OUTCOME OF STROKE AND HEALTH CARE RESOURCE UTILIZATION SANDHYA SAMAVEDAM PGY3 INTERNAL MEDICINE CATHOLIC HEALTH SYSTEM

Introduction Current standards for stroke care - without regard to age or functional status. Little data to guide adjustments to the medical and functional needs of the elderly. Unnecessary tests can only lead prolonged stay, less time for rehabilitation.

Aim To look at the health care utilization and its effect on outcomes, taking into account the severity of stroke among patients who were 80 and above. Health care resources : investigations, treatment, length of stay Outcome measures- functional independence, mortality, PEG dependence for feeding. Cutoff time for rehab. Centers was 90 days and cutoff for nursing home was 60 days.

Methods Under HIPAA Retrospective data collection from hospital records, nursing homes, rehabilitation centers. Data included 207 patients. Exclusion criteria: Hemorrhagic stroke (2), advanced malignancy (2), brain tumors, TIAs (16), HIV(0). Additional exclusion included missing charts (1), repetition (6), nursing homes not being able to provide with outcome data (2), miscoding (1), thus total remaining : 175 patients.

OUTCOME Favorable outcome: patient being discharged home becomes independent or mildly dependent does not get a PEG. Poor outcome: functional level remains moderate to severe dependency at cutoff point of time. If patient gets PEG tube or goes to hospice or deceases, then it is poor outcome. Functionality measured by FIM. The cutoff point of FIM equivalent rankin scores for defining moderate/severe dependency was 4 or above.

Statistics average age 86, max % - males, 64.4% - females. Origin 85% - home and 15% - nursing home, assisted living or rehabilitation center. 37% - moderate to severe dementia at presentation.

CONTINUOUS INDEPENDENT VARIABLES MinimumMaximumMean Standard deviation AGE NIH FIM AT D/C LENGTH OF STAY

DISCRETETE INDEPENDENT VARIABLES YESNO DYSPHAGIA33%67% DEMENTIA (mod-severe) 37%63% ATRIAL FIBRILLATION 46% (35% old, 11% newly diag.) 54% FEMALE64.4%35.6% HOME85%15%

Discharge destination DISCHARGE DESTINATION% HOME/ASSISTED LIVING28 REHABILITATION CENTER29 NURSING HOME15 HOSPICE/DEATH26 HOME VNA/ OTHERS2 discharges

DISCRETE VARIABLES CONTINUED TIME AFTER ONSET OF SYMPTOMS TREATMENT DISTRIBUTION

MORBIDITY DATA MORBIDITY LIST STROKE WITH HEMIPLEGIA OR RESIDUAL DEFECTS IMPAIRING MOBILITY CHF DM WITH ENDORGAN DAMAGE MOD-SEVERE PULMONARY DISEASES SEVERE ARTHRITIS/FRACTURE CAUSING IMMOBILITY PVD IMPAIRING MOBILITY MORBIDITY DISTRIBUTION

RISK FACTORS RISK FACTORS LIST HTN DYSLIPIDEMIA CAD/PVD/MI/AAA TIA A.FIB DM WITHOUT END ORGAN DAMAGE PFO RISK FACTORS % Risk factorsNo. subject%

Investigations used per protocol in acute situation CT scan brain CT STROKE PROTOCOL Doppler of carotids Further investigations as per need (if treatment could be changed with further investigations)

Per protocol investigations not followed: criteria When patient presents with stroke more than 6 hrs or with unknown time : both CT brain or stroke study as well as MRI When patients present after 3 hrs and CT and CTA already shows ischemic stroke and did correspond to clinical presentation, also had MRI/MRA When already CT angio or doppler showed arterial block, patient had MRA

Investigations No correlation between NIH with the number of investigations a subjects received. No correlation between time of presentation with the number of investigations a subjects received. Mean NIH was similar in both the groups as seen from t-test No of subjects who had investigations that did not yield extra information that changed management in this study was 58%.

OUTCOME STATS 64% SURVIVED STROKE 36% DIED AFTER CUTOFF TIME (DEATH DIRECTLY/INDIRECTLY RELATED TO STROKE OR MAY NOT RELATE TO STROKE) FAVORABLE OUTCOME SEEN IN 86 PATIENTS POOR OUTCOME SEEN IN 89 PATIENTS

Outcome stats There was no gender differences in the outcome groups More patients with dementia were in poor outcome group More patients with dysphagia were in poor outcome groups There was no significant correlation with atrial fibrillation Mean length of stay was about 2.6 days higher for patients with poor outcome. P-value = 0.04 (6.4 vs 9)

OUTCOME VS STROKE SEVERITY P-VALUE OF T-TEST= SIGNIFICANT DIFFERENCE IN OUTCOME OUTCOMENMEANSTD. DEVIATION NIH scoreFAVORABLE NON FAVORABLE

Outcome vs severity of stroke At about NIH 0f 8-9, data had more subjects with poor outcome than favorable outcome NIH correlates with outcome even after adjusting for time after onset of symptoms till presentation to ER. NIH also correlates when adjusted for type of treatment

Outcome vs comorbidities Chi square test was used to associate number of co-morbidities and outcome There was a significant correlation between the two. P-value was There was no significant relation between risk factors and outcome.

OUTCOME VS ONSET OF PRESENTATION Time of onset of symptoms did not correlate well with outcome. The above correlation was true even after adjusting for severity of stroke. Used chi square test.

Outcome vs investigations There was no correlation between outcome and investigations Used chi square test and logistic regression. This is true even after accounting for severity of stroke (NIH score) and co-morbid conditions.

LENGTH OF STAY AND INVESTIGATIONS Mean length of stay among those who got more investigational tests was 9 days and among those who had right amount of tests was about 6 days. There was a statistically significant difference between the two groups. After correcting for severity of stroke, the LOS was still statistically different between the two groups.

TREATMENT VS OUTCOME There was no statistically significant correlation between mode of treatment and outcome. Even after adjusting for severity of stroke, there was no significant correlation.

TREATMENT VS OUTCOME

Outcome vs functionality There is significant correlation with functional independence and outcome FAVORABLE OUTCOME POOR OUTCOME FIM (MEAN)6824 T-VALUE16.01 (P-VALUE= )

conclusion Outcome of stroke among patients more than 80 depended on NIH, Comorbid conditions, dysphagia, dementia. Outcome depended on functional independence. Investigational studies did not decide outcome Length of stay was more among those with poor outcome (difference of 3 days) Cutting down on investigation could save more on length of stay and could be used for functional improvement of patient

conclusion Patients presenting with NIH more than 9 mostly had worse outcome. Patients presenting after 3 hrs of onset of symptoms or after unknown time, there may be no requirement for more investigational studies than just CT head, perfusion study and carotid doppler.

strengths Simple retrospective study Data from a good stroke center Well defined outcome criteria Well defined functional level of patients were available in charts

weaknesses Sample size Needs further definition of investigational tests that did not help in change of treatment(Based on stroke protocol, which was designed for all stroke patients irrespective of age) Need further analysis with regards above.

references Guidelines for the Early Management of Patients With Ischemic Stroke A Scientific Statement From the Stroke Council of the American Stroke Association: Adams et al., Stroke. 2003;34: Recommendations for Imaging of Acute Ischemic Stroke: A Scientific Statement From the American Heart Association. Latchaw et al., Stroke 2009;40; ; originally published online Sep 24, 2009;

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