Death and Readmission Rates After Stroke 'Staggering' for Medicare Patients

Pauline Anderson

December 16, 2010

December 16, 2010 — Almost two-thirds of Medicare beneficiaries discharged from hospital after an ischemic stroke die or are readmitted within a year, a new study has found.

The study also showed that these postdischarge death and rehospitalization rates varied considerably among hospitals. Although academic hospitals and those in the Northeast and West had slightly more favorable outcomes, the size of an institution or its stroke center designation did not make much of a difference in terms of mortality and readmission rates.

"The very high rates of death and rehospitalization are in a sense staggering, and despite some advances, stroke continues to place a burden on this patient population, which is fee-for-service Medicare beneficiaries," said lead study author Gregg C. Fonarow, MD, professor of cardiovascular medicine at the University of California at Los Angeles and associate chief of the Division of Cardiology at the David Geffen School of Medicine. "Also striking is the very substantial variation in clinical outcomes by hospitals."

Their findings are published online December 16 in Stroke.

2-Fold Difference in Rates

For this analysis, Dr. Fonarow and colleagues linked data on ischemic stroke admissions in the Get With the Guidelines–Stroke (GWTG-Stroke) Program to enrollment files and inpatient claims from the Centers for Medicare and Medicaid Services. The study included 91,134 Medicare beneficiaries 65 years and older who were hospitalized for acute ischemic stroke between April 1, 2003, and December 31, 2006.

The median age of these subjects was 79.3 years; 57.9% were female and 82.4% were white. Comorbidities, including diabetes, coronary artery disease, and history of atrial fibrillation or flutter, were common.

They found that the overall rate of death or rehospitalizaton within 1 year of hospital discharge was 61.9%.

The outcome rates varied widely among hospitals. For example, there was about a 2-fold difference in unadjusted outcomes between the 10th and 90th percentile hospitals at 30 days, 90 days, and 1 year after discharge.

The 30-day, risk-adjusted death and admission for hospitals at the 10th percentile was 9.8% compared with 17.8% at the 90th percentile. Causes of first rehospitalization within 30 days were cerebrovascular disease (14.9%), cardiovascular disease (14.0%), and noncardiovascular (71.2%).

No Variation Over Time

There was almost no variation in outcomes between 2003 and 2006. For example, the 30-day mortality rate from admission was 14.1% in 2003 and 14.2% in 2006. This might call into question the role of the GWTG-Stroke Program during that period, but Dr. Fonarow noted that the study was not designed to investigate the impact of this program.

Rates were only slightly lower for academic hospitals compared with nonacademic centers. "That was surprising," said Dr. Fonarow. "Whether a hospital was academic or bedside or, more importantly, a joint commission primary stroke center really did not make a large difference in outcomes."

Hospitals located in the West and Northeast also had slightly better outcomes compared with those in the South or Midwest. However, this and other hospital characteristics accounted for only 2% to 5% of the variation in clinical outcomes; there were higher and lower performing hospitals among each type of hospital and for each outcome.

What is causing the wide variation among hospitals "is the great question," said Dr. Fonarow. "It wasn't the things we measured per se, which were things like the hospital characteristics and the patient characteristics or case mix."

Important Next Step

It will be up to future studies to try to understand what puts some hospitals in the highest percentiles of performance, added Dr. Fonarow.

"Understanding what it is about what they're doing is an important next step," he said. "It wasn't something as simple as where the hospital was located or the number of beds they had; it was more around the processes they had, the systems they had in place, and those were variables we didn’t have access to in this study."

Because the study did not include younger or non-Medicare patients, it does not paint the full picture; however, because most strokes occur in patients 65 years and older, "it does give us important information on a large cohort of patients who are having ischemic stroke," said Dr. Fonarow.

There are several areas of potential improvement in stroke care, the study authors write. For example, many acute ischemic stroke patients in the study arrived by private transport instead of through emergency medical services, and stroke severity was measured and documented in only 37% of patients.

As well, because more than half of readmissions were for noncardiovascular causes, there's room for better secondary prevention efforts, Dr. Fonarow notes.

"When you looked at causes of readmission, in many cases it was not a recurrent stroke or cardiovascular event but other comorbid conditions, things like pneumonia, falls, and [gastrointestinal] bleeds," he said. "It shows you that when caring for someone after a stroke, managing these comorbid conditions and related risks is going to be critical."

He added that the period after discharge for an ischemic stroke offers a "window of opportunity" for interventions to reduce the burden of postischemic stroke morbidity and mortality.

Evidence-Based Care

Approached for a comment, Ralph L. Sacco, MD, president of the American Heart Association (AHA) and chief of neurology at Jackson Memorial Hospital and the University of Miami's Miller School of Medicine in Florida, said stroke rates in this Medicare sample may be higher than for all stroke patients in the United States because they were older and had more cardiac conditions as well as prior strokes.  

"The bottom line is we need to do everything we can to improve the quality of life after stroke," Dr. Sacco said. "The AHA/ASA is continuing to help hospitals practice evidence-based care and help stroke survivors take their medications, control their blood pressure, cholesterol, and blood sugar, as well as strive towards ideal cardiovascular health."

Dr. Fonarow receives research support from the National Institutes of Health; served as a consultant to Pfizer, Merck, Schering Plough, Bristol Myers Squibb, and Sanofi-Aventis; received honoraria from Pfizer, Merck, Schering Plough, Bristol Myers Squibb, and Sanofi-Aventis; and is an employee of the University of California, which holds a patent on retriever devices for stroke. For disclosure information on other authors, see the original article.

Stroke. Published online December 16, 2010.

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