Variation in health care utilization and outcomes in ischemic stroke
Objectives: Little data is available about regional variation in utilization and outcomes during and after ischemic stroke (IS). Examining these relationships can lead to better understanding of the patient and process characteristics that influence stroke outcomes. Methods: Index IS admissions were identified using primary position ICD-9 codes 434 and 436 in a national cohort of veterans hospitalized at any VAMC from 10/90 to 10/97. Demographic, admission, mortality and outpatient data were extracted from VA administrative databases for the regions Northeast (NE), South (S), Midwest (MW) and West (W). Discharge diagnoses were used to assess risk factors and to construct the Charlson Index (CI), a predictor of mortality risk (↑ CI = ↑ risk). Time to death was modeled with Cox regression. Results: We identified 55,094 IS patients (98% male, 73% white, mean age 68). Regional data are summarized in the Table. NE patients were sicker (higher CI), had longer LOS and higher in-hospital mortality. However, adjusted subsequent mortality was lower in the NE and W (hazard ratio NE = .82, W = .91, p<.001 for both). More NE and W patients had a neurology or primary care visit within 60 days or 1 year. Conclusions: Regional variations exist in outcomes and patterns of care after IS. Adjusted subsequent mortality is lower in regions where more patients have follow-up. Prospective studies evaluating these variations are needed to determine the best strategies for providing optimal stroke care.