Published online before print May 17, 2007, doi: 10.1161/STROKEAHA.107.487249
(Stroke. 2007;38:1727.)
© 2007 American Heart Association, Inc.
Editorials |
Poststroke Care
Chronicles of a Neglected Battle
From the Stroke research Unit (G.S.), Division of Neurology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Canada; the Mobility Program (G.S.), Clinical Research Unit, Department of Medicine, Toronto, Canada; the Department of Medicine and Health Policy (M.K.K.), Management and Evaluation, University of Toronto; Division of General Internal Medicine and Clinical Epidemiology and Women’s Health Program, University Health Network, Canada; and the Institute for Clinical Evaluative Sciences (ICES) (M.K.K.), Toronto, Canada.
Correspondence to Dr Gustavo Saposnik, 55 Queen St EAST, Suite 9-31, Toronto, ON-M5C 1R6 Canada. E-mail saposnikg{at}smh.toronto.on.ca
See related article, pages 1899–1904.
Key Words: stroke • mortality • outcome research • rehospitalization • Health policy • health services research • hospital admissions • cerebrovascular disease
"Thinking is easy, acting is difficult, and to put one’s thoughts into action is the most difficult thing in the world".— —Goethe (1749–1832)
Major advances in acute stroke management have been seen over the past decade, including the use of thrombolysis, antithrombotic therapy, and organized in-hospital stroke care. However, relatively few studies have evaluated the effectiveness of these interventions in routine clinical practice, or have assessed issues related to delivery of services, access to care, and long-term care after discharge from stroke.
In this issue of Stroke, Bravata et al1 contribute to our understanding of outcomes after stroke by analyzing readmissions and deaths in the first 5 years after a hospitalization for stroke. The target population included stroke survivors aged over 65 years who were Medicare beneficiaries and who were discharged from Connecticut acute care hospitals in 1995. This population was followed from discharge in 1995 through 2000 using Medicare claims and Social Security Administration mortality data. Among 2603 patients discharged alive, 40% were readmitted at least once within the first year of discharge, 53% had died or been readmitted within 1 year and only 15% survived admission-free for 5 years. Leading causes for readmission included pneumonia (8.2% to 9.0%), stroke (3.9% to 6.1%) and acute myocardial infarction (4.2% to 6.0%). There was no apparent association between length of hospital stay and readmission rate (unreported data kindly provided by the authors, 2007), and no information was available on potential patient and system factors associated with higher hospital readmission rates.
Lower readmission rates of 25% to 27% within 1 year have been previously reported.2,3 These studies found that the average number of days of rehospitalization was 23.2 Stroke was the single most frequent reason for readmission followed by cardiac disease, with no significant differences among ethnic groups (blacks, Hispanics, and whites).3 However, the strikingly high death and readmission rates after stroke published by Bravata et al are consistent with findings from some previous reports. For example, in a study including veterans living in the state of Florida, 12-month rehospitalization rate was 31.1%, whereas mortality rate was 11.7%. Dual or triple system use (Veterans Health Administration, Medicare, or Medicaid), malnutrition, dysphagia and stroke type were associated with hospital readmissions.4 In another study including Medicare beneficiaries from 11 metropolitan regions in the eastern of US, mortality (18% to 23%) and rehospitalization (37% to 47%%) rates 11 months after stroke were similar for 30-day survivors.5
What Does This Study Add to Our Knowledge?
The study of Bravata et al revealed a mixed picture with regard to the often neglected battle against stroke: long-term poststroke care. This descriptive study confirms the enormous impact of stroke on hospitalization-free survival. However, the reasons behind the high observed death and readmission rates remain incompletely understood, and the reader may wonder whether these rates were expected or unexpected. Were these findings the natural consequence of older age, high comorbidity or other factors known to be associated with poor outcomes, or were there inadequacies in the care or follow-up of stroke patients that might have contributed to poor outcomes? The patients in this study cohort were elderly and with a high prevalence of baseline comorbid illness: 50% were aged over 80 years, 52% had a Charlson-Deyo comorbidity index score 
2 and 27% had been hospitalized in the year before the index stroke admission, all factors likely to be associated with death or hospitalization, regardless of the quality of stroke care delivery. The overall increasing stroke hospitalization rates associated with aging of the US population may be another contributing factor.6 On the other hand, health system factors (hospital stroke volume, provider specialty, level of experience, hospital status, variations in timing of service-day/night, weekday/weekends) have also been shown to influence stroke outcomes,7–12 as have interventions such as risk factor modification, secondary stroke prevention and stroke rehabilitation, and it is here that there may be opportunities for improvements in stroke care and patient outcomes.
Rehospitalization: A New End Point in Clinical Trials?
Rehospitalization is increasingly being used not only as a clinical outcome, but also as an end point in clinical trials of cardiovascular interventions. For example, in the area of cardiology, digoxin13,14 and angiotensin-converting enzyme inhibitors15 have been shown to decrease hospitalization rates in patients with congestive heart failure, and β-blockers have been shown to decrease the need for rehospitalization in survivors of an acute coronary syndrome.16 In the field of stroke, antiplatelet therapy before hospital discharge is a widely accepted recommendation for secondary stroke prevention as well as an indicator of quality of stroke care.17–19 In the CAPRIE trial (Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events), treatment with clopidogrel was associated with a significant decrease in rehospitalizations for ischemic events or bleeding (12.4% versus 13.6%; P=0.015). Because rehospitalization was not a prespecified end point, that information was determined from the adverse event forms not adjudicated by a clinical events committee.20 In the CHARISMA trial (Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance), the combination of clopidogrel plus aspirin was more effective than aspirin alone in reducing rehospitalizations for unstable angina, transient ischemic attacks or revascularization (11.1% versus 12.3%; risk reduction 0.90, 95% CI 0.82 to 0.98).21 In the MATCH trial (Management of Atherosclerosis with clopidogrel in high-risk patients), patients with a recent stroke or transient ischemic attack were randomized to aspirin plus clopidogrel versus clopidogrel alone. For the primary end point (ischemic stroke, myocardial infarction, vascular death, or rehospitalization for an acute ischemic event), the addition of aspirin to clopidogrel did not provide any additional benefit (event rates were 16% for aspirin plus clopidogrel and 17% for placebo plus clopidogrel; relative risk reduction 6.4%, nonsignificant).22 When analyzing readmission rates as a single end point, no significant differences were observed between both arms (4% versus 5%, nonsignificant).
Other nonpharmacological interventions showed an impact in preventing death and rehospitalizations. Recently, the role of specialist has also been analyzed in the management of cardio- and cerebrovascular conditions. For example, patients with acute myocardial infarction admitted to hospitals by cardiologists were more likely to have a cardiac procedure performed, but were 12% less likely to die over the ensuing year than if they were admitted by a noncardiac specialist primary care physician.23 Other studies found that hospital readmissions for congestive heart failure were lower in patients cared for by cardiologists.24 In the field of stroke, care by neurologists was associated with lower in-hospital mortality (5.6% versus 13.5%; odds ratio=0.38; 95% CI 0.22, 0.68; P=0.001) and higher proportion of patients discharged with little or no disability (54% versus 43%; odds ratio=0.64; 95% CI 0.45, 0.92; P=0.02) at the time of discharge. The benefit remained after controlling for stroke severity and comorbidity (odds ratio=0.63; 95% CI 0.42, 0.94; P=0.025).25
Practical Implications
Prevention of death, reducing risks of a recurrent event and its complications, and improving functioning and well-being are the main priorities in the treatment of stroke patients. Perhaps, rehospitalization is not the best outcome measure in stroke studies, but the high rehospitalization rate and dramatically low survival admission-free at 5 years published by Bravata and colleagues highlights a major public health burden and potential gaps between in-hospital and postdischarge (long-term) stroke care.
Stroke care is a continuum that begins before hospitalization and continues after discharge. Given the burden of cerebrovascular disease and the complexity of stroke care, short-term outcomes are meaningless for population health. Even in countries with universal health insurance, the contact with the healthcare system (family doctor, social worker, or neurologist) immediately poststroke discharge is crucial, particularly considering the need for appropriate risk factor modification and secondary prevention of stroke, the emotional distress associated with either a new environment (nursing home, rehabilitation institution) or a different health status if returning home, and healthcare postdischarge from a rehabilitation institution. As part of discharge planning, a connection between inpatient care with community services may help improve stroke outcomes by enabling stroke survivors to go home earlier with the support of occupational therapy, physiotherapy, speech language pathology and nursing services in the home, while reducing disability and need for long-term institutional care.26,27
Health administrators, providers, policymakers and clinical medical journals should encourage the implementation and publication of studies on health services research and novel strategies to improve the quality of stroke care. Future studies in this area should focus on understanding the reasons for readmission and death after stroke, as well as the evaluation of targeted interventions to improve long-term stroke outcomes.
As stroke care providers, our mission is to provide collaborative, high-quality, standardized, and cost-effective care, carried out by an interdisciplinary stroke team using protocols based on best practices. Our pending assignment is to optimize and implement strategies ensuring the continuum of stroke care postdischarge, and thus provide a more comprehensive and integrated approach translating into better long-term outcomes in stroke survivors.
Acknowledgments
We thank Dr Neville Bayer for his comments.
Sources of Funding
Dr Kapral is supported by a New Investigator Award from the Canadian Institutes for Health Research and by the University Health Network Women’s Health Program and by the Canadian Stroke Network. This research was supported in part by a grant of the Heart Stroke Foundation of Canada (HSFC) and Canadian Institutes for Health Research (CIHR) given to Dr Gustavo Saposnik.
Disclosures
The grants noted above were obtained based on competitive applications following publication of grant advertisements. The investigators acted as the sponsors of the study. None of the supporting agencies (HSFC, CIHR) had input on the design, access to the data, analyses, interpretation, or publication of the study.
Footnotes
The opinions in this editorial are not necessarily those of the editors or of the American Heart Association.
References
1. Bravata DM. Readmission and death after hospitalization for acute ischemic stroke: five-year follow-up in the medicare population. Stroke. 2007; 38: 1899–1904.
2. Thorngren M, Westling B, Norrving B. Outcome after stroke in patients discharged to independent living. Stroke. 1990; 21: 236–240.
3. Sacco R, Hauser W, Mohr J. Hospitalized stroke in blacks and Hispanics in northern Manhattan. Stroke. 1991; 22: 1491–1496.
4. Jia H, Zheng Y, Reker DM, Cowper DC, Wu SS, Vogel WB, Young GC, Duncan PW. Multiple system utilization and mortality for veterans with stroke. Stroke. 2007; 38: 355–360.
5. Smith MA, Frytak JR, Liou JI, Finch MD. Rehospitalization and survival for stroke patients in managed care and traditional medicare plans. Med Care. 2005; 43: 902–910.[CrossRef][Medline] [Order article via Infotrieve]
6. Fang J, Alderman MH. Trend of stroke hospitalization, United States, 1988–1997. Stroke. 2001; 32: 2221–2226.
7. Saposnik G, Baibergenova A, O’Donnell M, Hill M, Kapral M, Hachinski V. Hospital volume and stroke mortality: does it matter? Neurology. 2007; In press.
8. Birbeck GL, Zingmond DS, Cui X, Vickrey BG. Multispecialty stroke services in california hospitals are associated with reduced mortality. Neurology. 2006; 66: 1527–1532.
9. Saposnik G, Baibergenova A, Bayer N, Hachinski V. Weekends: a dangerous time for having a stroke? Stroke. 2007; 38: 1211–1215.
10. Johnston SC. Effect of endovascular services and hospital volume on cerebral aneurysm treatment outcomes. Stroke. 2000; 31: 111–117.
11. De Luca G, Suryapranata H, Ottervanger JP, van’t Hof AW, Hoorntje JC, Gosselink AT, Dambrink JH, Zijlstra F, de Boer MJ. Circadian variation in myocardial perfusion and mortality in patients with ST-segment elevation myocardial infarction treated by primary angioplasty. Am Heart J. 2005; 150: 1185–1189.[CrossRef][Medline] [Order article via Infotrieve]
12. Nadeau JO, Fang J, Kapral MK, Silver FL, Hill MD. Outcome after stroke upon awakening. Can J Neurol Sci. 2005; 32: 232–236.[Medline] [Order article via Infotrieve]
13. Ahmed A, Rich MW, Love TE, Lloyd-Jones DM, Aban IB, Colucci WS, Adams KF, Gheorghiade M. Digoxin and reduction in mortality and hospitalization in heart failure: a comprehensive post hoc analysis of the DIG trial. Eur Heart J. 2006; 27: 178–186.
14. The effect of digoxin on mortality and morbidity in patients with heart failure. The digitalis investigation group. N Engl J Med. 1997; 336: 525–533.
15. Luzier AB, Forrest A, Adelman M, Hawari FI, Schentag JJ, Izzo JL Jr. Impact of angiotensin-converting enzyme inhibitor underdosing on rehospitalization rates in congestive heart failure. Am J Cardiol. 1998; 82: 465–469.[CrossRef][Medline] [Order article via Infotrieve]
16. Soumerai SB, McLaughlin TJ, Spiegelman D, Hertzmark E, Thibault G, Goldman L. Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction. JAMA. 1997; 277: 115–121.
17. Adams H, Adams R, Del Zoppo G, Goldstein LB. Guidelines for the early management of patients with ischemic stroke: 2005 guidelines update a scientific statement from the stroke council of the American Heart Association/American Stroke Association. Stroke. 2005; 36: 916–923.
18. Sacco RL, Adams R, Albers G, Alberts MJ, Benavente O, Furie K, Goldstein LB, Gorelick P, Halperin J, Harbaugh R, Johnston SC, Katzan I, Kelly-Hayes M, Kenton EJ, Marks M, Schwamm LH, Tomsick T. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: A statement for healthcare professionals from the American Heart Association/American Stroke Association council on stroke: Cosponsored by the council on cardiovascular radiology and intervention: The American Academy of Neurology affirms the value of this guideline. Stroke. 2006; 37: 577–617.
19. Lindsay MP, Kapral MK, Gladstone D, Holloway R, Tu JV, Laupacis A, Grimshaw JM. The Canadian Stroke Quality of Care study: establishing indicators for optimal acute stroke care. CMAJ. 2005; 172: 363–365.
20. Bhatt DL, Hirsch AT, Ringleb PA, Hacke W, Topol EJ. Reduction in the need for hospitalization for recurrent ischemic events and bleeding with clopidogrel instead of aspirin. CAPRIE investigators. Am Heart J. 2000; 140: 67–73.[CrossRef][Medline] [Order article via Infotrieve]
21. Bhatt DL, Fox KA, Hacke W, Berger PB, Black HR, Boden WE, Cacoub P, Cohen EA, Creager MA, Easton JD, Flather MD, Haffner SM, Hamm CW, Hankey GJ, Johnston SC, Mak KH, Mas JL, Montalescot G, Pearson TA, Steg PG, Steinhubl SR, Weber MA, Brennan DM, Fabry-Ribaudo L, Booth J, Topol EJ. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med. 2006; 354: 1706–1717.
22. Diener HC, Bogousslavsky J, Brass LM, Cimminiello C, Csiba L, Kaste M, Leys D, Matias-Guiu J, Rupprecht HJ. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (match): Randomised, double-blind, placebo-controlled trial. Lancet. 2004; 364: 331–337.[CrossRef][Medline] [Order article via Infotrieve]
23. Jollis JG, DeLong ER, Peterson ED, Muhlbaier LH, Fortin DF, Califf RM, Mark DB. Outcome of acute myocardial infarction according to the specialty of the admitting physician. N Engl J Med. 1996; 335: 1880–1887.
24. Jong P, Gong Y, Liu PP, Austin PC, Lee DS, Tu JV. Care and outcomes of patients newly hospitalized for heart failure in the community treated by cardiologists compared with other specialists. Circulation. 2003; 108: 184–191.
25. Goldstein LB, Matchar DB, Hoff-Lindquist J, Samsa GP, Horner RD. VA stroke study: neurologist care is associated with increased testing but improved outcomes. Neurology. 2003; 61: 792–796.
26. Teasell R, Foley N, Bhogal S, Bagg S, Jutai J. Evidence-based practice and setting basic standards for stroke rehabilitation in Canada. Top Stroke Rehabil. 2006; 13: 59–65.[CrossRef][Medline] [Order article via Infotrieve]
27. Therapy-based rehabilitation services for stroke patients at home. Cochrane Database Syst Rev. 2003:CD002925. DOI 10.1002/14651858.CD002925
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