficient = 2.01, 95% CI .05-3.97, P = .044) and T max 4-6 second (β coefficient = 1.24, 95% CI -.85 to 3.34, P = .244).

CONCLUSION

In patients with symptomatic MCA stenosis, T max > 6 second perfusion delay is associated with prolonged LOS. Prospective studies are needed to validate our findings.

Beyond weight: examining the association of obesity with cardiometabolic related inpatient costs among Canadian adults using linked population based survey and hospital administrative data

BACKGROUND

The global population has transitioned to one where more adults are living with obesity than are underweight. Obesity is associated with the development of cardiometabolic diseases and widely attributed to increased hospital resource use; however, empirical evidence is limited regarding obesity prevention to support hospital cost containment. This study aims to test for obesity in predicting hospitalization costs for cardiometabolic conditions among the Canadian population aged 45 and over.

METHODS

Data from the 2007-2011 Canadian Community Health Survey were linked to eight years of hospital discharge records. A cohort was identified of inpatients admitted for diabetes, hypertension, and other cardiometabolic diseases. Multiple linear regressions were used to investigate the association between obesity status and inpatient costs, controlling for sociodemographic and behavioural factors.

RESULTS

The target cohort included 23,295 admissions for cardiometabolic diseases. Although inflation-adjusted inpatient costs generally increased over time, compared with the non-obese group, living with obesity was not a significant predictor of differences in cardiometabolic-related resource use (0.972 [95% CI: 0.926-1.021]). Being female and rural residence were found to be protective factors.

CONCLUSIONS

Obesity was not found in this study to be independently linked to higher cardiometabolic hospitalization costs, suggesting that actions to mitigate disease progression in the population may be more beneficial than simply promoting weight loss. Results amplified the need to consider gender and urbanization when formulating which levers are most amenable to adoption of healthy lifestyles to reduce impacts of obesogenic environments to the healthcare system.

Factors affecting in-hospital cost and mortality of patients with stroke: Evidence from a case study in a tertiary hospital in China

OBJECTIVE

The study aims to investigate the factors causing the difference of stroke patients' in-hospital cost and study these factors on health outcome in terms of mortality.

METHODS

Eight hundred and sixty-two in-patients with stroke in a tertiary hospital in China from 2017 to 2019 were included in the database. Descriptive statistics indexes were used to describe patients' in-hospital cost and mortality. Based on Elixhauser coding algorithms, multiple linear regression and logistic regressions (LRs) were used to evaluate the impact of factors identified from univariate analysis on in-hospital cost and mortality, respectively. In addition to LRs, a comparison study was then carried out with random forest, gradient boosting decision tree and artificial neural network.

RESULTS

Factors affecting both cost and mortality are age, discharged day-of-week, length of stay, stroke subtype, other neurological disorders, renal failure, fluid and electrolyte disorders and total number of comorbidities.

CONCLUSION

With the increase of age, the mortality rate of in-patients (except for the juvenile) with stroke increases and the cost of hospitalization decreases. Intracerebral haemorrhage is the most devastating stroke for its highest mortality in short length of stay. Medical services should focus on these specific comorbidities.

Costs structure of the inpatient ischemic stroke treatment using an exact costing method

Objectives

Most stroke care expenses are inhospital costs. Given the previously reported inaccuracy of conventional costing, the purpose of this study was to provide an accurate analysis of inpatient costs of stroke care in an acute care hospital.

Materials and methods

We used activity-based costing (ABC) for calculating the costs of ischemic stroke patients. We collected the activity data at the Helsinki University Central Hospital. Persons involved in patient care logged their activities on survey forms for one week. The costs of activities were calculated based on information about salaries, material prices, and other costs obtained from hospital accounting data. We calculated costs per inpatient days and episodes, analyzed cost structure, made a distinction in cost for stroke subtypes according to the Oxford and TOAST classification schemes, and compared cost per inpatient episode with the diagnoses-related group (DRG) -price of the hospital.

Results

The sample comprised 196 inpatient days of 41 patients. By using the ABC, the mean and median costs of an inpatient day were 346 € and 268 €, and of an inpatient episode 3322 € and 2573 €, respectively. Average costs differed considerably by stroke subtype. The first inpatient day was the most expensive. Working time costs comprised 63% of the average inpatient day cost, with nursing constituting the largest proportion. The mean cost of an inpatient episode was 21% lower with ABC than with DRG pricing.

Conclusion

We demonstrate that there are differences in cost estimates depending on the methods used. ABC revealed differences among patients having the same diagnosis. The cost of an episode was lower than the DRG price of the hospital. Choosing an optimal costing method is essential for both reimbursements of hospitals and health policy decision-making.

The Correlation of Routine Hematological Parameters with In-hospital Mortality and Length of Hospital Stay in Patients with Large Middle Cerebral Artery Infarction

Objective

Neutrophil-to-lymphocyte ratio (NLR) and red blood cell distribution width (RDW) reflect inflammation and these parameters have not been studied in patients with large cerebral artery infarction. This study investigated the correlation of these inflammation parameters with in-hospital mortality and length of hospital stay (LOS) in patients with large middle cerebral artery (MCA) infarction.

Materials and methods

The study was conducted with patients who had large MCA (M1 and M2 segments) infarction. Clinical data of the patients and laboratory results at presentation were obtained from our database and recorded for statistical analysis. Multivariate logistic regression analysis was used to investigate the prognostic factors. The correlation between hematological parameters and LOS was investigated using Spearman’s Rho and Pearson correlation tests.

Results

A total of 143 patients (48 patients with hospital mortality, 95 patients without hospital mortality) were included in the study. The median LOS in patients with hospital mortality [10 (2-90) days] was significantly higher compared to the patients without [7 (2-30) days] (p = 0.024). RDW-SD was found to be a poor prognostic factor according to the multivariate logistic regression model (p = 0.004). There was a significant but weak and positive correlation between LOS and NLR (p = 0.003, r: 0.248) and a significant but weak and negative correlation between LOS and eosinophil count (p = 0.001, r: -0.278).

Conclusions

High RDW at presentation is a poor prognostic factor in terms of in-hospital mortality in patients with large MCA infarction. In addition, a positive correlation has been found between NLR and LOS.

Infarct Volume Predicts Hospitalization Costs in Anterior Circulation Large-Vessel Occlusion Stroke

BACKGROUND AND PURPOSE

Anterior circulation large-vessel occlusion stroke, one of the most devastating stroke subtypes, is associated with substantial economic burden. We aimed to identify predictors of increased acute care hospitalization costs associated with anterior circulation large-vessel occlusion stroke.

MATERIALS AND METHODS

Comprehensive cost-tracking software was used to calculate acute care hospitalization costs for patients with anterior circulation large-vessel occlusion stroke admitted July 2012 to October 2014. Patient demographics and stroke characteristics were analyzed, including final infarct volume on follow-up neuroimaging. Predictors of hospitalization costs were determined using multivariable linear regression including subgroup cost analyses by treatment technique (endovascular, IV tPA-only, and no reperfusion therapy) and sensitivity analyses incorporating patients initially excluded due to early withdrawal of care.

RESULTS

Three hundred forty-one patients (median age, 69 years; interquartile range, 57-80 years; median NIHSS score, 16; interquartile range, 13-21) were included in our primary analysis. Final infarct volume, parenchymal hematoma, baseline NIHSS score, ipsilateral carotid stenosis, age, and obstructive sleep apnea were significant predictors of acute care hospitalization costs. Final infarct volume alone accounted for 20.87% of the total cost variance. Additionally, final infarct volume was consistently the strongest predictor of increased cost in primary, subgroup, and sensitivity analyses.

CONCLUSIONS

Final infarct volume was the strongest predictor of increased hospitalization costs in anterior circulation large-vessel occlusion stroke. Acute stroke therapies that reduce final infarct volume may not only improve clinical outcomes but may also prove cost-effective.

The impact of ischaemic stroke on atrial fibrillation-related healthcare cost: a systematic review

The aim of this study was to summarize healthcare costs incurred by patients with atrial fibrillation (AF) who developed ischaemic stroke, explore factors associated with increased cost, and highlight the importance of anticoagulation therapy for stroke prophylaxis. A systematic literature search of PubMed, EMBASE, Web of Science, and the health economic evaluation database was conducted up to December 2015. Studies focused on the cost and/or resource utilization of ischaemic stroke in patients with AF were included. Reported costs were converted to international dollars (I$) and adjusted to 2015 values. Alongside the narrative review of included studies, Spearman's correlation, independent-samples t-test, and one-way ANOVA were used to explore factors associated with cost differences between studies. Sixteen studies published from nine countries were identified. Based on currency conversion rates in 2015, ischaemic stroke-related healthcare costs were estimated to be I$41 420, I$12 895, and I$8184 for high-income, upper middle-income, and lower middle-income economies, respectively. Local GDP per capita accounted for ∼50% of the healthcare cost variation among countries. Major component of overall cost was from hospitalization. Ischaemic stroke incurring in patients with AF ≥75 years was 2.3 times that of their younger peers (P = 0.049). The economic burden from ischaemic stroke in patients with AF is considerable with positive association to country income. Clinicians and stakeholders should be aware of the importance of anticoagulation therapies in stroke prophylaxis, the occurrence of stroke, and the downstream economic burden on an increasingly ageing population.

Effects of centralizing acute stroke services: A prospective cohort study

OBJECTIVE

To investigate the effects of centralizing the acute stroke services in the Central Denmark Region (CDR).

METHODS

The CDR (1.3 million inhabitants) centralized acute stroke care from 6 to 2 designated acute stroke units with 7-day outpatient clinics. We performed a prospective "before-and-after" cohort study comparing all strokes from the CDR with strokes in the rest of Denmark to discover underlying general trends, adopting a difference-in-differences approach. The population comprised 22,141 stroke cases hospitalized from May 2011 to April 2012 and May 2013 to April 2014.

RESULTS

Centralization was associated with a significant reduction in length of acute hospital stay from a median of 5 to 2 days with a length-of-stay ratio of 0.53 (95% confidence interval 0.38-0.75, data adjusted) with no corresponding change seen in the rest of Denmark. Similarly, centralization led to a significant increase in strokes with same-day admission (mainly outpatients), whereas this remained unchanged in the rest of Denmark. We observed a significant improvement in quality of care captured in 11 process performance measures in both the CDR and the rest of Denmark. Centralization was associated with a nonsignificant increase in thrombolysis rate. We observed a slight increase in readmissions at day 30, but this was not significantly different from the general trend. Mortality at days 30 and 365 remained unchanged, as in the rest of Denmark.

CONCLUSIONS

Centralizing acute stroke care in the CDR significantly reduced the length of acute hospital stay without compromising quality. Readmissions and mortality stayed comparable to the rest of Denmark.

Impact of intravenous thrombolysis on length of hospital stay in cases of acute ischemic stroke

BACKGROUND

There are limited data available on factors associated with length of stay (LOS) in cases of acute ischemic stroke according to Poisson analysis, which is more appropriate than other methods.

MATERIALS AND METHODS

We retrospectively reviewed medical summary charts of patients with acute ischemic stroke in 30 hospitals across northeast Thailand, with the main outcome as LOS. Poisson regression was used to examine factors associated with LOS.

RESULTS

We included 898 patients in the analysis; 460 (51.2%) were male. The median age (interquartile; IQR) was 58 (67-75) years and the median LOS was 5 (4-7) days. The median National Institute of Health Stroke Scale (NIHSS [IQR]) was 8 (4-13). Results of the analysis showed that, after controlling for age, stroke severity, atrial fibrillation, and thrombolytic use, significant variables associated with LOS were moderate stroke (incidence rate ratio [IRR] 95% confidence interval [CI] =1.15 [range 1.01-1.30], P=0.040), severe stroke (IRR [95% CI] =1.27 [1.09-1.47], P=0.002), thrombolytic use (IRR [95% CI] =0.68 [0.60-0.76], P<0.001), and atrial fibrillation (IRR [95% CI] =1.15 [1.02-1.30], P=0.023). After adjusting for complications, thrombolytic use remained significantly associated with decreased LOS (IRR [95% CI] =0.74 [0.67-0.83], P=0.001). Other significant factors were atrial fibrillation (IRR [95% CI] =1.14 [1.02-1.28], P=0.018), pneumonia (IRR [95% CI] =1.48 [1.30-1.68], P<0.001), and urinary tract infection (IRR [95% CI] =1.41 [1.14-1.74], P=0.001).

CONCLUSION

According to Poisson analysis, intravenous thrombolysis, atrial fibrillation, pneumonia, and urinary tract infection are associated with LOS in cases of acute ischemic stroke, regardless of age, stroke severity, comorbidities, or complications.

Comparing the economic burden of ischemic stroke patients with and without atrial fibrillation: a retrospective study in Beijing, China

BACKGROUND

Little is known about the economic burden for ischemic stroke (IS) patients with atrial fibrillation (AF) in China.

AIM

We aimed to compare the economic burden of treatment-related costs in IS patients with AF vs. without AF in China.

METHODS

This retrospective analysis used economic burden data from the Beijing urban health insurance database. Using a random sampling method, 10% of the patients diagnosed with IS from 1 January through 31 December 2012 were enrolled. First hospitalization was considered as the index event and hospital utilization after the index event was followed up until September 2013. Overall healthcare cost during the study period was analyzed.

RESULTS

In 4061 patients with IS (mean ± SD age, 68.45 ± 13.95 years; AF: 992; without AF: 3069), the AF group had a higher percentage of patients with co-morbidities at baseline. Compared with the non-AF group, the AF group had significantly greater hospitalization at the index event (p < .001). Overall inpatient cost per patient during the observational period (Renminbi (RMB) 141,875.9 ± 121,071.8 vs. RMB 53,834.03 ± 63,535.72, in 2012 terms), total healthcare cost per patient (RMB 163,550.4 ± 131,103.5 vs. RMB 64,735.41 ± 67,584.95), total healthcare cost covered by health insurance, and annualized total healthcare cost per patient were higher in the AF group than in the non-AF group (p < .001). Treatment costs were significantly associated with old age, male gender, AF, and frequency of outpatient visits and hospitalization.

CONCLUSIONS

AF increased the use of healthcare resources, treatment cost, and economic burden in patients with IS. Therefore, prevention of cardio-embolic events in patients with AF by anticoagulants may decrease the economic burden in patients with IS.

Atrial Fibrillation as an Ischemic Stroke Clinical and Economic Burden Modifier: A 15-Year Nationwide Study

BACKGROUND

Atrial fibrillation (AF) is a major risk factor for ischemic stroke (IS). Patients with AF may undergo preventive therapy. Although the AF impact in the clinical burden of IS has been studied, information is lacking in Southern Europe and there are no studies about the impact in potential years of life lost. Moreover, no nationwide or long-term study analyzed the economic burden of IS stratified by AF.

OBJECTIVE

To study the impact of AF in the clinical and economic burden of IS.

METHODS

We conducted a retrospective study using nationwide administrative data for all public hospitalizations in mainland Portugal from 2000 to 2014. We considered IS hospitalizations stratified by the presence of AF as secondary diagnosis.

RESULTS

Of the total 275,173 IS hospitalizations, 22.6% reported AF. The total number of IS hospitalizations increased from 14,836 in 2000 to 19,561 in 2014 (32% increase), with an increase of 138% in the AF group (from 2,411 to 5,727). In-hospital mortality decreased from 13.6% to 11.5% and was consistently higher in the AF group (17.3% vs. 11.1%). Mean charges were also higher in the AF group (€2297 vs. €2191). Age-adjusted potential years of life lost rate was higher in the group without AF (39.6 vs. 7.5).

CONCLUSIONS

AF-associated IS hospitalizations more than doubled in the studied 15-year period. Also, AF was responsible for higher in-hospital mortality and hospitalization charges. These facts highlight the need for early detection of AF and preventive treatment to limit IS occurrence, its associated burden, and poorer health outcomes.

Predicting the length of hospital stay of post-acute care patients in Taiwan using the Chinese version of the continuity assessment record and evaluation item set

Background

The Chinese version of the Continuity Assessment Record and Evaluation (CARE-C) item set was developed to facilitate the assessment of post-acute care (PAC) patients in Taiwan. Considering that the length of hospital stay (LOS) has a significant effect on the total healthcare cost, determining whether the CARE-C scores could predict the LOS of PAC patients is of great interest to the PAC providers.

Methods

This prospective trial included PAC patients with stroke or central nervous system injuries. The demographic data and CARE-C scores were collected after admission and before discharge. A multivariable stepwise linear regression model was used to identify the predictors of the LOS using age, sex, tube placement status, CARE-C component scores at admission, and score differences between admission and discharge as independent variables.

Results

This study included 178 patients (66 women and 112 men), with a mean age of 61.9 ± 15.6 years. Indwelling urinary catheter placement status at admission (β = 0.241, p = 0.002) was a positive predictor of the LOS, whereas age (β = −0.189, p = 0.010), core transfer subscale score at admission (β = −0.176, p = 0.020), and difference in continence subscale score (β = −0.203, p = 0.008) were negative predictors of the LOS. The model explained 14% of the total variance.

Conclusions

Indwelling urinary catheter placement status at admission, age, core transfer subscale score at admission, and difference in the CARE-C continence subscale score were identified as predictors of the LOS. The explanatory power of these predictors might be limited due to the regulations of Taiwan’s National Health Insurance.

Morbidade hospitalar por acidente vascular encefálico e cobertura fonoaudiológica no Estado da Paraíba, Brasil

RESUMO Introdução O acidente vascular encefálico (AVE) é uma condição neurológica associada à morbidade hospitalar e que requer cuidados fonoaudiológicos, em razão de suas sequelas. Objetivo Analisar o perfil de morbidade hospitalar por acidente vascular encefálico e sua relação com a cobertura fonoaudiológica no Estado da Paraíba, Brasil. Métodos Estudo do tipo ecológico, realizado com dados obtidos no Sistema de Informações Hospitalares (SIH/SUS) e no Cadastro Nacional de Estabelecimentos de Saúde (CNES), nos anos de 2010 e 2014, considerando o número de autorizações de internação hospitalar aprovadas, sexo, faixa etária, valor médio gasto por internação, média de dias de internação e número de fonoaudiólogos no regime hospitalar público. Calculou-se a taxa de internação hospitalar, o coeficiente de incidência de hospitalização por AVE e a proporção de internações por AVE, em relação à cobertura fonoaudiológica. Resultados Houve declínio nas internações por AVE no Estado da Paraíba, entre 2010 e 2014. Ocorreu maior concentração de hospitalizações fora da Região Metropolitana de João Pessoa, em ambos os anos, aumento de 9,8% no valor gasto por internação e permanência de sete dias, em média, no ambiente hospitalar. O número de internações foi maior em indivíduos com 60 anos ou mais, com proporção semelhante quanto ao sexo. O número de fonoaudiólogos vinculados ao regime hospitalar público aumentou 82,8% em 2014, porém, com maior concentração na Região Metropolitana de João Pessoa. Em ambos os anos, a proporção de internações por AVE, em relação à cobertura fonoaudiológica, foi maior fora da Região Metropolitana de João Pessoa. Conclusão No Estado da Paraíba, entre 2010 e 2014, houve declínio da hospitalização por AVE, maior concentração de internações de indivíduos idosos fora da Região Metropolitana de João Pessoa, com mesma proporção entre os sexos. A cobertura fonoaudiológica foi mais escassa nas regiões mais distantes da capital.

The economic impact of mental healthcare consumption before and after stroke in a cohort of stroke patients in the Netherlands: a record linkage study

Background

Post-stroke healthcare consumption is strongly associated with a mental health diagnosis. This study aimed to identify stroke patients who utilised mental healthcare facilities, explored their mental healthcare consumption pre-stroke and post-stroke, and examined possible predictors of costs incurred by mental healthcare consumption post-stroke.

Methods

Three databases were integrated, namely the Maastricht University Medical Centre (MUMC) Medical Administration, the Stroke Registry from the Department of Neurology at MUMC, and the Psychiatric Case Registry South-Limburg. Patients from the MUMC who suffered their first-ever stroke between January 1 2000 and December 31 2004 were included and their records were analysed for mental healthcare consumption from 5 years preceding to 5 years following their stroke (1995–2009). Regression analysis was conducted to identify possible predictors of mental healthcare consumption costs.

Results

A total of 1385 patients were included and 357 (25.8%) received services from a mental healthcare facility during the 10-year reference period around their stroke. The costs of mental healthcare usage increased over time and peaked 1 year post-stroke (€7057; 22% of total mental healthcare costs). The number of hospitalisation days and mental healthcare consumption pre-stroke were significant predictors of mental healthcare costs. Explained variances of these models (costs during the 5 years post-stroke: R² = 15.5%, costs across a 10 year reference period: R² = 4.6%,) were low.

Conclusion

Stroke patients have a significant level of mental healthcare comorbidity leading to relatively high mental healthcare costs. There is a relationship between stroke and mental healthcare consumption costs, but results concerning the underlying factors responsible for these costs are inconclusive.

Neutrophil-to-Lymphocyte Ratio Predicts Length of Stay and Acute Hospital Cost in Patients with Acute Ischemic Stroke

BACKGROUND

Although several risk factors for prolonged length of stay (LOS) and increased hospital cost have been identified, the association between LOS, hospital cost, and neutrophil-to-lymphocyte ratio (NLR) has not yet been investigated. We aimed to investigate the influence of NLR on LOS and hospital cost in patients with acute ischemic stroke.

METHODS

Patients with acute ischemic stroke diagnosed within 24 hours of symptom onset were included. Univariate analysis and stepwise multiple regression analysis were used to identify independent predictors of LOS and hospital cost.

RESULTS

A total of 346 patients were included in the final analysis. The median LOS was 11 days (range 8-13 days). The median acute hospital cost per patient was 19,030.6 RMB (U.S. $ 3065.8) (range 14,450.8 RMB-25,218.2 RMB). Neutrophil count to lymphocyte count (NLR) (P < .001), diabetes mellitus (P = .034), stroke subtype (P = .005), and initial stroke severity (P < .001) were significantly associated with prolonged LOS in the univariate analysis. NLR (P < .001), smoking (P = .04), stroke subtype (P < .001), initial stroke severity (P < .001), and LOS (P < .001) were significantly associated with increased hospital cost in the univariate analysis. Multivariate regression analysis showed that NLR was an independent predictor of both LOS and acute hospital cost. In addition, high NLR was significantly correlated with poor outcome at discharge, prolonged LOS, and increased hospital cost.

CONCLUSIONS

NLR is significantly associated with LOS and acute hospital cost in patients presenting with acute ischemic stroke. It is a simple, inexpensive, and readily available biomarker and may serve as a clinically practical indicator for assessing the economic burden of stroke.

Exploring the impact of intravenous thrombolysis on length of stay for acute ischemic stroke: a retrospective cohort study

Background

Understanding the factors that influence the hospital length of stay (LOS) for patients with stroke will help in discharge planning and stroke unit management. We explored how intravenous thrombolysis (IVT) affects LOS in an acute-care hospital setting.

Methods

We analyzed adult patients with ischemic stroke who presented within 48 h of onset from a hospital-based stroke registry. The relationship between IVT and prolonged LOS (LOS ≥ 7 days) was studied by both multivariate logistic regression and the classification and regression tree (CART) analyses.

Results

Among the study population of 3054 patients, 1110 presented within 4.5 h. The median LOS (interquartile range) was 7 (4 to 11) days, and 1619 patients had prolonged LOS. Multivariate logistic regression revealed that IVT (odds ratio, 0.53; 95 % confidence interval 0.38–0.74) was an independent factor that reduced the risk of prolonged LOS, whereas age, National Institutes of Health Stroke Scale (NIHSS) score, diabetes mellitus, and leukocytosis at admission predicted prolonged LOS. CART analysis identified 4 variables (NIHSS score, IVT, leukocytosis at admission, and age) as important factors to partition the patients into six subgroups. The patient subgroup that had an NIHSS score of 5 to 7 and received IVT had the lowest probability (19 %) of prolonged LOS.

Conclusions

IVT reduced the risk of prolonged LOS in patients with acute ischemic stroke. Measures to increase the rate of IVT are encouraged.

Preliminary Prospective Study to Assess the Effect of Early Blood Urea Nitrogen/Creatinine Ratio-Based Hydration Therapy on Poststroke Infection Rate and Length of Stay in Acute Ischemic Stroke

BACKGROUND

This study aimed to determine whether blood urea nitrogen (BUN)/creatinine (Cr)-based hydration therapy can decrease the rate of poststroke infection and length of stay (LOS) in the neurology ward.

METHODS

This was a nonblinded, phase II single-arm prospective study with a historical control group of patients with acute ischemic stroke and a BUN/Cr ratio of 15 or higher. The study group (n = 134) received an intravenous saline bolus (300-500 mL) followed by maintenance saline (40-80 mL/hour) for the first 72 hours. The control group (n = 103) received maintenance saline infusions (40-60 mL/hour for the first 24 hours and 0-60 mL/hour for the next 24-72 hours).

RESULTS

The hydration group had a significantly lower poststroke infection rate than did the control group (7.5% versus 17.5%, P = .018) and significantly shorter LOS in the neurology ward (13.5 ± 11.6 versus 19.6 ± 14.6 days, P < .01). With regard to adverse events, two patients in each group had cerebral edema.

CONCLUSIONS

The findings suggest that the BUN/Cr ratio needs to be corrected in a timely manner in patients with acute ischemic stroke. Providing prompt saline hydration therapy based on the daily BUN/Cr ratio might decrease the poststroke infection rate and shorten LOS.

Predictors for total medical costs for acute hemorrhagic stroke patients transferred to the rehabilitation ward at a regional hospital in Taiwan

BACKGROUND

One-third of the acute stroke patients in Taiwan receive rehabilitation. It is imperative for clinicians who care for acute stroke patients undergoing inpatient rehabilitation to identify which medical factors could be the predictors of the total medical costs.

OBJECTIVES

The aim of this study was to identify the most important predictors of the total medical costs for first-time hemorrhagic stroke patients transferred to inpatient rehabilitation using a retrospective design.

METHODS

All data were retrospectively collected from July 2002 to June 2012 from a regional hospital in Taiwan. A stepwise multivariate linear regression analysis was used to identify the most important predictors for the total medical costs.

RESULTS

The medical records of 237 patients (137 males and 100 females) were reviewed. The mean total medical cost per patient was United States dollar (USD) 5939.5 ± 3578.5.The following were the significant predictors for the total medical costs: impaired consciousness [coefficient (B), 1075.7; 95% confidence interval (CI) = 138.5-2012.9], dysphagia [coefficient (B), 1025.8; 95% CI = 193.9-1857.8], number of surgeries [coefficient (B), 796.4; 95% CI = 316.0-1276.7], pneumonia in the neurosurgery ward [coefficient (B), 2330.1; 95% CI = 1339.5-3320.7], symptomatic urinary tract infection (UTI) in the rehabilitation ward [coefficient (B), 1138.7; 95% CI = 221.6-2055.7], and rehabilitation ward stay [coefficient (B), 64.9; 95% CI = 31.2-98.7] (R(2) = 0.387).

CONCLUSIONS

Our findings could help clinicians to understand that cost reduction may be achieved by minimizing complications (pneumonia and UTI) in these patients.

The SOAR stroke score predicts hospital length of stay in acute stroke: an external validation study

AIMS

The objective of this study is to externally validate the SOAR stroke score (Stroke subtype, Oxfordshire Community Stroke Project Classification, Age and prestroke modified Rankin score) in predicting hospital length of stay (LOS) following an admission for acute stroke.

METHODS

We conducted a multi-centre observational study in eight National Health Service hospital trusts in the Anglia Stroke & Heart Clinical Network between September 2008 and April 2011. The usefulness of the SOAR stroke score in predicting hospital LOS in the acute settings was examined for all stroke and then stratified by discharge status (discharged alive or died during the admission).

RESULTS

A total of 3596 patients (mean age 77 years) with first-ever or recurrent stroke (92% ischaemic) were included. Increasing LOS was observed with increasing SOAR stroke score (p < 0.001 for both mean and median) and the SOAR stroke score of 0 had the shortest mean LOS (12 ± 20 days) while the SOAR stroke score of 6 had the longest mean LOS (26 ± 28 days). Among patients who were discharged alive, increasing SOAR stroke score had a significantly higher mean and median LOS (p < 0.001 for both mean and median) and the LOS peaked among patients with score value of 6 [mean (SD) 35 ± 31 days, median (IQR) 23 (14-48) days]. For patients who died as in-patient, there was no significant difference in mean or median LOS with increasing SOAR stroke score (p = 0.68 and p = 0.79, respectively).

CONCLUSION

This external validation study confirms the usefulness of the SOAR stroke score in predicting LOS in patients with acute stroke especially in those who are likely to survive to discharge. This provides a simple prognostic score useful for clinicians, patients and service providers.

Global epidemiology of atrial fibrillation

Atrial fibrillation (AF) is a major public health burden worldwide, and its prevalence is set to increase owing to widespread population ageing, especially in rapidly developing countries such as Brazil, China, India, and Indonesia. Despite the availability of epidemiological data on the prevalence of AF in North America and Western Europe, corresponding data are limited in Africa, Asia, and South America. Moreover, other observations suggest that the prevalence of AF might be underestimated-not only in low-income and middle-income countries, but also in their high-income counterparts. Future studies are required to provide precise estimations of the global AF burden, identify important risk factors in various regions worldwide, and take into consideration regional and ethnic variations in AF. Furthermore, in response to the increasing prevalence of AF, additional resources will need to be allocated globally for prevention and treatment of AF and its associated complications. In this Review, we discuss the available data on the global prevalence, risk factors, management, financial costs, and clinical burden of AF, and highlight the current worldwide inadequacy of its treatment.

Disability impacts length of stay in general internal medicine patients

BACKGROUND

Disability is prevalent among patients treated in Internal Medicine (IM), but its impact on length of inpatient stay (LOS) is unknown. Current systems of patient management and resource allocation are disease-focused with scant attention paid to functional impairment. Earlier studies in selected cohorts suggest that disability prolongs LOS.

OBJECTIVE

To investigate the relationship of disability with LOS in IM, controlling for comorbidity.

DESIGN

Prospective cohort study.

PATIENTS

We charted 448 patients from an IM team admitted between 2008 and 2012 for sociodemographic, disease, biochemical and functional characteristics. Each IM team is on duty for one month annually, and patients were hence recruited for one month each year.

MAIN MEASURES

Disability was measured using the Functional Independence Measure (FIM) recorded at discharge. Comorbidity was measured using the Charlson Comorbidity Index (CCI).

KEY RESULTS

Of the 448 patients, 57.4 % were male with mean age 68.6 years. The mean LOS was 9.58 days. The mean motor and cognitive FIM scores were 57.1 and 25.7, respectively. The mean CCI score was 2.69. Thirty-four percent had major social issues impacting discharge plans. The five most common diagnoses for admission were pneumonia (8.9 %), urinary tract infection (7.8 %), cellulitis (7.6 %), heart failure (7.1 %) and falls (6.0 %). Both cognitive and motor FIM scores were negatively correlated with longer LOS (P < 0.001). On multivariate analysis, variables independently associated with longer LOS included the motor FIM score (P < 0.001), presence of social issues such as caregiver unavailability (P < 0.001), non-realistic patient expectations (P = 0.001) and administrative issues impeding discharge (P = 0.016).

CONCLUSION

Disability predicts LOS in IM patients, and thus their comprehensive care should involve functional assessment. As social and administrative factors were also independently associated with LOS, there is a need to involve social workers and administrators in a multidisciplinary approach towards optimizing LOS.