OUTCOME OF STROKE AND HEALTH CARE RESOURCE UTILIZATION

1. OUTCOME OF STROKE AND HEALTH CARE RESOURCEUTILIZATION SANDHYA SAMAVEDAM PGY3 INTERNAL MEDICINE CATHOLIC HEALTH SYSTEM

2. 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. Introduction

3. 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. Aim

4. 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. Methods

5. 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. OUTCOME

6. Statistics • average age 86, max - 100 • 35.6% - males , 64.4% - females. • Origin 85% - home and 15% - nursing home, assisted living or rehabilitation center. • 37% - moderate to severe dementia at presentation.

7. CONTINUOUS INDEPENDENT VARIABLES

8. DISCRETETE INDEPENDENT VARIABLES

9. Discharge destination discharges

10. DISCRETE VARIABLES CONTINUED TIME AFTER ONSET OF SYMPTOMS TREATMENT DISTRIBUTION

11. MORBIDITY DATA MORBIDITY LIST MORBIDITY DISTRIBUTION • 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

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

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

14. 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

15. 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 Investigations No of subjects who had investigations that did not yield extra information that changed management in this study was 58%.

16. 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

17. 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)

18. OUTCOME VS STROKE SEVERITYP-VALUE OF T-TEST= 0.000SIGNIFICANT DIFFERENCE IN OUTCOME

19. 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

20. 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 0.039 • There was no significant relation between risk factors and outcome.

21. 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.

22. 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.

23. 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.

24. 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.

25. TREATMENT VS OUTCOME

26. Outcome vs functionality There is significant correlation with functional independence and outcome

27. 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

28. 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.

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

30. 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.

31. 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;34:1056-1083 Recommendations for Imaging of Acute Ischemic Stroke: A Scientific Statement From the American Heart Association. Latchaw et al., Stroke 2009;40;3646-3678; originally published online Sep 24, 2009;

32. references • Shaw TG, Mortel KF, Meyers JS et al: Cerebral blood flow changes in benign aging and cerebrovascular disease. Neurology 1984; 34; 855-862 • Falconer JA, Naughton BJ, Dunlop DD, Roth EJ, Strasser DC, Sinacore JM: Predicting stroke inpatient rehabilitation outcome using a classification tree approach. • Mauthe R., Haaf D., Hayn P., Krau J. Predicting discharge destination of stroke patients using a mathematical model based on six items from Functional independent measure. Archives of physical medicine and rehabilitation 1996; 77; 10-13. • Kelly-Hayes M, Robertson JT, Broderick JP, Duncan PW, Hershey LA, Roth EJ, Thies WH, Trombly CA. The American Heart Association Stroke Outcome Classification: Executive summary. Circulation 1998; 97; 2474-2478.