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Ischemic stroke
ORIGINAL RESEARCH
Discharge disposition to skilled nursing facility after endovascular reperfusion therapy predicts a poor prognosis Samir R Belagaje,1,2 Chung-Huan J Sun,1 Raul G Nogueira,1,2 Brenda A Glenn,3 Lisa Ann Wuermser,4 Vishal Patel,1,2 Michael R Frankel,1,2 Aaron M Anderson,1,2 Tommy T Thomas,1,2 Christopher M Horn,1,2 Rishi Gupta3 ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ neurintsurg-2013-011045). 1
Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA 2 Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA 3 Wellstar Neurosurgery, Wellstar Health Systems, Marietta, Georgia, USA 4 Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia, USA Correspondence to Dr R Gupta, Wellstar Neurosurgery, Wellstar Health Systems, 61 Whitcher Street, Suite 3110, Marietta, GA 30060, USA; [email protected] Received 21 November 2013 Accepted 31 December 2013 Published Online First 17 January 2014
ABSTRACT Objective We explore the impact of discharge disposition (independent rehabilitation facility (IRF) vs skilled nursing facility (SNF)) on 90 day outcomes in persons with stroke who received acute endovascular treatment. Methods Using a database from a single primary care stroke center, discharge disposition, National Institutes of Health Stroke Scale (NIHSS), Totaled Health Risks in Vascular Events (THRIVE), Houston Intra-Arterial Therapy 2 (HIAT-2), and Acute Physiology and Chronic Health Evaluation (APACHE II) scores, and successful reperfusion were obtained. Univariate analysis was performed to assess predictors of good clinical outcome, as defined by 90 day modified Rankin Scale (mRS) scores ≤2. A binary logistic regression model was used to determine the impact of placement to an IRF versus an SNF on clinical outcomes. Results 147 subjects were included in the analysis with a mean age of63±14 years and median NIHSS of 18 (IQR 14–21). Final infarct volumes, and modified APACHE II, THRIVE, and HIAT-2 scores were similar between those discharged to an IRF and those discharged to an SNF.However, their 90 day outcomes were significantly different, with far fewer patients at SNFs achieving good clinical outcomes (25% vs 46%; p=0.023). Disposition to SNF was significantly associated with a lower probability of achieving an mRS score of 0–2 at 90 days (OR = 0.337 (95% CI 0.12 to 0.94); p7 were defined as ‘favorable’ in the analysis.19 Patients that went directly to interventional radiology from outside hospitals did not have ASPECTS assessed. Lastly, data regarding the side of ischemic stroke burden as well as patient insurance status were analyzed as possible determinants of patient outcome. Ninety day modified Rankin Scale (mRS) scores were adjudicated at 3 month follow-ups by an independent certified examiner blinded to the initial National Institutes of Health Stroke Scale (NIHSS) scores and recanalization results. A ‘good outcome’ was defined as mRS score of 0–2 and a ‘poor outcome’ as mRS score of 3–6.
Statistical analysis A univariate analysis was conducted comparing baseline characteristics and 90 day outcomes between patients discharged to home, AR, or SNF. Only anterior circulation strokes were used in the analysis. All neurological assessments and medical scoring systems (ie, NIHSS, THRIVE, HIAT-2, APACHE II, and ASPECTS) were compared using the Mann–Whitney U or Kruskal–Wallis test, as appropriate. Student t tests, ANOVAs, and χ2 tests were calculated for all continuous and categorical variables. A secondary univariate analysis was performed to identify predictors of good outcome among patients discharged to AR or SNF. All variables with p0.4, p7 (n (%))* 26 (58) 30 (55) 0.746 Reperfusion success (n (%)) 37 (77) 46 (77) 0.959 Hemorrhagic conversion HI 1/2 (n (%)) 14 (29) 18 (30) 0.925 PH 1/2 (n (%)) 1 (2) 3 (5) 0.425 Postop infarct volume 43 (24–77) 33 (18–85) 0.675 (median (IQR)) Time metrics (min) LKN to reperfusion (mean (SD)) 351 (311–533) 378 (307–494) 0.839 LKN to GP (mean (SD)) 295 (209–452) 295 (232–423) 0.567 Outcome 90 day mRS (median (IQR)) 3 (2–4) 4 (3–5) 0.001 Good outcome mRS 0–2 22 (46) 15 (25) 0.023 (n (%)) Hospital course Length of stay (mean (SD)) 9 (7–13) 15 (8–23)
Ischemic stroke
ORIGINAL RESEARCH
Discharge disposition to skilled nursing facility after endovascular reperfusion therapy predicts a poor prognosis Samir R Belagaje,1,2 Chung-Huan J Sun,1 Raul G Nogueira,1,2 Brenda A Glenn,3 Lisa Ann Wuermser,4 Vishal Patel,1,2 Michael R Frankel,1,2 Aaron M Anderson,1,2 Tommy T Thomas,1,2 Christopher M Horn,1,2 Rishi Gupta3 ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ neurintsurg-2013-011045). 1
Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA 2 Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA 3 Wellstar Neurosurgery, Wellstar Health Systems, Marietta, Georgia, USA 4 Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia, USA Correspondence to Dr R Gupta, Wellstar Neurosurgery, Wellstar Health Systems, 61 Whitcher Street, Suite 3110, Marietta, GA 30060, USA; [email protected] Received 21 November 2013 Accepted 31 December 2013 Published Online First 17 January 2014
ABSTRACT Objective We explore the impact of discharge disposition (independent rehabilitation facility (IRF) vs skilled nursing facility (SNF)) on 90 day outcomes in persons with stroke who received acute endovascular treatment. Methods Using a database from a single primary care stroke center, discharge disposition, National Institutes of Health Stroke Scale (NIHSS), Totaled Health Risks in Vascular Events (THRIVE), Houston Intra-Arterial Therapy 2 (HIAT-2), and Acute Physiology and Chronic Health Evaluation (APACHE II) scores, and successful reperfusion were obtained. Univariate analysis was performed to assess predictors of good clinical outcome, as defined by 90 day modified Rankin Scale (mRS) scores ≤2. A binary logistic regression model was used to determine the impact of placement to an IRF versus an SNF on clinical outcomes. Results 147 subjects were included in the analysis with a mean age of63±14 years and median NIHSS of 18 (IQR 14–21). Final infarct volumes, and modified APACHE II, THRIVE, and HIAT-2 scores were similar between those discharged to an IRF and those discharged to an SNF.However, their 90 day outcomes were significantly different, with far fewer patients at SNFs achieving good clinical outcomes (25% vs 46%; p=0.023). Disposition to SNF was significantly associated with a lower probability of achieving an mRS score of 0–2 at 90 days (OR = 0.337 (95% CI 0.12 to 0.94); p7 were defined as ‘favorable’ in the analysis.19 Patients that went directly to interventional radiology from outside hospitals did not have ASPECTS assessed. Lastly, data regarding the side of ischemic stroke burden as well as patient insurance status were analyzed as possible determinants of patient outcome. Ninety day modified Rankin Scale (mRS) scores were adjudicated at 3 month follow-ups by an independent certified examiner blinded to the initial National Institutes of Health Stroke Scale (NIHSS) scores and recanalization results. A ‘good outcome’ was defined as mRS score of 0–2 and a ‘poor outcome’ as mRS score of 3–6.
Statistical analysis A univariate analysis was conducted comparing baseline characteristics and 90 day outcomes between patients discharged to home, AR, or SNF. Only anterior circulation strokes were used in the analysis. All neurological assessments and medical scoring systems (ie, NIHSS, THRIVE, HIAT-2, APACHE II, and ASPECTS) were compared using the Mann–Whitney U or Kruskal–Wallis test, as appropriate. Student t tests, ANOVAs, and χ2 tests were calculated for all continuous and categorical variables. A secondary univariate analysis was performed to identify predictors of good outcome among patients discharged to AR or SNF. All variables with p0.4, p7 (n (%))* 26 (58) 30 (55) 0.746 Reperfusion success (n (%)) 37 (77) 46 (77) 0.959 Hemorrhagic conversion HI 1/2 (n (%)) 14 (29) 18 (30) 0.925 PH 1/2 (n (%)) 1 (2) 3 (5) 0.425 Postop infarct volume 43 (24–77) 33 (18–85) 0.675 (median (IQR)) Time metrics (min) LKN to reperfusion (mean (SD)) 351 (311–533) 378 (307–494) 0.839 LKN to GP (mean (SD)) 295 (209–452) 295 (232–423) 0.567 Outcome 90 day mRS (median (IQR)) 3 (2–4) 4 (3–5) 0.001 Good outcome mRS 0–2 22 (46) 15 (25) 0.023 (n (%)) Hospital course Length of stay (mean (SD)) 9 (7–13) 15 (8–23)
