Data suggest that nationally representative readmission metrics be used to benchmark hospital’s performance.
Farhaan S. Vahidy, PhD, MBBS, MPH
In a 6-year population-based cohort study of approximately 2 million adult patients who had a stroke, 30-day hospital readmission declined by an annual mean of 3.3% between 2010-2014.
The study which provides the first comprehensive nationwide analysis of 30-day readmission rates for both Medicare and privately insured patients with different types of stroke, was conducted to provide US nationwide estimates and a temporal trend for overall, planned and potentially preventable 30-day hospital readmission among patients with ischemic and hemorrhagic stroke; to investigate the association between hospitals’ stroke discharge volume, teaching status, and 30-day readmission; and to highlight explanations for 30-day readmission, exploring the association of 30-day readmission in terms of mortality, length of stay, and cost of care among patients.
"The primary finding of our study is that early (30-day) readmissions among stroke patients have declined in the period between 2010 and 2014," Farhaan Vahidy, MBBS, PhD, MPH, assistant professor in neurology at McGovern Medical School at UTHealth in Houston, told NeurologyLive. "However, it seems that this readmission reduction may be associated with an overall decline in readmission for other conditions such as cardiac conditions. Readmissions that had the same discharge diagnoses as the index admission have not declined and have unfortunately increased for ischemic stroke patients. This finding coupled with the primary reason for readmission highlights the continued focus on secondary stroke prevention. Our study also demonstrates, for the first time, that readmission rates among brain hemorrhage patients are higher as compared to patients with ischemic stroke. It is well known that patients with brain hemorrhage experience higher level of mortality but an added increased burden of readmission has wider systems of care and health policy implications."
Researchers analyzed more than 2 million stroke events in the Nationwide Readmissions Database of the Healthcare Cost and Utilization Project between Jan. 1, 2010 and Sept. 30, 2015 stratified by stroke type, which represented 50% of all hospitalizations in 22 states. Readmission was defined as any admission within 30 days of index hospitalization discharge. Participants were adults with a primary discharge diagnosis of intracerebral hemorrhage, acute ischemic stroke of subarachnoid hemorrhage. Based on criteria, researchers included data from 2,078,854 patients with a mean age of 70.02 years and 51.9% female.
Hospitals were categorized by annual stroke discharge volume as low (11—50), medium (51–175), high (176–350) or very high (>350), and were classified as teaching hospitals if there was an American Medical Association-approved program or if they had a ratio of full-time equivalent interns and residents to beds of 0.25 or higher.
The results found that 30-day readmission was highest for patients with intracerebral hemorrhage (13.70%; 95% CI, 13.40%-13.99%), followed by patients with acute ischemic stroke (12.44%; 95% CI, 12.33%-12.55%) and patients with subarachnoid hemorrhage (11.48%; 95% CI, 11.01%-11.96%). More than 90% of all 30-day stroke-related readmissions were unplanned and depending on stroke type, up to 13.6% were considered potentially preventable.
The overall proportion of 30-day stroke-related readmission was reported highest in 2010 (13.47%; 95% CI, 13.19%-13.76%). Researchers reported a statistically significant annual decline in the likelihood of 30-day readmission rate by 4% throughout the period of investigation (OR, 0.96; 95% CI, 0.95-.097) after potential changes in demographic, social and comorbidity case mix across years was controlled.
The study also reported that patients with acute ischemic stroke who experience 30-day readmission have a greater mortality rate, longer length of stay and higher cost per stay on readmission versus the mean of the metrics on index admission. Excess cost on readmission is likely explained by a longer length of stay and is attributable to the need for higher intensity of care. Significant differences in readmission rates between payers was also reported (OR, 0.70; 95% CI, 0.68-0.72 for private insurance versus Medicare), after controlling for age.
Despite readmission rates falling by 3.3% a year on average between 2010-2014, those discharged from nonteaching hospitals with high stroke discharge volume faced a significantly greater risk of readmission primarily due to acute cerebrovascular disease and related complications or septicemia. It’s likely that many teaching hospitals are reporting data to national registries and are regional telestroke centers, consistently providing a better quality of life to patients with stroke even at higher volumes.
"Several aspects of teaching hospitals may be helpful in reducing readmissions," added Vahidy. "First, it has been shown in our prior work that treatment with IV tPA (clot dissolving drug) is associated with lower rates of 30-day readmissions. It is also known that likelihood of IV tPA treatment is higher at teaching hospitals for eligible ischemic stroke patients. Second, a number of teaching hospitals in our data may be certified in providing better quality of care to stroke patients. Such certifications, for instance, certification by The Joint Commission for Primary and Comprehensive stroke centers may enable teaching hospitals to track, report, and remedy quality of care issues. These issues include measures of secondary stroke prevention and since we find that to be a major reason for readmission, it may explain why teaching hospitals tend to have lower 30-day readmission. Finally, teaching hospitals may be utilizing better procedures and technology for early patient follow-up either via traditional post-discharge clinics, or use of telemedicine technologies. These measures may have a potential beneficial influence for reducing readmissions."
Researchers provide novel and contemporary evidence of declining 30-day readmission among patients with stroke, which seems to be explained by the overall decline in 30-day readmission for other high-volume conditions. Nonteaching hospitals with a higher stroke discharge volume were identified as potential targets for improving stroke-related readmission, possibly focusing on secondary stroke prevention.
This research highlights a plethora of information that individual hospitals can utilize to identify issues and prevent secondary complications of stroke. The researchers provide an estimate of a temporal trend as a metric for planning and evaluating readmission reduction strategies for each hospital. More robust approaches and planning strategies are needed to minimize hospital readmissions and improve outcomes for patients who had a stroke.
"Our ongoing work is targeted to understand the reasons for readmission among stroke patients. Readmission is a complex issue and can occur not only due to reasons related to clinical care but patient level, health care systems level, and societal level factors all interplay in causality of readmissions. Understanding the contribution of such factors is not possible by utilizing existing databases and a directed effort is needed to understand such phenomenon," Vahidy concluded. "Our study provides preliminary evidence that there may be differences in hospital types for rates of 30-day readmission, even when we compare same type of stroke patients. This question needs to be further evaluated and hospital level factors that may curtail readmission need to be understood better."
Bambhroliya A, Donnelly J, Thomas E, et al. Estimates and Temporal Trend for US Nationwide 30-Day Hospital Readmission Among Patients With Ischemic and Hemorrhagic Stroke. JAMA Neurology Open. 2018;1(4):e181190.