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Factors Associated With 90-Day Readmission After Stroke/TIA
Study Questions:
What are the patient and health system–level factors associated with all-cause and unplanned hospital readmission within 90 days after acute stroke or transient ischemic attack (TIA)?
Methods:
The investigators used person-level linkages between data from the Australian Stroke Clinical Registry (2009–2013), hospital admissions data, and national death registrations from four Australian states. Time to first readmission (all-cause or unplanned) for discharged patients was examined within 30, 90, and 365 days, using competing risks regression to account for deaths post-discharge. Covariates included age, stroke severity (ability to walk on admission), stroke type, admissions before stroke/TIA, and the Charlson Comorbidity Index (derived from the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, [Australian modified] coded hospital data in the preceding 5 years). Multilevel multivariable logistic regression models were used to identify the initial factors associated with readmission within 90 days. In the second stage, factors identified through this process were used to generate multilevel multivariable Cox proportional hazards regression models, enabling assessment of the time to first readmission.
Results:
Among the 13,594 patients discharged following stroke/TIA (45% female, 65% ischemic stroke, 11% intracerebral hemorrhage, 4% undetermined stroke, and 20% TIA), 25% had an all-cause readmission and 15% had an unplanned readmission within 90 days. In multivariable analyses, the factors independently associated with a greater risk of unplanned readmission within 90 days were being female (subhazard ratio, 1.13; 95% confidence interval [CI], 1.03–1.24), greater Charlson Comorbidity Index scores (subhazard ratio, 1.11; 95% CI, 1.09–1.12), and having an admission ≤90 days before the index event (subhazard ratio, 1.85; 95% CI, 1.59–2.15). Compared with being discharged to rehabilitation or aged care, those who were discharged directly home were more likely to have an unplanned readmission within 90 days (subhazard ratio, 1.44; 95% CI, 1.33–1.55). These factors were similar for readmissions within 30 and 365 days.
Conclusions:
The authors concluded that apart from comorbidities and patient-level characteristics, readmissions after stroke/TIA were associated with discharge destination.
Perspective:
This study reports that hospital readmission within 90 days is frequent after stroke, with 15% of the cohort experiencing an unplanned readmission and 25% experiencing an all-cause readmission. Of note, patients who were discharged directly home (compared with transfer for inpatient rehabilitation, or other care including residential aged care) were at greater risk of 90-day readmission. These data suggest that prevention of readmission may require greater individualization of focused interventions during the post-discharge period. The much lower proportion of readmissions in patients receiving inpatient rehabilitation suggests that attention to clinical processes of care central to rehabilitation, such as patient-centered goal setting, and improvement in function, would be an appropriate starting point.
Keywords: Brain Ischemia, Cerebral Hemorrhage, Comorbidity, Ischemic Attack, Transient, Patient Discharge, Patient Readmission, Rehabilitation, Secondary Prevention, Stroke, Vascular Diseases
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