HONOLULU – Health care reformers looking to drive down preventable 30-day readmission rates will find slim pickings among the nation’s elderly hospitalized for ischemic stroke, according to Judith H. Lichtman, Ph.D.
An analysis of national fee-for-service Medicare data concluded that a mere 1.7% of patients hospitalized for ischemic stroke in 2006 had a potentially preventable readmission within 30 days of discharge, she reported at the International Stroke Conference sponsored by the American Heart Association.
"National programs aimed at reducing 30-day poststroke readmissions may have limited impact unless they focus on the small subset of potentially preventable readmissions. Identifying patients at greatest risk is an important first step for developing postdischarge interventions to minimize preventable readmissions and improve the care transitions for our stroke patients," said Dr. Lichtman of the department of epidemiology at Yale University, New Haven, Conn.
Toward that goal, she and her coinvestigators identified several strong predictors of preventable readmissions following ischemic stroke discharge. These included diabetes, heart failure, age greater than 85, black race, female gender, and prior MI, each of which was independently associated with a 1.4- to 2.3-fold increased risk.
Dr. Lichtman’s study included all 302,565 fee-for-service Medicare patients discharged alive after hospitalization for ischemic stroke in 2006. Of this group, 12.9% had at least one readmission within 30 days, of which 1.7% (5,322) were determined to be potentially preventable using evidence-based measures established by the Agency for Healthcare Research and Quality.
Potentially preventable readmission rates were slightly but statistically significantly higher in the Southeast and Mid-Atlantic states and lower than average in the Mountain and Pacific regions. But outlier hospitals with significantly higher-than-average rates were identified throughout the United States.
Patients deemed by AHRQ criteria to have had a potentially preventable readmission had significantly more comorbid conditions than those who weren’t rehospitalized within 30 days of discharge. For example, they had a 34% prevalence of heart failure and a 36% prevalence of diabetes, compared with 15% and 28% rates, respectively, in those without readmission.
Session cochair Dr. Cheryl Bushnell honed in on this finding, asking whether patients who are already sicker when they have their stroke are less able to withstand the rigors of the hospital experience, and therefore more likely to require early readmission.
"Stroke patients frequently don’t get much sleep in the hospital. They’re NPO until their swallowing status is established, so they’re not getting nutrition. They’re exposed to the risk of infections in the hospital environment. How many of these readmissions are due to the so-called posthospital syndrome – that is, once you’ve been in the hospital and subjected to all the things we need to do to people in the hospital, you’re basically at risk for anything?" commented Dr. Bushnell of Wake Forest University in Winston-Salem, N.C.
Point well taken, replied Dr. Lichtman. The fact is that it’s not at all clear as of yet how many so-called preventable readmissions truly are preventable and thus a quality-of-care problem. This is a hot issue for hospitals now with regard to acute MI because they’re starting to receive financial penalties for higher-than-expected early readmission rates after MI.
Dr. Lichtman’s study was funded by the National Institute of Neurological Disorders and Stroke. She reported having no relevant financial conflicts.