High Mortality among 30-Day Readmission after Stroke: Predictors and Etiologies of Readmission
High Mortality among 30-Day Readmission after Stroke: Predictors and Etiologies of Readmission
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DOI：
10.3389/fneur.2017.00632
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发表时间：
2017-12-07
影响因子：
3.4
通讯作者：
Staff, Ilene
中科院分区：
文献类型：
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作者：
Nouh, Amre M.;McCormick, Lauren;Staff, Ilene
背景：尽管中风再住院的一些危险因素已有报道，但死亡风险尚不清楚。我们试图评估30天再次住院的病因和预测因素，并确定相关的死亡风险。方法：这是一项回顾性病例对照研究，评估了2013年1月至2014年12月因中风(出血性、缺血性或短暂性脑缺血发作)而入院的1544名患者。在这些患者中，134名在30天内再次住院的患者被确定为病例；其他1418名没有再次住院的患者被确定为对照。再次入院接受临终关怀或择期手术的患者被排除在外。另外248名在指数入院时死亡的患者仅用于死亡率的比较。研究因素包括社会人口学特征、临床合并症、中风特征和住院时间。采用卡方比例检验和多变量Logistic回归分析来确定30天再入院中风的独立预测因素。结果：在主要分析的1,544名患者中，67%的指标卒中入院患者为缺血性中风，22%为出血性中风，11%为短暂性脑缺血发作。30天再住院率为8.7%。再次住院的最常见原因是感染(30%)、反复中风和短暂性脑缺血发作(20%)和心脏并发症(14%)。因复发中风和短暂性脑缺血发作而再次住院的患者中，在第一周内出现的比例明显较高(p=0.039)，住院时间指数较短(p=0.027)。再次入院30天的危险因素包括年龄75岁(p=0.02)、中风前住过院舍(p=0.01)、既往中风病史(p=0.03)、糖尿病(p=0.03)、慢性心力衰竭(p=0.001)、房颤(p=0.03)、非神经科住院指数(p<；0.01)、出院(p<；0.01)。在多变量分析中，非神经科住院指数是30天再住院的独立预测因素(p=0.01)。卒中后30天内再入院的死亡率高于入院指数(36.6vs.13.8%，p=0.001)(OR 3.6，95%CI2.5-5.3)。在再次入院的患者中，因再发卒中入院的患者死亡率显著较高(p=0.006)。结论：在30天的再入院患者中，约三分之一与感染有关，五分之一的患者因再发卒中或短暂性脑缺血发作而返回。进入非神经科服务的指数是30天再入院的独立危险因素。卒中后30天再入院的死亡率是指数入院的2.5倍以上，在因复发而再次入院的患者中死亡率最高。确定再次住院的高危患者，确保适当的服务水平，以及早期门诊随访，可能有助于减少30天的再次住院和相关的高死亡风险。
Background: Although some risk factors for stroke readmission have been reported, the mortality risk is unclear. We sought to evaluate etiologies and predictors of 30-day readmissions and determine the associated mortality risk.Methods: This is a retrospective case-control study evaluating 1,544 patients admitted for stroke (hemorrhagic, ischemic, or TIA) from January 2013 to December 2014. Of these, 134 patients readmitted within 30 days were identified as cases; 1,418 other patients, with no readmissions were identified as controls. Patients readmitted for hospice or elective surgery were excluded. An additional 248 patients deceased on index admission were included for only a comparison of mortality rates. Factors explored included socio-demographic characteristics, clinical comorbidities, stroke characteristics, and length of stay. Chi-square test of proportions and multivariable logistic regression were used to identify independent predictors of 30-day stroke readmissions. Mortality rates were compared for index admission and readmission and among readmission diagnoses.Results: Among the 1,544 patients in the main analysis, 67% of index stroke admissions were ischemic, 22% hemorrhagic, and 11% TIA. The 30-day readmission rate was 8.7%. The most common etiologies for readmission were infection (30%), recurrent stroke and TIA (20%), and cardiac complications (14%). Significantly higher proportion of those readmitted for recurrent strokes and TIAs presented within the first week (p = 0.039) and had a shorter index admission length of stay (p = 0.027). Risk factors for 30-day readmission included age > 75 (p = 0.02), living in a facility prior to index stroke (p = 0.01), history of prior stroke (p = 0.03), diabetes (p = 0.03), chronic heart failure (p = 0.001), atrial fibrillation (p = 0.03), index admission to non-neurology service (p < 0.01), and discharge to other than home (p < 0.01). On multivariate analysis, index admission to a non-neurology service was an independent predictor of 30-day readmission (p = 0.01). The mortality after a within 30-day readmission after stroke was higher than index admission (36.6 vs. 13.8% p = 0.001) (OR 3.6 95% CI 2.5-5.3). Among those readmitted, mortality was significantly higher for those admitted for a recurrent stroke (p = 0.006).Conclusion: Approximately one-third of 30-day readmissions were infection related and one-fifth returned with recurrent stroke or TIA. Index admission to non-neurology service was an independent risk factor of 30-day readmissions. The mortality rate for 30-day readmission after stroke is more than 2.5 times greater than index admissions and highest among those readmitted for recurrent stroke. Identifying high-risk patients for readmission, ensuring appropriate level of service, and early outpatient follow-up may help reduce 30-day readmission and the high associated risk of mortality.