30-Day risk-standardized mortality and readmission rates after ischemic stroke in critical access hospitals

Association of short-term hospital-level outcome metrics with 1-year mortality and recurrence for US Medicare beneficiaries with ischemic stroke

BACKGROUND

Whether stroke patients treated at hospitals with better short-term outcome metrics have better long-term outcomes is unknown. We investigated whether treatment at US hospitals with better 30-day hospital-level stroke outcome metrics was associated with better 1-year outcomes, including reduced mortality and recurrent stroke, for patients after ischemic stroke.

METHODS

This cohort study included Medicare fee-for-service beneficiaries aged ≥65 years discharged alive from US hospitals with a principal diagnosis of ischemic stroke from 07/01/2015 to 12/31/2018. We categorized patients by the treating hospital's performance on the CMS hospital-specific 30-day risk-standardized all-cause mortality and readmission measures for ischemic stroke from 07/01/2012 to 06/30/2015: Low-Low (both CMS mortality and readmission rates for the hospital were <25th percentile of national rates), High-High (both >75th percentile), and Intermediate (all other hospitals). We balanced characteristics between hospital performance categories using stabilized inverse probability weights (IPW) based on patient demographic and clinical factors. We fit Cox models assessing patient risks of 1-year all-cause mortality and ischemic stroke recurrence across hospital performance categories, weighted by the IPW and accounting for competing risks.

RESULTS

There were 595,929 stroke patients (mean age 78.9±8.8 years, 54.4% women) discharged from 2,563 hospitals (134 Low-Low, 2288 Intermediate, 141 High-High). For Low-Low, Intermediate, and High-High hospitals, respectively, 1-year mortality rates were 23.8% (95% confidence interval [CI] 23.3%-24.3%), 25.2% (25.1%-25.3%), and 26.5% (26.1%-26.9%), and recurrence rates were 8.0% (7.6%-8.3%), 7.9% (7.8%-8.0%), and 8.0% (7.7%-8.3%). Compared with patients treated at High-High hospitals, those treated at Low-Low and Intermediate hospitals, respectively, had 15% (hazard ratio 0.85; 95% CI 0.82-0.87) and 9% (0.91; 0.89-0.93) lower risks of 1-year mortality but no difference in recurrence.

CONCLUSIONS

Ischemic stroke patients treated at hospitals with better CMS short-term outcome metrics had lower risks of post-discharge 1-year mortality, but similar recurrent stroke rates, compared with patients treated at other hospitals.

Relationships among hospital acute ischemic stroke volumes, hospital characteristics, and outcomes in the US

BACKGROUND AND OBJECTIVES

Prior research on volume-based patient outcomes related to acute ischemic stroke (AIS) have demonstrated contradictory results and fail to reflect recent advances in stroke care. We sought to examine contemporary relationships between hospital AIS volumes and outcomes.

METHODS

We used complete Medicare datasets in a retrospective cohort study using validated International Classification of Diseases Tenth Revision codes to identify patients admitted with AIS from January 1, 2016 through December 31, 2019. AIS volume was calculated as the total number of AIS admissions per hospital during the study period. We examined several hospital characteristics by AIS volume quartile. We performed adjusted logistic regressions testing associations of AIS volume quartiles with: inpatient mortality, receipt of tissue plasminogen activator (tPA) and endovascular therapy (ET), discharge home, and 30-day outpatient visit. We adjusted for sex, age, Charlson comorbidity score, teaching hospital status, MDI, hospital urban-rural designation, stroke certification status and ICU and neurologist availability at the hospital.

RESULTS

There were 952400 AIS admissions among 5084 US hospitals; AIS 4-year volume quartiles were: 1^st: 1-8 AIS admissions; 2^nd: 9-44; 3^rd: 45-237; 4^th: 238+. Highest quartile hospitals more often were stroke-certified (49.1% vs 8.7% in lowest quartile, p<0.0001), with ICU bed availability (19.8% vs 4.1%, p<0.0001) and with neurologist expertise (91.1% vs 3%, p<0.0001). In the highest AIS quartile (compared to the lowest quartile), there was lower inpatient mortality (odds ratio [OR] 0.71 [95%CI 0.57-0.87, p<0.0001]), lower 30-day mortality (0.55 [0.49-0.62], p<0.0001), greater receipt of tPA (6.60 [3.19-13.65], p<0.0001) and ET (16.43 [10.64-25.37], p<0.0001, and greater likelihood of discharge home (1.38 [1.22-1.56], p<0.0001). However, when the highest quartile hospitals were examined separately, higher volumes were associated with higher mortality despite higher rates of tPA and ET receipt.

CONCLUSIONS

High AIS-volume hospitals have greater utilization of acute stroke interventions, stroke certification and availability of neurologist and ICU care. These features likely play a role in the better outcomes observed at such centers, including inpatient and 30-day mortality and discharge home. However, the highest volume centers had higher mortality despite greater receipt of interventions. Further research is needed to better understand volume-outcome relationships in AIS to improve care at lower volume centers.

Sex differences in cardiovascular response to sepsis

Recently, there has been increased recognition of the importance of sex as a biological factor affecting disease and health. Many preclinical studies have suggested that males may experience a less favorable outcome in response to sepsis than females. The underlying mechanisms for these differences are still largely unknown but are thought to be related to the beneficial effects of estrogen. Furthermore, the immunosuppressive role of testosterone is also thought to contribute to the sex-dependent differences that are present in clinical sepsis. There are still significant knowledge gaps in this field. This mini-review will provide a brief overview of sex-dependent variables in relation to sepsis and the cardiovascular system. Preclinical animal models for sepsis research will also be discussed. The intent of this mini-review is to inspire interest for future considerations of sex-related variables in sepsis that should be addressed to increase our understanding of the underlying mechanisms in sepsis-induced cardiovascular dysfunction for the identification of therapeutic targets and improved sepsis management and treatment.

Rural-Urban Disparities in Outcomes of Myocardial Infarction, Heart Failure, and Stroke in the United States

BACKGROUND

U.S. policy efforts have focused on reducing rural-urban health inequities. However, it is unclear whether gaps in care and outcomes remain among older adults with acute cardiovascular conditions.

OBJECTIVES

This study aims to evaluate rural-urban differences in procedural care and mortality for acute myocardial infarction (AMI), heart failure (HF), and ischemic stroke.

METHODS

This is a retrospective cross-sectional study of Medicare fee-for-service beneficiaries aged ≥65 years with acute cardiovascular conditions from 2016 to 2018. Cox proportional hazards models with random hospital intercepts were fit to examine the association of presenting to a rural (vs urban) hospital and 30- and 90-day patient-level mortality.

RESULTS

There were 2,182,903 Medicare patients hospitalized with AMI, HF, or ischemic stroke from 2016 to 2018. Patients with AMI were less likely to undergo cardiac catherization (49.7% vs 63.6%, P < 0.001), percutaneous coronary intervention (42.1% vs 45.7%, P < 0.001) or coronary artery bypass graft (9.0% vs 10.2%, P < 0.001) within 30 days at rural versus urban hospitals. Thrombolysis rates (3.1% vs 10.1%, P < 0.001) and endovascular therapy (1.8% vs 3.6%, P < 0.001) for ischemic stroke were lower at rural hospitals. After adjustment for demographics and clinical comorbidities, the 30-day mortality HR was significantly higher among patients presenting to rural hospitals for AMI (HR: 1.10, 95% CI: 1.08 to 1.12), HF (HR: 1.15; 95% CI: 1.13 to 1.16), and ischemic stroke (HR: 1.20; 95% CI: 1.18 to 1.22), with similar patterns at 90 days. These differences were most pronounced for the subset of critical access hospitals that serve remote, rural areas.

CONCLUSIONS

Clinical, public health, and policy efforts are needed to improve rural-urban gaps in care and outcomes for acute cardiovascular conditions.

Association of Rural and Critical Access Hospital Status With Patient Outcomes After Emergency Department Visits Among Medicare Beneficiaries

IMPORTANCE

Rural US residents disproportionately rely on emergency departments (ED), yet little is known about patient outcomes after ED visits to rural hospitals or critical access hospitals (CAHs).

OBJECTIVE

To compare 30-day outcomes after rural vs urban ED visits and in CAHs, a subset of rural hospitals.

DESIGN, SETTING, AND PARTICIPANTS

This propensity-matched, retrospective cohort study used a 20% sample of national Medicare fee-for-service beneficiaries from January 1, 2011, to October 31, 2015. Rural and urban ED visits were matched on demographics, patient prior use of EDs, comorbidities, and diagnoses. Thirty-day outcomes overall and stratified by 25 common ED diagnoses were evaluated, with similar analysis of CAHs vs non-CAHs. Data were analyzed from February 15, 2020, to May 17, 2021.

MAIN OUTCOMES AND MEASURES

The primary outcome was 30-day all-cause mortality. Secondary outcomes were ED revisits with and without hospitalization.

RESULTS

The matched cohort included 473 152 rural and urban Medicare beneficiaries with a mean (SD) age of 75.1 (7.9) years (59.1% and 59.3% women, respectively; 86.9% and 87.1% White, respectively). Medicare beneficiaries at rural vs urban EDs experienced similar all-cause 30-day mortality (3.9% vs 4.1%; effect size, 0.01), ED revisits (18.1% vs 17.8%; effect size, 0.00), and ED revisits with hospitalization (6.0% vs 8.1%; effect size, 0.00). Rural ED visits were associated with more transfer (6.2% vs 2.0%; effect size, 0.22) and fewer hospitalizations (24.7% vs 39.2; effect size, 0.31). Stratified by diagnosis, patients in rural EDs with life-threatening illnesses experienced more transfer with 30-day mortality similar to that of patients in urban EDs. In contrast, mortality differed for patients in rural EDs with symptom-based diagnoses, including chest pain (odds ratio [OR], 1.54 [95% CI, 1.25-1.89]), nausea and vomiting (OR, 1.68 [95% CI, 1.26-2.24), and abdominal pain (OR, 1.73 [95% CI, 1.42-2.10]). All findings were similar for CAHs.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study of rural ED care suggest that patient mortality for potentially life-threatening conditions is comparable to that in urban settings. Further research is needed to understand the sources of greater rural ED mortality for symptom-based conditions. These findings underscore the importance of ensuring access to treatment of life-threatening conditions at local EDs in rural communities, which are increasingly endangered by hospital closures.

Regional differences in the care and outcomes of acute stroke patients in Australia: an observational study using evidence from the Australian Stroke Clinical Registry (AuSCR)

OBJECTIVE

To compare the processes and outcomes of care in patients who had a stroke treated in urban versus rural hospitals in Australia.

DESIGN

Observational study using data from a multicentre national registry.

SETTING

Data from 50 acute care hospitals in Australia (25 urban, 25 rural) which participated in the Australian Stroke Clinical Registry during the period 2010-2015.

PARTICIPANTS

Patients were divided into two groups (urban, rural) according to the Australian Standard Geographical Classification Remoteness Area classification. Data pertaining to 28 115 patients who had a stroke were analysed, of whom 8159 (29%) were admitted to hospitals located within rural areas.

PRIMARY AND SECONDARY OUTCOME MEASURES

Regional differences in processes of care (admission to a stroke unit, thrombolysis for ischaemic stroke, discharge on antihypertensive medication and provision of a care plan), and survival analyses up to 180 days and health-related quality of life at 90-180 days.

RESULTS

Compared with those admitted to urban hospitals, patients in rural hospitals less often received thrombolysis (urban 12.7% vs rural 7.5%, p<0.001) or received treatment in stroke units (urban 82.2% vs rural 76.5%, p<0.001), and fewer were discharged with a care plan (urban 61.3% vs rural 44.7%, p<0.001). No significant differences were found in terms of survival or overall self-reported quality of life.

CONCLUSIONS

Rural access to recommended components of acute stroke care was comparatively poorer; however, this did not appear to impact health outcomes at approximately 6 months.

Association of Diagnosis Coding With Differences in Risk-Adjusted Short-term Mortality Between Critical Access and Non-Critical Access Hospitals

IMPORTANCE

Critical access hospitals (CAHs) provide care to rural communities. Increasing mortality rates have been reported for CAHs relative to non-CAHs. Because Medicare reimburses CAHs at cost, CAHs may report fewer diagnoses than non-CAHs, which may affect risk-adjusted comparisons of outcomes.

OBJECTIVE

To assess serial differences in risk-adjusted mortality rates between CAHs and non-CAHs after accounting for differences in diagnosis coding.

DESIGN, SETTING, AND PARTICIPANTS

Serial cross-sectional study of rural Medicare Fee-for-Service beneficiaries admitted to US CAHs and non-CAHs for pneumonia, heart failure, chronic obstructive pulmonary disease, arrhythmia, urinary tract infection, septicemia, and stroke from 2007 to 2017. The final date of follow-up was December 31, 2017.

EXPOSURE

Admission to a CAH vs non-CAH.

MAIN OUTCOMES AND MEASURES

Discharge diagnosis count including trends from 2010 to 2011 when Medicare expanded the allowable number of billing codes for hospitalizations, and combined in-hospital and 30-day postdischarge mortality adjusted for demographics, primary diagnosis, preexisting conditions, and with vs without further adjustment for Hierarchical Condition Category (HCC) score to understand the contribution of in-hospital secondary diagnoses.

RESULTS

There were 4 094 720 hospitalizations (17% CAH) for 2 850 194 unique Medicare beneficiaries (mean [SD] age, 76.3 [11.7] years; 55.5% women). Patients in CAHs were older (median age, 80.1 vs 76.8 years) and more likely to be female (58% vs 55%). In 2010, the adjusted mean discharge diagnosis count was 7.52 for CAHs vs 8.53 for non-CAHs (difference, -0.99 [95% CI, -1.08 to -0.90]; P < .001). In 2011, the CAH vs non-CAH difference in diagnoses coded increased (P < .001 for interaction between CAH and year) to 9.27 vs 12.23 (difference, -2.96 [95% CI, -3.19 to -2.73]; P < .001). Adjusted mortality rates from the model with HCC were 13.52% for CAHs vs 11.44% for non-CAHs (percentage point difference, 2.08 [95% CI, 1.74 to 2.42]; P < .001) in 2007 and increased to 15.97% vs 12.46% (difference, 3.52 [95% CI, 3.09 to 3.94]; P < .001) in 2017 (P < .001 for interaction). Adjusted mortality rates from the model without HCC were not significantly different between CAHs and non-CAHs in all years except 2007 (12.19% vs 11.74%; difference, 0.45 [95% CI, 0.12 to 0.79]; P = .008) and 2010 (12.71% vs 12.28%; difference, 0.42 [95% CI, 0.07 to 0.77]; P = .02).

CONCLUSIONS AND RELEVANCE

For rural Medicare beneficiaries hospitalized from 2007 to 2017, CAHs submitted significantly fewer hospital diagnosis codes than non-CAHs, and short-term mortality rates adjusted for preexisting conditions but not in-hospital comorbidity measures were not significantly different by hospital type in most years. The findings suggest that short-term mortality outcomes at CAHs may not differ from those of non-CAHs after accounting for different coding practices for in-hospital comorbidities.

Trends Among Rural and Urban Medicare Beneficiaries in Care Delivery and Outcomes for Acute Stroke and Transient Ischemic Attacks, 2008-2017

Importance

Over the last decade or so, there have been substantial investments in the development of stroke systems of care to improve access and quality of care in rural communities. Whether these have narrowed rural-urban disparities in care is unclear.

Objective

To describe trends among rural and urban patients with acute ischemic stroke or transient ischemic attack in the type of health care centers to which patients were admitted, what care was provided, and the outcomes patients experienced.

Design, Setting, and Participants

This descriptive observational study included 100% claims for beneficiaries of traditional fee-for-service Medicare from 2008 through 2017. All rural and urban areas in the US were included, defined by whether a beneficiary's residential zip code was in a metropolitan or nonmetropolitan area. All admissions in the US among patients with traditional Medicare who had a transient ischemic attack or acute stroke (N = 4.01 million) were eligible to be included in this study. Admissions for beneficiaries with end-stage kidney disease (n = 85 927 [2.14%]), beneficiaries with unidentified Rural-Urban Commuting Area codes (n = 12 797 [0.32%]), and beneficiaries not continuously enrolled in traditional Medicare in the 12 months before and 3 months after their admission (n = 442 963 [11.0%]) were excluded.

Exposures

Residence in an urban or rural area; admission to a hospital with a transient ischemic attack or acute stroke.

Main Outcomes and Measures

Discharge from a certified stroke center, receiving a neurology consultation during admission, treatment with alteplase, days institutionalized, and 90-day mortality.

Results

The final sample included 3.47 million admissions from 2008 through 2017. In this sample, 2.01 million patients (58.0%) were female, and the mean (SD) age was 78.6 (10.5) years. In 2008, 24 681 patients (25.2%) and 161 217 patients (60.6%) in rural and urban areas, respectively, were cared for at a certified stroke center (disparity, -35.4%). By 2017, this disparity was -26.6%, having narrowed by 8.7 percentage points (95% CI, 6.6-10.8 percentage points). There was also narrowing in the rural-urban disparity in neurologist evaluation during admission (6.3% [95% CI, 4.2%-8.4%]). However, the rural-urban disparity widened or was similar with regard to receiving alteplase (0.5% [95% CI, 0.1%-0.8%]), mean days in an institution from admission (0.5 [95% CI, 0.2-0.8] days), and mortality at 90 days (0.3% [95% CI, -0.02% to 0.6%]), respectively.

Conclusions and Relevance

In the last decade, care for rural residents with acute ischemic stroke and transient ischemic attack has shifted to certified stroke centers and now more likely includes neurologist input. However, disparities in access to treatments, such as alteplase, and outcomes persist, highlighting that work still is needed to extend improvements in stroke care to all US residents.

Trends in Hospital Mortality for Uninsured Rural and Urban Populations, 2012-2016

PURPOSE

Rural-urban health disparities have received increasing scrutiny as rural individuals continue to have worse health outcomes. However, little is known about how insurance status contributes to urban-rural disparities. This study characterizes how rural uninsured patients compare to the urban uninsured, determines whether rurality among the uninsured is associated with worse clinical outcomes, and examines how clinical outcomes based on rurality have changed over time.

METHODS

We conducted a retrospective cohort study of the 2012-2016 National Inpatient Sample hospital discharge data including 1,478,613 uninsured patients, of which 233,816 were rural. Admissions were broken into 6 rurality categories. Logistic regression models were used to determine the independent association between rurality and hospital mortality.

FINDINGS

Demographic and clinical characteristics differed significantly between rural and urban uninsured patients: rural patients were more often white, lived in places with lower median household income, and were more often admitted electively and transferred. Rurality was associated with significantly higher in-hospital mortality rates (1.44% vs 1.89%, OR 1.32, P < .001). This association strengthened after adjusting for medical comorbidities and hospital characteristics. Further, disparities between urban and rural mortality were found to be growing, with the gap almost doubling between 2012 and 2016.

CONCLUSIONS

Rural and urban uninsured patients differed significantly, specifically in terms of race and median income. Among the uninsured, rurality was associated with higher in-hospital mortality, and the gap between urban and rural in-hospital mortality was widening. Our findings suggest the rural uninsured are a vulnerable population in need of informed, tailored policies to reduce these disparities.

Call to Action: Rural Health: A Presidential Advisory From the American Heart Association and American Stroke Association

Understanding and addressing the unique health needs of people residing in rural America is critical to the American Heart Association's pursuit of a world with longer, healthier lives. Improving the health of rural populations is consistent with the American Heart Association's commitment to health equity and its focus on social determinants of health to reduce and ideally to eliminate health disparities. This presidential advisory serves as a call to action for the American Heart Association and other stakeholders to make rural populations a priority in programming, research, and policy. This advisory first summarizes existing data on rural populations, communities, and health outcomes; explores 3 major groups of factors underlying urban-rural disparities in health outcomes, including individual factors, social determinants of health, and health delivery system factors; and then proposes a set of solutions spanning health system innovation, policy, and research aimed at improving rural health.

Web-Based Dashboard for the Interactive Visualization and Analysis of National Risk-Standardized Mortality Rates of Sepsis in the US

Sepsis mortality is heavily influenced by the quality of care in hospitals. Comparing risk-standardized mortality rate (RSMR) of sepsis patients in different states in the United States has potentially important clinical and policy implications. In the current study, we aimed to compare national sepsis RSMR using an interactive web-based dashboard. We analyzed sepsis mortality using the National Inpatient Sample Database of the US. The RSMR was calculated by the hierarchical logistic regression model. We wrote the interactive web-based dashboard using the Shiny framework, an R package that integrates R-based statistics computation and graphics generation. Visual summarizations (e.g., heat map, and time series chart), and interactive tools (e.g., year selection, automatic year play, map zoom, copy or print data, ranking data by name or value, and data search) were implemented to enhance user experience. The web-based dashboard (https://sepsismap.shinyapps.io/index2/) is cross-platform and publicly available to anyone with interest in sepsis outcomes, health inequality, and administration of state/federal healthcare. After extrapolation to the national level, approximately 35 million hospitalizations were analyzed for sepsis mortality each year. Eight years of sepsis mortality data were summarized into four easy to understand dimensions: Sepsis Identification Criteria; Sepsis Mortality Predictors; RSMR Map; RSMR Trend. Substantial variation in RSMR was observed for different states in the US. This web-based dashboard allows anyone to visualize the substantial variation in RSMR across the whole US. Our work has the potential to support healthcare transparency, information diffusion, health decision-making, and the formulation of new public policies.

Impact of Missing Stroke Severity Data on the Accuracy of Hospital Ischemic Stroke Mortality Profiling

BACKGROUND

The Centers for Medicare and Medicaid Services have proposed 30-day ischemic stroke risk-standardized mortality rates that include adjustment for stroke severity using the National Institute of Health Stroke Scale (NIHSS), which is often undocumented. We used simulations to quantify the effect of missing NIHSS data on the accuracy of hospital-level ischemic stroke risk-standardized mortality rate profiling for 100 hypothetical hospitals with different case volumes.

METHODS AND RESULTS

We generated simulated data sets of patients with NIHSS scores and other predictors of 30-day mortality based on empirical analysis of data from 7654 patients with ischemic stroke in the Michigan Stroke Registry. We assigned and rank-ordered a true (known) 30-day mortality rate to each hospital in the simulated data sets of N=100 hospitals with either low (100 patients with stroke), medium (300), or high (500) case volumes. We then estimated and rank-ordered 30-day risk-standardized mortality rates for the N=100 hospitals in each simulated data set using hierarchical logistic regression models. In each data set, we systematically varied the rate of missing NIHSS data and whether missing NIHSS data was independent (missing completely at random) or dependent (missing not at random) on the NIHSS score. With no missing NIHSS data, the Spearman correlation between the true hospital performance rank order assigned during data set generation and the estimated 30-day risk-standardized mortality rate rank order was 0.72, 0.88, and 0.91 in low, medium, and high volume hospitals, respectively. However, this fell to as low as 0.50, 0.71, and 0.79 as missing NIHSS data reached 70%.

CONCLUSIONS

Missing NIHSS data had substantial detrimental effects on the accuracy of profiling of ischemic stroke mortality, especially in lower volume hospitals. Even with complete NIHSS documentation, significant limitations in ischemic stroke mortality profiling remain.

The Advanced Practice Nurse Will See You Now: Impact of a Transitional Care Clinic on Hospital Readmissions in Stroke Survivors

BACKGROUND

There is a paucity of evidence-based, posthospital stroke care in the United States proven to reduce preventable hospital readmissions.

LOCAL PROBLEM

Follow-up with a provider after hospitalization for stroke or transient ischemic attack had low compliance rates. This may contribute to preventable readmissions.

METHODS

A retrospective, descriptive chart review to determine whether an advanced practice registered nurse (APRN)-led transitional care clinic for stroke survivors impacted 30- and 90-day hospital readmissions. Readmissions between clinic patients and nonclinic patients were compared.

INTERVENTIONS

The site implemented an APRN-led transitional care stroke clinic to improve patient transitions from hospital to home.

RESULTS

The 30-day readmission proportion was significantly higher in nonclinic patients (n = 335) than in clinic patients (n = 68) (13.4% vs 1.5%, respectively; P = .003). The 90-day readmission proportion was numerically higher in nonclinic patients (12.8% vs 4.4%, respectively; P = .058).

CONCLUSIONS

The results suggest the APRN-led clinic may impact 30-day hospital readmissions in stroke/transient ischemic attack survivors.

Emergency Surgery for Medicare Beneficiaries Admitted to Critical Access Hospitals

OBJECTIVE

The aim of this study was to compare the surgical outcomes of emergency operations performed at critical access and non-critical access hospitals.

BACKGROUND

Critical access hospitals are often the only source of surgical care for rural populations. Previous studies have demonstrated that patients undergoing common, elective operations at these rural hospitals have similar outcomes to their urban counterparts. Little is known, however, about the quality of care these hospitals provide for emergency operations for which they are most essential.

METHODS

We performed a cross-sectional retrospective review of 219,170 urgent or emergency colon resections among Medicare beneficiaries between 2009 and 2012. We compared mortality, serious complications, reoperation, and readmission rates at critical access and non-critical access hospitals using a multivariable logistic regression to adjust for patient factors (age, sex, race, Elixhauser comorbidities,) indication (cancer, diverticulitis, obstruction, inflammatory bowel disease, bleeding), year of operation, and type of operation.

RESULTS

Operative indications were similar at both critical access and non-critical access hospitals with the most common being cancer (38.5% vs 31.1%) followed by diverticulitis (26.9% vs 28.0%). Compared with patients treated at non-critical access hospitals, patients undergoing surgery at critical access hospitals were less likely to have multiple comorbid diseases (% of patients with 2 or more comorbid conditions, 67.5% vs 75.9%; P < 0.01). After accounting for these differences, patients in critical access hospitals had lower risk-adjusted 30-day mortality rates (14.3% vs 16.2%; P = 0.012) and lower rates of serious complications (11.1% vs 27.2%; P < 0.001). However, critical access hospitals had higher rates of reoperation (2.1% vs 1.4%; P = 0.009) and readmissions (22.3% vs 19.4%; P < 0.001).

CONCLUSIONS

For emergency colectomy procedures, Medicare beneficiaries in critical access hospitals experienced lower mortality rates but more frequent reoperation and readmission. These findings suggest that critical access hospitals provide safe, essential emergency surgical care, but may need more resources for postoperative care coordination in these high-risk operations.

Urban-rural differences in the care and outcomes of acute stroke patients: Systematic review

OBJECTIVE

To describe literature pertaining to urban-rural differences in both the quality of care and outcomes of acute stroke patients.

METHODS

We systematically searched CINAHL, PubMed, ProQuest Dissertations & Theses, and Scopus for published and unpublished literature until 9th December 2017. Studies were included if they compared the acute care provided to, or outcomes of, patients hospitalised for stroke in urban versus rural settings. Abstract, full-text review, and data extraction were conducted in duplicate. Findings are presented in the form of narrative syntheses.

RESULTS

A total of 28 studies were included in the review (16 on care, 12 on outcomes). With few exceptions, studies addressing the provision of care suggested that rural patients have less access to most aspects of acute stroke care. Studies reporting urban-rural differences in patient outcomes were inconsistent in their findings, however, few of these studies were primarily focused on the issue of urban-rural disparities. Overall, study findings did not appear to differ in line with study quality ratings, stroke subtypes included, or how inter-facility patient transfers were accounted for.

CONCLUSIONS

There is convincing, albeit not unanimous, evidence to suggest that stroke patients in rural areas receive less acute care than their urban counterparts. Despite this, the available data and methodology have largely not been used to study urban-rural differences in patient outcomes. PROSPERO registration information: URL: https://www.crd.york.ac.uk/prospero. Unique identifier: CRD42017073262.

Association between medication-related adverse events and non-elective readmission in acute ischemic stroke

Background

There is limited data on the effects of medication-related adverse events occurring during inpatient stays for stroke. The objectives of our study were to characterize reasons for acute readmission after acute ischemic stroke (AIS) and determine if medication-related adverse events occuring during AIS hospitalization were associated with 30-day readmission. Secondary objectives examined whether demographic, clinical, and hospital characterisitcs were associated with post-AIS readmission.

Methods

We used the Nationwide Readmission Database to identify index AIS hospitalizations in the United States between January and November 2014. Inpatient records were screened for diagnostic and external causes of injury codes indicative of medication-related adverse events, including adverse effects of prescribed drugs, unintentional overdosing, and medication errors. Nationally representative estimates of AIS hospitalizations, medication-related adverse events, and acute non-elective readmissions were computed using survey weighting methods. Adjusted odds of readmission for medication-related adverse events and select characteristics were estimated using unconditional logistic regression.

Results

We identified 439,682 individuals who were hospitalized with AIS, 4.7% of whom experienced a medication-related adverse event. Overall, 10.7% of hospitalized individuals with AIS were readmitted within 30 days of discharge. Reasons for readmission were consistent with those observed among older adults. Inpatients who experienced medication-related adverse events had significantly greater odds of being readmitted within 30 days (adjusted odds ratio (AOR): 1.22; 95% CI: 1.14–1.30). Medication-related adverse events were associated with readmission for non-AIS conditions (AOR, 1.26; 95% CI: 1.17–1.35), but not with readmission for AIS (AOR, 0.91; 95% CI: 0.75–1.10). Several factors, including but not limited to being younger than 40 years (AOR, 1.12; 95% CI: 1.00–1.26), Medicare insurance coverage (AOR, 1.33; 95% CI: 1.26–1.40), length of stay greater than 1 week (AOR, 1.38; 95% CI: 1.33–1.42), having 7 or more comorbidites (AOR, 2.20; 95% CI: 2.08–2.34), and receiving care at a for-profit hospital (AOR, 1.20; 95% CI: 1.12–1.29), were identified as being associated with all-cause 30-day readmission.

Conclusions

In this nationally representative sample of AIS hospitalizations, medication-related adverse events were positively associated with 30-day readmission for non-AIS causes. Future studies are necessary to determine whether medication-related adverse events and readmissions in AIS are avoidable.

Regional Variation in 30-Day Ischemic Stroke Outcomes for Medicare Beneficiaries Treated in Get With The Guidelines-Stroke Hospitals

BACKGROUND

We explored regional variation in 30-day ischemic stroke mortality and readmission rates and the extent to which regional differences in patients, hospitals, healthcare resources, and a quality of care composite care measure explain the observed variation.

METHODS AND RESULTS

This ecological analysis aggregated patient and hospital characteristics from the Get With The Guidelines-Stroke registry (2007-2011), healthcare resource data from the Dartmouth Atlas of Health Care (2006), and Medicare fee-for-service data on 30-day mortality and readmissions (2007-2011) to the hospital referral region (HRR) level. We used linear regression to estimate adjusted HRR-level 30-day outcomes, to identify HRR-level characteristics associated with 30-day outcomes, and to describe which characteristics explained variation in 30-day outcomes. The mean adjusted HRR-level 30-day mortality and readmission rates were 10.3% (SD=1.1%) and 13.1% (SD=1.1%), respectively; a modest, negative correlation (r=-0.17; P=0.003) was found between one another. Demographics explained more variation in readmissions than mortality (25% versus 6%), but after accounting for demographics, comorbidities accounted for more variation in mortality compared with readmission rates (17% versus 7%). The combination of hospital characteristics and healthcare resources explained 11% and 16% of the variance in mortality and readmission rates, beyond patient characteristics. Most of the regional variation in mortality (65%) and readmission (50%) rates remained unexplained.

CONCLUSIONS

Thirty-day mortality and readmission rates vary substantially across HRRs and exhibit an inverse relationship. While regional variation in 30-day outcomes were explained by patient and hospital factors differently, much of the regional variation in both outcomes remains unexplained.

Rural versus urban academic hospital mortality following stroke in Canada

Introduction

Stroke is one of the leading causes of death in Canada. While stroke care has improved dramatically over the last decade, outcomes following stroke among patients treated in rural hospitals have not yet been reported in Canada.

Objectives

To describe variation in 30-day post-stroke in-hospital mortality rates between rural and urban academic hospitals in Canada. We also examined 24/7 in-hospital access to CT scanners and selected services in rural hospitals.

Materials and methods

We included Canadian Institute for Health Information (CIHI) data on adjusted 30-day in-hospital mortality following stroke from 2007 to 2011 for all acute care hospitals in Canada excluding Quebec and the Territories. We categorized rural hospitals as those located in rural small towns providing 24/7 emergency physician coverage with inpatient beds. Urban hospitals were academic centres designated as Level 1 or 2 trauma centres. We computed descriptive data on local access to a CT scanner and other services and compared mean 30-day adjusted post-stroke mortality rates for rural and urban hospitals to the overall Canadian rate.

Results

A total of 286 rural hospitals (3.4 million emergency department (ED) visits/year) and 24 urban hospitals (1.5 million ED visits/year) met inclusion criteria. From 2007 to 2011, 30-day in-hospital mortality rates following stroke were significantly higher in rural than in urban hospitals and higher than the Canadian average for every year except 2008 (rural average range = 18.26 to 21.04 and urban average range = 14.11 to 16.78). Only 11% of rural hospitals had a CT-scanner, 1% had MRI, 21% had in-hospital ICU, 94% had laboratory and 92% had basic x-ray facilities.

Conclusion

Rural hospitals in Canada had higher 30-day in-hospital mortality rates following stroke than urban academic hospitals and the Canadian average. Rural hospitals also have very limited local access to CT scanners and ICUs. These rural/urban discrepancies are cause for concern in the context of Canada’s universal health care system.

The Impact of the Sepsis-3 Septic Shock Definition on Previously Defined Septic Shock Patients

OBJECTIVE

The Third International Consensus Definitions Task Force (Sepsis-3) recently recommended changes to the definitions of sepsis. The impact of these changes remains unclear. Our objective was to determine the outcomes of patients meeting Sepsis-3 septic shock criteria versus patients meeting the "old" (1991) criteria of septic shock only.

DESIGN

Secondary analysis of two clinical trials of early septic shock resuscitation.

SETTING

Large academic emergency departments in the United States.

PATIENTS

Patients with suspected infection, more than or equal to two systemic inflammatory response syndrome criteria, and systolic blood pressure less than 90 mm Hg after fluid resuscitation.

INTERVENTIONS

Patients were further categorized as Sepsis-3 septic shock if they demonstrated hypotension, received vasopressors, and exhibited a lactate greater than 2 mmol/L. We compared in-hospital mortality in patients who met the old definition only with those who met the Sepsis-3 criteria.

MEASUREMENTS AND MAIN RESULTS

Four hundred seventy patients were included in the present analysis. Two hundred (42.5%) met Sepsis-3 criteria, whereas 270 (57.4%) met only the old definition. Patients meeting Sepsis-3 criteria demonstrated higher severity of illness by Sequential Organ Failure Assessment score (9 vs 5; p < 0.001) and mortality (29% vs 14%; p < 0.001). Subgroup analysis of 127 patients meeting only the old definition demonstrated significant mortality benefit following implementation of a quantitative resuscitation protocol (35% vs 10%; p = 0.006).

CONCLUSION

In this analysis, 57% of patients meeting old definition for septic shock did not meet Sepsis-3 criteria. Although Sepsis-3 criteria identified a group of patients with increased organ failure and higher mortality, those patients who met the old criteria and not Sepsis-3 criteria still demonstrated significant organ failure and 14% mortality rate.

Rural-Urban Differences in the Effect of Follow-Up Care on Postdischarge Outcomes

OBJECTIVE

To assess rural-urban differences in quality of postdischarge care among Medicare beneficiaries, controlling for selection bias of postdischarge services.

DATA SOURCES

The Medicare Current Beneficiary Survey (MCBS), Cost and Use Files from 2000 to 2010, the Area Resource File, Provider of Services File, and the Dartmouth Atlas of Health Care.

STUDY DESIGN

Retrospective analysis of 30- and 60-day hospital readmission, emergency department (ED) use, and mortality using two-stage residual inclusion; receipt of 14-day follow-up care was the main independent variable.

DATA EXTRACTION METHOD

We defined index admission from the MCBS as any admission without a previous admission within 60 days.

PRINCIPAL FINDINGS

Noninstrumental variables estimation was the preferred estimation strategy. Fourteen-day follow-up care reduced the risk of readmission, ED use, and mortality. There were no rural- urban differences in the effect of 14-day follow-up care on readmission and mortality. Rural beneficiaries experienced a greater effect of 14-day follow-up care on reducing 30-day ED use compared to urban beneficiaries.

CONCLUSIONS

Follow-up care reduces 30- and 60-day readmission, ED use, and mortality. Rural and urban Medicare beneficiaries experience similar beneficial effects of follow-up care on the outcomes. Policies that improve follow-up care in rural settings may be beneficial.

Predictors of hospital readmission 1 year after ischemic stroke

Predictors of short-term readmission after ischemic stroke have been previously identified, but few studies analyzed predictors of long-term readmission, namely early imaging findings and treatment with intravenous thrombolysis (IVT). To characterize predictors of hospital readmission during the first year after hospitalization for ischemic stroke. The study consists of a retrospective cohort of consecutive ischemic stroke patients admitted in a Portuguese university hospital during 2013, who survived index hospitalization. We collected clinical and imaging information using the electronical clinical record. Information concerning 1-year unplanned hospital readmissions was assessed using the Portuguese electronic Health Data Platform. Descriptive and univariate analyses, Kaplan-Meier survival curve and multivariate survival analysis with Cox regression model were used. We included 480 patients, 50.6 % women, median age 79 years (interquartile range = 68-85). One-year hospital readmissions occurred in 165 patients [34.4 %, 95 % confidence interval (95 % CI) 30.2-38.7]. The main causes for readmission were infectious diseases (43.8 %), ischemic stroke or transient ischemic attack recurrence (13.2 %) and cardiac diseases (6.4 %). In-hospital mortality associated with readmission was 23.0 %. The independent predictors of 1-year hospital readmission after ischemic stroke were admission mini-National Institute of Health Stoke Scale [hazards ratio (HR) 1.05, 95 % CI 1.02-1.08, p = 0.002], and mild or absent early signs of ischemia on admission computed tomography (CT) (HR 0.54, 95 % CI 0.32-0.91, p = 0.021) and IVT (HR 0.11, 95 % CI 0.01-0.80, p = 0.029). Hospital readmission during the first year after ischemic stroke occurs in 1/3 of patients and is associated with high in-hospital mortality. Clinical stroke severity, early signs of ischemia on admission CT, and treatment with IVT are independent predictors of 1-year hospital readmission.

Impact of Postdischarge Follow-Up Care on Medicare Expenditures: Does Rural Make a Difference?

Reducing postdischarge Medicare expenditures is a key focus for hospitals. Early follow-up care is an important piece of this focus, but it is unclear whether there are rural–urban differences in the impact of follow-up care on Medicare expenditures. To assess this difference, we use the Medicare Current Beneficiary Survey, Cost and Use Files, 2000-2010. We conduct a retrospective analysis of 30-day postdischarge Medicare expenditures using two-stage residual inclusion with a quantile regression, where the receipt of 7-day follow-up care was the main independent variable. Postdischarge follow-up care increased the 25th percentile of 30-day expenditures, decreased the 75th percentile, and there were no rural–urban differences. Partial effects show postdischarge follow-up care resulted in higher 30-day expenditures among low-cost rural beneficiaries. Ensuring early follow-up care for high-cost beneficiaries may be advantageous to both rural and urban providers in helping reduce postdischarge Medicare expenditures.

Impact of Neurological Follow-Up on Early Hospital Readmission Rates for Acute Ischemic Stroke

INTRODUCTION

Despite advances in stroke care, readmission rates for patients with ischemic stroke remain high. Although factors such as age, diabetes, and continuous use of antiplatelet agents have been found to predict readmission rates, the impact of after-hospital care has not been examined.

METHODS

The present study reviewed the charts of 416 patients with acute ischemic stroke and recorded stroke-related comorbidities, neurology follow-up within 21 days, readmission at 0 to 30 days, readmission at 31 to 90 days, and any reasons for readmission.

RESULTS

For those readmitted within 0 to 30 days, reasons for readmission were other medical conditions (62.5%), recurrent stroke (30.4%), and elective procedure (7.1%). For those readmitted within 31 to 90 days, reasons for readmission were other medical conditions (62.3%), recurrent stroke (15.1%), and elective procedure (22.6%). There was no significant relationship between being evaluated within 21 days and readmission at 0 to 30 or 31 to 90 days. However, those who did have a neurology follow-up at any point in time had a lower readmission rate of 10.6% compared to those who never came back (19.2%, P = .017). Patients with coronary artery disease and diabetes had a significantly higher likelihood of readmission within 0 to 30 days.

CONCLUSION

The present study suggests that neurology follow-up at any point in time for patients with acute ischemic stroke may reduce short-term readmissions, but special attention to optimizing management of other underlying medical conditions, coronary artery disease, or diabetes may also help reduce overall readmissions. Patients with stroke, therefore, may benefit from a follow-up with both the primary care and neurology in a coordinated fashion to prevent early readmissions at 30 days.

Minimum-distance requirements could harm high-performing critical-access hospitals and rural communities

Since the inception of the Medicare Rural Hospital Flexibility Program in 1997, over 1,300 rural hospitals have converted to critical-access hospitals, which entitles them to Medicare cost-based reimbursement instead of reimbursement based on the hospital prospective payment system (PPS). Several changes to eligibility for critical-access status have recently been proposed. Most of the changes focus on mandating that hospitals be located a certain minimum distance from the nearest hospital. Our study found that critical-access hospitals located within fifteen miles of another hospital generally are larger, provide better quality, and are financially stronger compared to critical-access hospitals located farther from another hospital. Returning to the PPS would have considerable negative impacts on critical-access hospitals that are located near another hospital. We conclude that establishing a minimum-distance requirement would generate modest cost savings for Medicare but would likely be disruptive to the communities that depend on these hospitals for their health care.

Assessing the Public's Health

Metrics are an important part of the assessment of public health. They include traditional measures of mortality and newly described summary measures to describe the disability engendered by diseases. Epidemiology has transformed the understanding of risk factors for disease; however, a holistic approach includes recognition of social determinants and the neighborhood and communities where the people most at risk reside.

Systematic Review of Hospital Readmissions in Stroke Patients

Background. Previous evidence on factors and causes of readmissions associated with high-impact users of stroke is scanty. The aim of the study was to investigate common causes and pattern of short- and long-term readmissions stroke patients by conducting a systematic review of studies using hospital administrative data. Common risk factors associated with the change of readmission rate were also examined. Methods. The literature search was conducted from 15 February to 15 March 2016 using various databases, such as Medline, Embase, and Web of Science. Results. There were a total of 24 studies (n = 2,126,617) included in the review. Only 4 studies assessed causes of readmissions in stroke patients with the follow-up duration from 30 days to 5 years. Common causes of readmissions in majority of the studies were recurrent stroke, infections, and cardiac conditions. Common patient-related risk factors associated with increased readmission rate were age and history of coronary heart disease, heart failure, renal disease, respiratory disease, peripheral arterial disease, and diabetes. Among stroke-related factors, length of stay of index stroke admission was associated with increased readmission rate, followed by bowel incontinence, feeding tube, and urinary catheter. Conclusion. Although risk factors and common causes of readmission were identified, none of the previous studies investigated causes and their sequence of readmissions among high-impact stroke users.

Does the Volume of Ischemic Stroke Admissions Relate to Clinical Outcomes in the Ontario Stroke System?

BACKGROUND

Better outcomes have been found among hospitals treating higher volumes of patients for specific surgical and medical conditions. We examined hospital ischemic stroke (IS) volume and 30-day mortality to inform regionalization planning.

METHODS AND RESULTS

Using a population-based hospital discharge administrative database (2005/2006 to 2011/2012), average annual IS patient volumes were calculated for 162 Ontario acute hospitals. Hospitals were ranked and classified as small (<126), medium (126-202), and large (>202). Hierarchical multivariable logistic regression was used to estimate the odds of death within 7 and 30 days to account for the homogeneity in outcomes for patients treated at the same hospital. Overall, 73 368 patients were hospitalized for IS, and 30-day mortality was 15.3%. The mean (±SD) of annual hospitalizations for IS was 29 (31) for small-volume hospitals, 156 (20) for medium-volume hospitals, and 300 (78) for high-volume hospitals. High-volume hospitals admitted younger patients (mean [±SD] age, 73.0 [13.9] years) compared with medium- and small-volume hospitals (74.0 [13.2] and 75.5 [12.5] years, respectively; P<0.0001). Patients at small-volume hospitals were more likely than patients at high-volume hospitals to die at 30 days after an acute IS (adjusted odds ratio, 1.37; 95% confidence interval, 1.14-1.65).

CONCLUSIONS

Hospital IS volume is associated with 30-day mortality in Ontario. Patients admitted to hospitals with annual IS volumes <126 annually are more likely to die within 30 days than patients admitted to hospitals that see on average 300 patients annually. This finding supports centralizing care in stroke-specialized hospitals.

Variation in Risk-Standardized Mortality of Stroke among Hospitals in Japan

Despite recent advances in care, stroke remains a life-threatening disease. Little is known about current hospital mortality with stroke and how it varies by hospital in a national clinical setting in Japan. Using the Diagnosis Procedure Combination database (a national inpatient database in Japan), we identified patients aged ≥ 20 years who were admitted to the hospital with a primary diagnosis of stroke within 3 days of stroke onset from April 2012 to March 2013. We constructed a multivariable logistic regression model to predict in-hospital death for each patient with patient-level factors, including age, sex, type of stroke, Japan Coma Scale, and modified Rankin Scale. We defined risk-standardized mortality ratio as the ratio of the actual number of in-hospital deaths to the expected number of such deaths for each hospital. A hospital-level multivariable linear regression was modeled to analyze the association between risk-standardized mortality ratio and hospital-level factors. We performed a patient-level Cox regression analysis to examine the association of in-hospital death with both patient-level and hospital-level factors. Of 176,753 eligible patients from 894 hospitals, overall in-hospital mortality was 10.8%. The risk-standardized mortality ratio for stroke varied widely among the hospitals; the proportions of hospitals with risk-standardized mortality ratio categories of ≤ 0.50, 0.51-1.00, 1.01-1.50, 1.51-2.00, and >2.00 were 3.9%, 47.9%, 41.4%, 5.2%, and 1.5%, respectively. Academic status, presence of a stroke care unit, higher hospital volume and availability of endovascular therapy had a significantly lower risk-standardized mortality ratio; distance from the patient's residence to the hospital was not associated with the risk-standardized mortality ratio. Our results suggest that stroke-ready hospitals play an important role in improving stroke mortality in Japan.

Post-Acute Care Data for Predicting Readmission After Ischemic Stroke: A Nationwide Cohort Analysis Using the Minimum Data Set

BACKGROUND

Reducing hospital readmissions is a key component of reforms for stroke care. Current readmission prediction models lack accuracy and are limited by data being from only acute hospitalizations. We hypothesized that patient-level factors from a nationwide post-acute care database would improve prediction modeling.

METHODS AND RESULTS

Medicare inpatient claims for the year 2008 that used International Classification of Diseases, Ninth Revision codes were used to identify ischemic stroke patients older than age 65. Unique individuals were linked to comprehensive post-acute care assessments through use of the Minimum Data Set (MDS). Logistic regression was used to construct risk-adjusted readmission models. Covariates were derived from MDS variables. Among 39 178 patients directly admitted to nursing homes after hospitalization due to acute stroke, there were 29 338 (75%) with complete MDS assessments. Crude rates of readmission and death at 30 days were 8448 (21%) and 2791 (7%), respectively. Risk-adjusted models identified multiple independent predictors of all-cause 30-day readmission. Model performance of the readmission model using MDS data had a c-statistic of 0.65 (95% CI 0.64 to 0.66). Higher levels of social engagement, a marker of nursing home quality, were associated with progressively lower odds of readmission (odds ratio 0.71, 95% CI 0.55 to 0.92).

CONCLUSIONS

Individual clinical characteristics from the post-acute care setting resulted in only modest improvement in the c-statistic relative to previous models that used only Medicare Part A data. Individual-level characteristics do not sufficiently account for the risk of acute hospital readmission.

Stroke and Bleeding Risk Associated With Antithrombotic Therapy for Patients With Nonvalvular Atrial Fibrillation in Clinical Practice

BACKGROUND

The quality of antithrombotic therapy for patients with nonvalvular atrial fibrillation during routine medical care is often suboptimal. Evidence linking stroke and bleeding risk with antithrombotic treatment is limited. The purpose of this study was to evaluate the associations between antithrombotic treatment episodes and outcomes.

METHODS AND RESULTS

A retrospective longitudinal observational cohort study was conducted using patients newly diagnosed with nonvalvular atrial fibrillation with 1 or more stroke risk factors (CHADS2 ≥1) in Kaiser Permanente Southern California between January 1, 2006 and December 31, 2011. A total of 1782 stroke and systemic embolism (SE) and 3528 major bleed events were identified from 23 297 patients during the 60 021 person-years of follow-up. The lowest stroke/SE rates and major bleed rates were observed in warfarin time in therapeutic range (TTR) ≥55% episodes (stroke/SE: 0.87 [0.71 to 1.04]; major bleed: 4.91 [4.53 to 5.28] per 100 person-years), which was similar to the bleed rate in aspirin episodes (4.95 [4.58 to 5.32] per 100 person-years). The warfarin TTR ≥55% episodes were associated with a 77% lower risk of stroke/SE (relative risk=0.23 [0.18 to 0.28]) compared to never on therapy; and the warfarin TTR <55% and on-aspirin episodes were associated with a 20% lower and with a 26% lower risk of stroke/SE compared to never on therapy, respectively. The warfarin TTR <55% episodes were associated with nearly double the risk of a major bleed compared to never on therapy (relative risk=1.93 [1.74 to 2.14]).

CONCLUSIONS

Continuation of antithrombotic therapy as well as maintaining an adequate level of TTR is beneficial to prevent strokes while minimizing bleeding events.

Differences in access to services in rural emergency departments of Quebec and Ontario

Introduction

Rural emergency departments (EDs) are important safety nets for the 20% of Canadians who live there. A serious problem in access to health care services in these regions has emerged. However, there are considerable geographic disparities in access to trauma center in Canada. The main objective of this project was to compare access to local 24/7 support services in rural EDs in Quebec and Ontario as well as distances to Levels 1 and 2 trauma centers.

Materials and Methods

Rural EDs were identified through the Canadian Healthcare Association's Guide to Canadian Healthcare Facilities. We selected hospitals with 24/7 ED physician coverage and hospitalization beds that were located in rural communities. There were 26 rural EDs in Quebec and 62 in Ontario meeting these criteria. Data were collected from ministries of health, local health authorities, and ED statistics. Fisher’s exact test, the t-test or Wilcoxon-Mann-Whitney test, were performed to compare rural EDs of Quebec and Ontario.

Results

All selected EDs of Quebec and Ontario agreed to participate in the study. The number of EDs visits was higher in Quebec than in Ontario (19 322 ± 6 275 vs 13 446 ± 8 056, p = 0.0013). There were no significant differences between Quebec and Ontario’s local population and small town population density. Quebec’s EDs have better access to advance imaging services such as CT scanner (77% vs 15%, p < .0001) and most the consultant support and ICU (92% vs 31%, p < .0001). Finally, more than 40% of rural EDs in Quebec and Ontario are more than 300 km away from Levels 1 and 2 trauma centers.

Conclusions

Considering that Canada has a Universal health care system, the discrepancies between Quebec and Ontario in access to support services are intriguing. A nationwide study is justified to address this issue.

Developing a stroke severity index based on administrative data was feasible using data mining techniques

OBJECTIVES

Case-mix adjustment is difficult for stroke outcome studies using administrative data. However, relevant prescription, laboratory, procedure, and service claims might be surrogates for stroke severity. This study proposes a method for developing a stroke severity index (SSI) by using administrative data.

STUDY DESIGN AND SETTING

We identified 3,577 patients with acute ischemic stroke from a hospital-based registry and analyzed claims data with plenty of features. Stroke severity was measured using the National Institutes of Health Stroke Scale (NIHSS). We used two data mining methods and conventional multiple linear regression (MLR) to develop prediction models, comparing the model performance according to the Pearson correlation coefficient between the SSI and the NIHSS. We validated these models in four independent cohorts by using hospital-based registry data linked to a nationwide administrative database.

RESULTS

We identified seven predictive features and developed three models. The k-nearest neighbor model (correlation coefficient, 0.743; 95% confidence interval: 0.737, 0.749) performed slightly better than the MLR model (0.742; 0.736, 0.747), followed by the regression tree model (0.737; 0.731, 0.742). In the validation cohorts, the correlation coefficients were between 0.677 and 0.725 for all three models.

CONCLUSION

The claims-based SSI enables adjusting for disease severity in stroke studies using administrative data.

National trends in stroke after acute myocardial infarction among Medicare patients in the United States: 1999 to 2010

BACKGROUND

Stroke is a common and important adverse event after acute myocardial infarction (AMI) in the elderly. It is unclear whether the risk of stroke after AMI has changed with improvements in treatments and outcomes for AMI in the last decade.

METHODS

To assess trends in risk of stroke after AMI, we used a national sample of Medicare data to identify Fee-for-Service patients (n = 2,305,441) aged ≥65 years who were discharged alive after hospitalization for AMI from 1999 to 2010.

RESULTS

We identified 57,848 subsequent hospitalizations for ischemic stroke and 4,412 hospitalizations for hemorrhagic stroke within 1 year after AMI. The 1-year rate of ischemic stroke decreased from 3.4% (95% CI 3.3%-3.4%) to 2.6% (2.5%-2.7%; P < .001). The risk-adjusted annual decline was 3% (hazard ratio, 0.97; [0.97-0.98]) and was similar across all age and sex-race groups. The rate of hemorrhagic stroke remained stable at 0.2% and did not differ by subgroups. The 30-day mortality for patients admitted with ischemic stroke after AMI decreased from 19.9% (18.8%-20.9%) to 18.3% (17.1%-19.6%) and from 48.3% (43.0%-53.6%) to 45.7% (40.3%-51.2%) for those admitted with hemorrhagic stroke. We observed a decrease in 1-year mortality from 37.8% (36.5%-39.1%) to 35.3% (33.8%-36.8%) for ischemic stroke and from 66.6% (61.4%-71.5%) to 60.6% (55.1%-65.9%) for hemorrhagic stroke.

CONCLUSIONS

From 1999 to 2010, the 1-year risk for ischemic stroke after AMI declined, whereas the risk of hemorrhagic stroke remained unchanged. However, 30-day and 1-year mortality continued to be high.

Influence of hospital-level practices on readmission after ischemic stroke

OBJECTIVE

To inform stroke quality improvement initiatives by determining the relationship between hospital-level stroke practices and readmission after accounting for patient-level factors.

METHODS

Retrospective cohort study of adult patients hospitalized for ischemic stroke (principal ICD-9-CM codes 433.x1, 434.x1, and 436) in 5 states from 2003 to 2009 from State Inpatient Databases. The primary outcome was any unplanned readmission within 30 days. Multilevel logistic regression was used to estimate the association between hospital-level practice patterns of care (diagnostic testing, procedures, intensive care unit, tissue plasminogen activator, and therapeutic modalities) and readmission after adjustment for patient factors and whether individual patients received a given practice.

RESULTS

Thirty-day unplanned readmission occurred in 15.2% of stroke admissions; the median hospital readmission rate was 13.6% (interquartile range 9.8%-18.2%). Of the 25 hospital practice patterns of care analyzed, 3 practices were associated with readmission: hospitals with higher use of occupational therapy and higher proportion of transfers from other hospitals had lower adjusted readmission rates, whereas hospitals with higher use of hospice had higher predicted readmission rates. Readmission rates in lowest vs highest utilizing quintile were as follows: occupational therapy 16.2% (95% confidence interval [CI] 14.5%-18.0%) vs 12.3% (95% CI 11.3%-13.2%); transfers 13.8% (95% CI 13.2%-14.5%) vs 12.5% (95% CI 11.6%-13.5%); and hospice 13.1% (95% CI 12.3%-14.0%) vs 14.8% (95% CI 13.5%-16.1%).

CONCLUSIONS

Hospital practices have a role in stroke readmission that is complex and poorly understood. Further work is needed to identify specific strategies to reduce readmission rates and to ensure that public reporting of readmission rates will not result in adverse unintended consequences.

Prognosis of emergency department patients with suspected infection and intermediate lactate levels: a systematic review

PURPOSE

Previous studies have shown a correlation between blood lactate greater than 4.0 mmol/L and mortality in patients with suspected infection in the emergency department (ED), but data are more limited regarding the prognosis of intermediate blood lactate (2.0-3.9 mmol/L), particularly in the absence of hemodynamic instability. We sought to quantify the prognostic significance of intermediate blood lactate levels in ED patients with suspected infection, emphasizing patients without hypotension.

METHODS

A systematic review of 4 databases was conducted to identify studies using a comprehensive search strategy. All studies performed on adult ED patients with suspected infection and available data on hemodynamics, intermediate lactate levels, and mortality rates were included.

RESULTS

We identified 20 potential publications, 8 of which were included. Intermediate lactate elevation was found in 11,062 patients with suspected or confirmed infection, 1672 (15.1%) of whom died. Subgroup analysis of normotensive patients demonstrated a mortality of 1561 (14.9%) of 10,442, with rates from individual studies between 3.2% and 16.4%.

CONCLUSION

This systematic review found that among ED patients with suspected infection, intermediate lactate elevation is associated with a moderate to high risk of mortality, even among patients without hypotension. Physicians should consider close monitoring and aggressive treatment for such patients.

A descriptive study of access to services in a random sample of Canadian rural emergency departments

OBJECTIVE

To examine 24/7 access to services and consultants in a sample of Canadian rural emergency departments (EDs).

DESIGN

Cross-sectional study-mixed methods (structured interview, survey and government data bases) with random sampling of hospitals.

SETTING

Canadian rural EDs (rural small town (RST) definition-Statistics Canada).

PARTICIPANTS

28% (95/336) of Canadian rural EDs providing 24/7 physician coverage located in hospitals with acute care hospitalisation beds.

MAIN OUTCOME MEASURES

General characteristics of the rural EDs, information about 24/7 access to consultants, equipment and services, and the proportion of rural hospitals more than 300 km from levels 1 and 2 trauma centres.

RESULTS

Of the 336 rural EDs identified, 122 (36%) were randomly selected and contacted. Overall, 95 EDs participated in the study (participation rate, 78%). Hospitals had, on an average, 23 acute care beds, 7 ED stretchers and 13 500 annual ED visits. The proportion of rural hospitals with local access to the following 24/7 services was paediatrician, 5%; obstetrician, 10%; psychiatrist, 11%; internist, 12%; intensive care unit, 17%; CT scanner, 20%; surgeon, 26%; ultrasound, 28%; basic X-ray, 97% and laboratory services, 99%. Forty-four per cent and 54% of the RST EDs were more than 300 km from a level 1 and level 2 trauma centre, respectively.

CONCLUSIONS

This is the first study describing the services available in Canadian rural EDs. Apart from basic laboratory and X-ray services, most rural EDs have limited access to consultants, advanced imaging and critical care services. A detailed study is needed to evaluate the impact of these limited services on patient outcomes, costs and interfacility transport demands.

Preventable readmissions within 30 days of ischemic stroke among Medicare beneficiaries

BACKGROUND AND PURPOSE

The Centers for Medicare and Medicaid Services proposes to use 30-day hospital readmissions after ischemic stroke as part of the Hospital Inpatient Quality Reporting Program for payment determination beginning in 2016. The proportion of poststroke readmissions that is potentially preventable is unknown.

METHODS

Thirty-day readmissions for all Medicare fee-for-service beneficiaries aged≥65 years discharged alive with a primary diagnosis of ischemic stroke (International Classification of Diseases, Ninth Revision, Clinical Modification 433, 434, 436) between December 2005 and November 2006 were analyzed. Preventable readmissions were identified based on 14 Prevention Quality Indicators developed for use with administrative data by the US Agency for Healthcare Research and Quality. National, hospital-level, and regional preventable readmission rates were estimated. Random-effects logistic regression was also used to determine patient-level factors associated with preventable readmissions.

RESULTS

Among 307 887 ischemic stroke discharges, 44 379 (14.4%) were readmitted within 30 days; 5322 (1.7% of all discharges) were the result of a preventable cause (eg, pneumonia), and 39 057 (12.7%) were for other reasons (eg, cancer). In multivariate analysis, older age and cardiovascular-related comorbid conditions were strong predictors of preventable readmissions. Preventable readmission rates were highest in the Southeast, Mid-Atlantic, and US territories and lowest in the Mountain and Pacific regions.

CONCLUSIONS

On the basis of Agency for Healthcare Research and Quality Prevention Quality Indicators, we found that a small proportion of readmissions after ischemic stroke were classified as preventable. Although other causes of readmissions not reflected in the Agency for Healthcare Research and Quality measures could also be avoidable, hospital-level programs intended to reduce all-cause readmissions and costs should target high-risk patients.