Abstract
Background
Whether stroke patients treated at hospitals with better short-term outcome metrics have better long-term outcomes is unknown. We investigated whether treatment at US hospitals with better 30-day hospital-level stroke outcome metrics was associated with better 1-year outcomes, including reduced mortality and recurrent stroke, for patients after ischemic stroke.
Methods
This cohort study included Medicare fee-for-service beneficiaries aged ≥65 years discharged alive from US hospitals with a principal diagnosis of ischemic stroke from 07/01/2015 to 12/31/2018. We categorized patients by the treating hospital’s performance on the CMS hospital-specific 30-day risk-standardized all-cause mortality and readmission measures for ischemic stroke from 07/01/2012 to 06/30/2015: Low-Low (both CMS mortality and readmission rates for the hospital were <25th percentile of national rates), High-High (both >75th percentile), and Intermediate (all other hospitals). We balanced characteristics between hospital performance categories using stabilized inverse probability weights (IPW) based on patient demographic and clinical factors. We fit Cox models assessing patient risks of 1-year all-cause mortality and ischemic stroke recurrence across hospital performance categories, weighted by the IPW and accounting for competing risks.
Results
There were 595,929 stroke patients (mean age 78.9±8.8 years, 54.4% women) discharged from 2,563 hospitals (134 Low-Low, 2288 Intermediate, 141 High-High). For Low-Low, Intermediate, and High-High hospitals, respectively, 1-year mortality rates were 23.8% (95% confidence interval [CI] 23.3%-24.3%), 25.2% (25.1%-25.3%), and 26.5% (26.1%-26.9%), and recurrence rates were 8.0% (7.6%-8.3%), 7.9% (7.8%-8.0%), and 8.0% (7.7%-8.3%). Compared with patients treated at High-High hospitals, those treated at Low-Low and Intermediate hospitals, respectively, had 15% (hazard ratio 0.85; 95% CI 0.82–0.87) and 9% (0.91; 0.89–0.93) lower risks of 1-year mortality but no difference in recurrence.
Conclusions
Ischemic stroke patients treated at hospitals with better CMS short-term outcome metrics had lower risks of post-discharge 1-year mortality, but similar recurrent stroke rates, compared with patients treated at other hospitals.
Funder
National Institute on Aging
American Heart Association
Publisher
Public Library of Science (PLoS)
Reference31 articles.
1. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline for healthcare professionals from the American Heart Association/American Stroke Association;WN Kernan;Stroke,2014
2. Stroke impact on mortality and psychologic morbidity within the Childhood Cancer Survivor Study;S Mueller;Cancer,2020
3. Recurrent ischemic stroke: Strategies for prevention;R Oza;Am Fam Physician,2017
4. Centers for Medicare & Medicaid Services. Outcome Measures. [cited 2021 September 26]. Available from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/OutcomeMeasures.
5. Centers for Medicare & Medicaid Services. Provider Data Catalog. [cited 2022 July 2]. Available from: https://data.cms.gov/provider-data/.