Abstract
Background
Limited data exist regarding differences in ischemic stroke care across the care continuum between patients with and without prestroke disability. We investigated differences in in‐hospital and postdischarge ischemic stroke cause evaluation and treatment between patients with and without prestroke disability using population‐based data in the United States.
Methods
We ascertained all adult patients (≥18 years) hospitalized with acute ischemic stroke within the Greater Cincinnati/Northern Kentucky population between January 1, 2015, and December 31, 2015. We used univariate analyses and logistic regression to compare differences in acute ischemic stroke reperfusion therapies, stroke cause evaluation, prescription of secondary stroke prevention treatments, and rehabilitation between patients with prestroke disability (modified Rankin Scale score ≥2) and those without prestroke disability (modified Rankin Scale score 0–1).
Results
Of 2476 ischemic stroke patients, 1326 (53%) had prestroke disability. Prestroke disability was associated with lower odds of receiving thrombolysis (adjusted odds ratio [aOR], 0.43 [95% CI, 0.28–0.68], P<0.01) and endovascular thrombectomy (aOR, 0.32 [95% CI, 0.13–0.78], P<0.01). Patients with prestroke disability were less likely to receive complete in‐hospital stroke cause evaluation (aOR, 0.48 [95% CI, 0.33–0.69], P<0.01) and there were small differences in antiplatelet (84% versus 87%) and statin therapy (80% versus 86%) prescribed at discharge. Those with prestroke disability were more likely to receive in‐hospital (aOR, 2.6 [95% CI, 2.11–3.21], P<0.01) and postdischarge rehabilitative therapies (aOR, 2.27 [95% CI, 1.86–2.77], P<0.01).
Conclusion
Further research into factors driving medical decision‐making for patients with prestroke disability is needed to optimize the entire spectrum of ischemic stroke care for this population.
Keywords: disability, ischemic stroke, prevention
Subject Categories: Cerebrovascular Disease/Stroke
Nonstandard Abbreviations and Acronyms
- EVT
endovascular thrombectomy
- GCNKSS
Greater Cincinnati/Northern Kentucky Stroke Study
- IVT
intravenous thrombolysis
- LKW
last known well
- mRS
modified Rankin Scale
- NIHSS
National Institutes of Health Stroke Scale
Clinical Perspective.
What Is New?
Patients living with a functional disability before stroke (prestroke disability) in the United States were less likely to receive acute ischemic stroke reperfusion therapies—including intravenous thrombolysis and endovascular thrombectomy—compared with patients without prestroke disability
There were differences in stroke cause evaluation between patients with and without prestroke disability, with patients with prestroke disability less likely to receive complete in‐hospital stroke cause testing (echocardiogram and cerebrovascular vessel imaging) and postdischarge cardiac monitoring.
What Are the Clinical Implications?
Targeted interventions should be developed to improve ischemic stroke care across the care continuum for patients with prestroke disability as the underlying reasons for differences in ischemic stroke care between patients with and without prestroke disability are further understood.
Stroke is a leading cause of death and disability worldwide, costing an estimated $800 billion globally and causing poor quality of life in survivors of stroke. 1 , 2 , 3 , 4 , 5 , 6 Individuals living with a functional disability before stroke onset (prestroke disability), who make up ~30% of the stroke patient population, accumulate disproportional, incremental disability after ischemic stroke compared with those without prestroke disability. 7 , 8 This incremental disability is associated with worsening quality of life and significant societal impact. 7 , 9 Thus, improving stroke care for patients with prestroke disability represents an opportunity to greatly reduce the societal and economic impact of ischemic stroke.
Previous studies showed patients with prestroke disability are less likely to receive acute ischemic stroke reperfusion therapies. 10 , 11 , 12 , 13 , 14 There are fewer data examining practice patterns in stroke cause evaluation and use of secondary stroke prevention therapies in patients with prestroke disability. The data that exist on these topics are limited by the registry‐based nature of the studies 14 , 15 , 16 that may not accurately reflect routine clinical care due to patient selection biases and the fact that many studies investigated differences in stroke care according to the presence of cognitive impairment or age, 14 , 16 , 17 some of whom may not meet the definition of functionally disabled according to consensus‐based definitions using the modified Rankin Scale (mRS). 18 Further, there are a lack of data on these topics from the United States. Thus, there is a need to investigate gaps across the continuum of stroke care, including both in‐hospital and postdischarge care, among patients with prestroke functional disability from a sample of patients in the United States encountered in routine clinical care. Understanding these gaps is vital to plan targeted interventions that may improve outcomes in this vulnerable patient population. Using a population‐based study that reflects routine clinical practice for an ischemic stroke population in the United States, we aimed to investigate differences in in‐hospital and postdischarge ischemic stroke cause evaluation and treatment according to prestroke functional status.
METHODS
This study was approved by institutional review boards at all participating hospitals with a waiver from informed consent. The data and models that support the findings of this study are available from the corresponding author upon reasonable request.
Population
The GCNKSS (Greater Cincinnati/Northern Kentucky Stroke Study) was used for this study. The GCNKSS is a population‐based stroke study occurring in 5 contiguous counties in Southern Ohio and Northern Kentucky with a population size of approximately 1.3 million people. Its composition represents the United States in terms of Black race, socioeconomic status, and educational attainment. Methods for case ascertainment in the GCNKSS have been previously published in detail. 19 Briefly, all potential stroke cases in the study region were ascertained during 5 periods: July 1993 to June 1994 and the calendar years of 1999, 2005, 2010, and 2015. This analysis included only ischemic stroke cases among individuals 18 years and older from the study period of calendar year 2015 (January 1, 2015–December 31, 2015), which reflects the most recent clinical care from the data available. Cases were identified from all local hospitals using International Classification of Diseases, Ninth Revision (ICD‐9, 430–436) or Tenth Revision (ICD‐10, I60‐69/G45‐46). Cases were adjudicated by trained study physicians; although all stroke subtypes are collected through our method, only ischemic strokes were included in this analysis. For each case, clinical data, including a specific, ordinal prestroke functional status defined using 6 categories of the mRS 18 , 20 ranging from 0 (no symptoms) to 5 (bedbound, requires constant nursing care), were abstracted by a trained research nurse with a standardized case report form. Prestroke mRS score of 6 (death) was not included as a patient cannot be dead before their stroke. Estimation of mRS status from medical records was determined by research nurses through review of available clinical documentation. Notes from the hospital admission for stroke from a variety of care providers (physicians, nurses, physical/occupational therapists, social workers, etc.) were reviewed. Research nurses were trained to abstract information regarding the presence of any symptoms from previous strokes or other medical conditions, level of independence, and ability to walk independently or with assistance, all of which are essential to distinguish between the mRS categories. 21 In cases where these types of data were not available, place of residence before stroke was used to estimate prestroke mRS status. For example, patients living in a nursing home before stroke were assigned an mRS score of at least 3, with the assumption being they could not live independently. 18 This approach to deriving prestroke mRS status was developed by the principal investigators of the GCNKSS, and research nurses were trained on this approach by the lead study coordinator with over 17 years of experience in research and medical record review for the GCNKSS.
Two distinct populations were identified from GCNKSS to investigate differences in (1) acute ischemic stroke reperfusion therapies, and (2) in‐hospital and postdischarge ischemic stroke cause evaluation, secondary stroke prevention treatment, and rehabilitation for patients with and without prestroke disability. In the analysis investigating differences in acute ischemic stroke reperfusion therapies, the population included only patients presenting to an emergency department (ED); patients with in‐hospital strokes and those identified in the outpatient setting were excluded. In investigating differences in intravenous thrombolysis (IVT), we included only patients presenting to an ED within 4 hours of last known well (LKW) and included only patients within 23.5 hours from LKW in investigating differences in endovascular therapy (EVT). These times were chosen because the majority of IVT is administered within 4.5 hours from LKW and EVT is recommended only up to 24 hours from LKW. 22 In the analysis investigating differences in in‐hospital and postdischarge stroke cause evaluation, secondary stroke prevention treatments, and rehabilitation therapy, the population included all hospitalized patients with ischemic stroke who were not given comfort care. Patients with a prestroke disability were defined as having an mRS score ≥2 before incident ischemic stroke and those without a prestroke disability were defined as having an mRS score 0 to 1 before incident ischemic stroke. 18 The mRS was used to define prestroke disability status given its widespread use in clinical practice and clinical research to describe a patient's baseline global functional status. These definitions of prestroke functional status are in line with expert consensus definitions of global functional disability using the mRS. 18
Outcomes
The primary outcomes for the analysis investigating differences in acute ischemic stroke reperfusion therapies were (1) administration of IVT, and (2) EVT performed. The primary outcome for the analysis investigating differences in in‐hospital and postdischarge ischemic stroke care was complete in‐hospital stroke cause evaluation. For the purposes of this analysis, we considered a complete in‐hospital stroke cause evaluation to include completion of in‐hospital echocardiogram and cerebrovascular vessel imaging with computed tomography angiography, magnetic resonance angiography, or carotid ultrasound. Secondary outcomes included postdischarge cardiac monitoring in those without known atrial fibrillation, secondary stroke prevention treatments prescribed at discharge (antiplatelet, statin, antihypertensive, and anticoagulation therapy), in‐hospital rehabilitation evaluation, in‐hospital rehabilitation therapy, and planned postdischarge rehabilitation therapy.
Covariates
Patient sociodemographic factors (age, sex, race) and acute stroke presentation clinical characteristics were obtained from the medical charts. The covariates in the analysis investigating differences in IVT were age, prestroke disability status, presenting National Institutes of Health Stroke Scale (NIHSS) score, time from LKW to presentation, and baseline anticoagulation use. These are all clinical factors that commonly affect IVT decision‐making for acute ischemic stroke. The same covariates were used in the analysis investigating EVT except for anticoagulation use, as this does not typically affect EVT decision‐making. The covariates in the analysis investigating differences in complete stroke cause evaluation and rehabilitation therapy were age, prestroke disability status, presenting NIHSS score, and insurance status. These covariates were chosen because patients with minimal neurologic deficits as measured by the NIHSS may not require rehabilitation evaluation or treatment and insurance status may affect testing and treatment decisions due to potential prohibitive costs borne by the patient and lack of access to postdischarge health care resources. Covariates in analysis investigating differences in postdischarge cardiac monitoring included age, atrial fibrillation, and anticoagulation use at discharge. Models to investigate differences in secondary stroke prevention treatments at discharge included age and relevant comorbidities.
Statistical Analysis
Univariate analyses using Wilcoxon rank sum or chi‐square tests were conducted to compare demographics, clinical characteristics, acute ischemic stroke reperfusion treatments, in‐hospital and postdischarge stroke cause evaluation testing, in‐hospital and post‐discharge rehabilitation therapy, and prescription of secondary stroke prevention treatments at discharge between individuals with a prestroke disability and those without a prestroke disability who had an index ischemic stroke during the study period. In addition to univariate analyses investigating differences in postdischarge cardiac monitoring and prescription of secondary stroke prevention treatments at discharge, logistic regression was used to evaluate the association of prestroke disability with these secondary outcomes after adjustment for covariates. Logistic regression was used to evaluate the association between prestroke disability status and the odds of receiving IVT and EVT adjusting for age, presenting NIHSS score, time from LKW to presentation, and baseline anticoagulation use. Logistic regression was used to evaluate the association between prestroke disability status and complete in‐hospital stroke cause evaluation testing, in‐hospital rehabilitative treatment, and planned postdischarge rehabilitation treatment adjusting for age, presenting NIHSS score, and insurance status. Statistical significance was defined as a P value <0.05. All analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC).
Sensitivity Analyses
We performed 2 sensitivity analyses. First, in the investigation into differences in provision of EVT for patients with and without prestroke disability, we performed logistic regression to evaluate the association between prestroke disability and EVT in patients with ischemic stroke presenting to an ED within 23.5 hours from LKW and with an NIHSS score ≥6. This was to select a patient population more likely to harbor a large vessel occlusion amenable to EVT, as an NIHSS score ≥6 is relatively sensitive in identifying large vessel occlusions. 23 Imaging to assess for large vessel occlusions, such as with computed tomography angiogram, was not routinely used in acute stroke assessments in the 2015 study period from the GCNKSS, as this was before widespread adoption of EVT. Thus, we do not have reliable imaging data on whether patients harbored a large vessel occlusion. In our second sensitivity analysis, logistic regression was used to evaluate the association between the primary outcomes and prestroke disability defined as mRS score ≥3 before stroke rather than mRS score ≥2 before stroke. Although consensus‐based definitions of disabled mRS categories include mRS score 2 to 5, 18 we performed this sensitivity analysis in recognition of the variable definitions of prestroke disability in clinical practice and the literature. 18 , 24
RESULTS
For the analysis investigating differences in acute ischemic stroke reperfusion therapies, a total of 2191 patients with acute ischemic stroke who presented to an ED in the GCNK population were identified during the 2015 study period (Figure 1). Demographics and clinical characteristics of these patients stratified by prestroke functional status are shown in Table 1. Patients with prestroke disability were older, more likely to be female, and had higher rates of medical comorbidities. Presenting NIHSS score was higher (3 [1–8] versus 2 [1–5], P<0.01) and time from LKW to ED presentation was longer in patients with prestroke disability. Patients with prestroke disability were more often transported by emergency medical services (64% versus 44%, P<0.01). Results were similar when defining prestroke disability as mRS score≥3 before stroke onset (Table S1).
Figure 1. Flow diagram of the 2 distinct populations used to investigate differences in (1) acute ischemic stroke reperfusion therapies, and (2) in‐hospital and postdischarge ischemic stroke cause evaluation, secondary stroke prevention treatment, and rehabilitation, between patients with and without prestroke disability.
AIS indicates acute ischemic stroke; ED, emergency department; and GCNKSS, Greater Cincinnati/Northern Kentucky Stroke Study.
Table 1.
Demographics and Clinical Characteristics of Patients With Ischemic Stroke Presenting to an ED Stratified by Prestroke Functional Status
| Prestroke mRS score ≥2 (n=1134) | Prestroke mRS score 0–1 (n=1057) | P value | |
|---|---|---|---|
| Age, y, median (IQR) | 77 (65–86) | 65 (55–74) | <0.01 |
| Female sex | 702 (62%) | 452 (43%) | <0.01 |
| Race | |||
| White | 842 (74%) | 816 (77%) | |
| Black | 282 (25%) | 228 (22%) | |
| Other* | 10 (1%) | 12 (1%) | |
| Diabetes | 485 (43%) | 337 (32%) | <0.01 |
| Hypertension | 1017 (90%) | 795 (75%) | <0.01 |
| Atrial fibrillation | 328 (29%) | 163 (15%) | <0.01 |
| Hyperlipidemia | 758 (67%) | 592 (56%) | <0.01 |
| Prior stroke | 435 (38%) | 147 (14%) | <0.01 |
| Baseline antiplatelet use | 703 (62%) | 459 (43%) | <0.01 |
| Baseline anticoagulation use | 157 (14%) | 100 (9%) | <0.01 |
| Presenting National Institutes of Health Stroke Scale score, median (IQR) | 3 (1–8) | 2 (1–5) | <0.01 |
| Time from last known well to presentation | <0.01 | ||
| ≤=4 h | 309 (27%) | 369 (35%) | |
| >4 to 9 h | 158 (14%) | 111 (11%) | |
| >9 to 24 h | 299 (26%) | 274 (26%) | |
| >24 h | 297 (26%) | 246 (23%) | |
| Unknown | 71 (6%) | 57 (5%) | |
| Modality of transport— emergency medical services | 728 (64%) | 461 (44%) | <0.01 |
| Intravenous thrombolysis | 72 (6%) | 119 (11%) | <0.01 |
| Endovascular thrombectomy | 11 (1%) | 30 (3%) | <0.01 |
ED indicates emergency department; IQR, interquartile range; and mRS, modified Rankin Scale.
Other includes American Indian or Alaska Native, Asian, Native Hawaiian or Pacific Islander.
Figure 2 depicts differences in ischemic stroke evaluation and treatment across the care continuum between patients with and without prestroke disability. IVT was administered less often (6% versus 11%, P<0.01) and EVT was performed less often (1% versus 3%, P<0.01) in patients with ischemic stroke with prestroke disability presenting to an ED compared with patients without prestroke disability. Among patients presenting to an ED within 4 hours from LKW (n=678), prestroke disability was associated with lower odds of receiving IVT (odds ratio [OR], 0.43 [95% CI, 0.28–0.68], P<0.01) after adjusting for age, NIHSS score, time from LKW to presentation, and baseline anticoagulation use (Table 2). Among patients presenting to an ED within 23.5 hours from LKW (n=1516), prestroke disability was associated with lower odds of receiving EVT (OR, 0.32 [95% CI, 0.13–0.78], P<0.01) after adjusting for age, NIHSS score, and time from LKW to presentation (Table 2). Results were similar in sensitivity analyses defining prestroke disability as mRS score ≥3 (Table S2). In sensitivity analyses among patients presenting to an ED within 23.5 hours from LKW and a NIHSS score ≥6 (n=511), prestroke disability was associated with lower odds of receiving EVT (OR, 0.32 [95% CI, 0.14–0.74], P<0.01) (Table S3).
Figure 2. Differences in ischemic stroke evaluation and treatment across the care continuum between patients with and without prestroke disability.
EVT indicates endovascular thrombectomy; IVT, intravenous thrombolysis; and mRS, modified Rankin Scale.
Table 2.
Logistic Regression Models for Receiving Intravenous Thrombolysis and Endovascular Thrombectomy Among Patients With Ischemic Stroke Presenting to an ED
| Odds ratio (95% CI) | P value | |
|---|---|---|
| Intravenous thrombolysis among patients presenting within 4 h of LKW (n=678) | ||
| Prestroke mRS score | ||
| 0–1 | Reference | |
| ≥2 | 0.43 (0.28–0.68) | <0.01 |
| Age, per year | 1.01 (0.99–1.02) | 0.30 |
| Baseline anticoagulation use | 0.29 (0.15–0.57) | 0.01 |
| Presenting NIHSS score, per point | 1.11 (1.09–1.14) | <0.01 |
| Time from LKW to presentation, per hour | 0.55 (0.44–0.69) | <0.01 |
| Endovascular thrombectomy among patients presenting within 23.5 h of LKW (n=1516) | ||
| Pre‐stroke mRS score | ||
| 0–1 | Reference | |
| ≥2 | 0.32 (0.13–0.78) | 0.01 |
| Age, per year | 0.97 (0.95–0.99) | 0.01 |
| Presenting NIHSS score, per point | 1.16 (1.12–1.20) | <0.01 |
| Time from LKW to presentation, per hour | 0.66 (0.53–0.84) | <0.01 |
ED indicates emergency department; LKW, last known well; mRS, modified Rankin Scale; and NIHSS, National Institutes of Health Stroke Scale.
Table 3 shows demographics and clinical characteristics of all hospitalized patients with ischemic stroke with and without prestroke disability. This was the population used to investigate differences in in‐hospital and postdischarge stroke cause evaluation, secondary stroke prevention treatment at discharge, and rehabilitation therapy. Again, patients with prestroke disability were older, more likely to be female, had more comorbidities, were more likely to reside in a nursing home or assisted facility at time of admission, and had more severe strokes at presentation as indicated by higher median NIHSS scores (4 [1–9] versus 2 [1–5], P<0.01). More patients with prestroke disability were receiving antiplatelet (63% versus 45%, P<0.01), anticoagulant (17% versus 11%, P<0.01), and antihypertensive therapy (86% versus 67%, p<0.01) before incident ischemic stroke compared with patients without prestroke disability.
Table 3.
Demographics and Clinical Characteristics of All Hospitalized Patients With Ischemic Stroke Stratified by Prestroke Functional Status
| Prestroke mRS score ≥2 (n=1326) | Prestroke mRS score 0–1 (n=1150) | P‐value | |
|---|---|---|---|
| Age, y, median (IQR) | 77 (65–86) | 65 (56–74) | <0.01 |
| Female sex | 822 (62%) | 497 (43%) | <0.01 |
| Race | 0.12 | ||
| White | 991 (75%) | 897 (78%) | |
| Black | 323 (24%) | 240 (21%) | |
| Other* | 12 (1%) | 12 (1%) | |
| Insurance status | <0.01 | ||
| Medicare/Medicaid/Veterans Affairs | 1231 (93%) | 752 (66%) | |
| Private/commercial | 81 (6%) | 343 (30%) | |
| Self‐pay | 12 (1%) | 53 (5%) | |
| Marital status | <0.01 | ||
| Married/living with partner | 451 (34%) | 607 (53%) | |
| Single/divorced/widowed/separated | 868 (66%) | 542 (47%) | |
| Residence at time of admission | <0.01 | ||
| Home | 1134 (86%) | 1135 (99%) | |
| Nursing home/assisted living | 175 (13%) | 3 (0.3%) | |
| Other | 17 (1%) | 12 (1%) | |
| Diabetes | 582 (44%) | 361 (31%) | <0.01 |
| Hypertension | 1195 (90%) | 870 (76%) | <0.01 |
| Atrial fibrillation | 394 (30%) | 179 (16%) | <0.01 |
| Dementia | 257 (19%) | 9 (1%) | <0.01 |
| Hyperlipidemia | 897 (68%) | 654 (57%) | <0.01 |
| Prior stroke | 497 (37%) | 161 (14%) | <0.01 |
| Baseline antiplatelet use | 830 (63%) | 512 (45%) | <0.01 |
| Baseline antihypertensive use | 1139 (86%) | 776 (67%) | <0.01 |
| Baseline anticoagulant use | 224 (17%) | 127 (11%) | <0.01 |
| Baseline antidiabetic use | 426 (32%) | 312 (27%) | 0.01 |
| Baseline statin use | 767 (58%) | 483 (42%) | <0.01 |
| Presenting National Institutes of Health Stroke Scale score, median (IQR) | 4 (1–9) | 2 (1 to 5) | <0.01 |
| Given comfort care | 207 (16%) | 48 (4%) | <0.01 |
IQR indicates interquartile range; and mRS, modified Rankin Scale.
Other includes American Indian or Alaska Native, Asian, Native Hawaiian or Pacific Islander.
In general, patients with prestroke disability who were not given comfort care underwent less stroke cause evaluation testing compared with patients without prestroke disability (Figure 2 and Table 4). In‐hospital echocardiograms (78% versus 88%, P<0.01) and cerebrovascular vessel imaging (80% versus 92%, P<0.01) were performed less often in patients with prestroke disability. Postdischarge prolonged cardiac monitoring also occurred less frequently in patients with prestroke disability without a history of atrial fibrillation (7% versus 13%, P<0.01) and prestroke disability was associated with lower odds of receiving postdischarge cardiac monitoring in adjusted logistic regression models (OR, 0.56 [95% CI, 0.40–0.79], P<0.01) (Table S4). After adjusting for age, presenting NIHSS score, and insurance status, there were lower odds of receiving complete in‐hospital stroke cause evaluation testing in patients with prestroke disability compared with patients without prestroke disability (OR, 0.48 [95% CI 0.33–0.69]) (Table 5). Results were similar in sensitivity analyses defining prestroke disability as mRS score ≥3 (Table S5).
Table 4.
In‐Hospital and Postdischarge Stroke Evaluation Testing, Secondary Stroke Prevention Treatment, and Rehabilitation Services Stratified by Prestroke Functional Status
| Prestroke mRS score ≥2 | Pre‐troke mRS score 0–1 | P value | |
|---|---|---|---|
| In‐hospital evaluation and treatment | |||
| PT evaluation* | 1176 (89%) | 993 (86%) | 0.08 |
| OT evaluation* | 1076 (81%) | 894 (78%) | 0.04 |
| ST evaluation* | 881 (66%) | 716 (62%) | 0.03 |
| PT treatment† | 811 (72%) | 535 (49%) | <0.01 |
| OT treatment† | 732 (65%) | 454 (41%) | <0.01 |
| ST treatment† | 530 (47%) | 345 (31%) | <0.01 |
| Echocardiogram† | 1037 (78%) | 1009 (88%) | <0.01 |
| Vessel imaging (computed tomography angiography, magnetic resonance angiography, carotid ultrasound)† | 1061 (80%) | 1061 (92%) | <0.01 |
| Antiplatelet prescribed before discharge‡ | 961 (84%) | 964 (87%) | 0.01 |
| Anticoagulant prescribed before discharge‡ | 258 (22%) | 220 (20%) | 0.14 |
| Statin prescribed before discharge‡ | 919 (80%) | 944 (86%) | <0.01 |
| Antihypertensive prescribed before discharge‡ | 965 (84%) | 874 (79%) | <0.01 |
| Postdischarge evaluation and treatment | |||
| Discharge disposition† | <0.01 | ||
| Home/relative or friend | 571 (43%) | 959 (83%) | |
| Skilled nursing facility/assisted living/rehabilitation | 510 (38%) | 126 (11%) | |
| Hospice/expired | 177 (13%) | 46 (4%) | |
| Other | 68 (5%) | 19 (2%) | |
| Postdischarge PT‡ | 866 (75%) | 525 (48%) | <0.01 |
| Postdischarge OT‡ | 795 (69%) | 487 (44%) | <0.01 |
| Postdischarge ST‡ | 535 (47%) | 398 (36%) | <0.01 |
| Cardiac monitoring§ | 58 (7%) | 116 (13%) | <0.01 |
mRS indicates modified Rankin Scale; OT, occupational therapy; PT, physical therapy; and ST, speech therapy.
All patients hospitalized with ischemic stroke (n=2746).
Patients hospitalized with ischemic stroke and not given comfort care (n=2221).
Patients hospitalized with ischemic stroke discharged alive and not in hospice (n=2253).
Patients hospitalized with ischemic stroke discharged alive and not in hospice with no history of atrial fibrillation (n=1725).
Table 5.
Logistic Regression Model for Receiving Complete In‐Hospital Stroke Cause Evaluation Testing
| Odds ratio (95% CI) | P value | |
|---|---|---|
| Prestroke modified Rankin Scale score | ||
| 0–1 | Reference | |
| ≥2 | 0.48 (0.33–0.69) | <0.01 |
| Age, per year | 0.98 (0.97–0.99) | <0.01 |
| Presenting National Institutes of Health Stroke Scale score, per point | 0.97 (0.95–0.98) | <0.01 |
| Insurance status | 0.16 | |
| Medicare/Medicaid/Veterans Affairs | 2.09 (0.85–5.18) | |
| Private/commercial | 2.67 (0.98–7.25) | |
| Self‐pay | Reference | |
Rates of in‐hospital evaluation for rehabilitation services were higher in patients with prestroke disability (Table 4). In addition, patients with prestroke disability more often received in‐hospital (OR, 2.6 [95% CI, 2.11–3.21], P<0.01) and referrals for postdischarge rehabilitation therapies (OR, 2.27 [95% CI, 1.86–2.77], P<0.01) compared with patients without prestroke disability. Patients with prestroke disability were more often discharged to rehabilitation, skilled nursing, or assisted living facilities compared with patients without pre‐troke disability (Table 4). It should be noted that patients with prestroke disability were more frequently residing in an institution before stroke (Table 3). However, among patients residing at home before stroke onset and discharged alive and not given comfort care, those with prestroke disability were less often discharged to home (57% versus 88%, P<0.01) and more often discharged to rehabilitation, skilled nursing, or assisted living facilities (38% versus 11%, P<0.01).
Table 4 shows differences in prescription of secondary stroke prevention therapies at discharge between patients with and without prestroke disability. Antiplatelet (84% versus 87%) and statin therapy (80% versus 86%) were less often prescribed at discharge in patients with prestroke disability, although differences were small. Antihypertensive therapy was slightly more often prescribed at discharge (84% versus 79%) in patients with prestroke disability versus those without prestroke disability. After adjustment for comorbidities, prestroke disability was associated with lower odds of receiving antihypertensive, antiplatelet, and statin therapy at discharge (Tables S6–S8). There were no differences in prescription of anticoagulation therapy at discharge between the two groups (22% versus 20%) and there was no statistically significant association between prestroke disability and prescription of anticoagulation therapy at discharge (Table S9).
DISCUSSION
In this large population‐based study, we found differences in ischemic stroke evaluation and treatment across the continuum of stroke care according to prestroke functional status, with prestroke disabled patients less likely to receive acute ischemic stroke reperfusion therapies and complete in‐hospital and postdischarge stroke cause evaluation testing.
Our results are consistent with previous studies that showed low rates of acute ischemic stroke reperfusion therapies for patients with prestroke disability. 13 Many studies suggest that the sole presence of prestroke disability is a reason for exclusion of patients from IVT and EVT. 14 , 25 Our results are in line with these findings in that even when adjusting for common factors that influence acute ischemic stroke reperfusion therapy decision‐making (age, NIHSS score, time from LKW to presentation, and baseline anticoagulation use), prestroke disability was still associated with lower odds of receiving IVT and EVT. The reason for this finding is likely multifactorial. Current evidence‐based guidelines acknowledge the lack of randomized and high‐quality data investigating treatment effects of IVT and EVT in patients with prestroke disability and thus recommend acute reperfusion therapies in only select cases for this patient population. 22 , 26 , 27 There is a consistent trend toward higher mortality after IVT and EVT in patients with prestroke disability compared with those without prestroke disability. 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 Institutionalization is common after ischemic stroke for patients with prestroke disability, 7 which was also seen in our study. Many of these factors likely contribute to lower rates of reperfusion therapies in patients with prestroke disability. In some cases, withholding treatment for patients with prestroke disability may be justified based on patient preferences, severity of prestroke disability, and the lack of robust data in this patient population. However, it should be noted that prestroke disability may simply be a variable that affects outcomes after ischemic stroke rather than a mitigator of treatment effect for IVT and EVT. Indeed, the available evidence, albeit observational, suggests that patients with prestroke disability treated with IVT and EVT have a substantial opportunity to return to their prestroke functional status as compared with patients with prestroke disability not treated with IVT or EVT. 13 Thus, future research is needed to investigate system‐, patient‐, and clinician‐level factors that may influence acute reperfusion therapy decision‐making for patients with prestroke disability. Further, closing the gap in provision of acute ischemic stroke reperfusion therapies for patients with prestroke disability may represent an opportunity to expand indications for IVT and EVT, an ongoing effort within the stroke community to reduce stroke‐related disability for a larger proportion of patients suffering from ischemic stroke.
Our study adds US population‐based data to the limited literature investigating differences in hospital‐based and postdischarge stroke cause evaluation and secondary stroke prevention treatment between patients with and without prestroke disability. The results from our study are similar to previous population‐based and registry studies outside the United States that showed older patients and those with preexisting cognitive impairment, both groups with high prevalence of prestroke disability, 7 were less likely to receive carotid vessel imaging while hospitalized and less likely to be admitted to a dedicated stroke unit. 14 , 15 There are no previous data we know of that examined differences in long‐term cardiac monitoring between patients with and without prestroke disability. Thus, our finding that patients with prestroke disability were less likely to receive prolonged cardiac monitoring at discharge, even when accounting for factors that may influence the decision to perform cardiac monitoring (atrial fibrillation history, anticoagulant use, comfort care/hospice), is novel. There are many possible reasons for this finding, including bleeding diatheses and other medical conditions that would preclude initiation of anticoagulant therapy, lower suspicion for embolic cause of stroke, and patient and family care decision preferences. There are inconsistent data regarding differences in secondary stroke prevention treatments between patients with and without prestroke disability, with some studies reporting lower rates of antithrombotic use in patient populations with high prevalence of prestroke disability and other studies showing no differences. 15 , 36 Prescription of antiplatelet and statin therapy at discharge were only slightly lower in patients with prestroke disability in our study. There is a relatively consistent trend in low rates of anticoagulation therapy in patients with high prevalence of prestroke disability. 37 , 38 , 39 These findings contrast with our results that showed no difference in anticoagulant treatment at discharge between patients with and without prestroke disability. However, it should be noted that many of these studies were conducted before widespread use of direct oral anticoagulant agents and many did not specifically compare differences between those with and without prestroke disability, rather just between patient populations that are at high risk of having prestroke disability (older, frail, and nursing home residents). Further, decision‐making for secondary stroke prevention evaluation and treatment is nuanced and is highly dependent on patient cohort characteristics, which differ between studies. As is the case for differences in acute stroke decision‐making, our results highlight the need for further research investigating the reasons behind differences in secondary stroke prevention care for patients with prestroke disability.
The high rates of institutionalization and rehabilitation needs after stroke in patients with prestroke disability seen in our study highlight the alarming consequences of stroke‐related disability in this patient population. Nearly 40% of patients with prestroke disability required institutionalization after ischemic stroke in our cohort, as compared with only ~10% of those without prestroke disability. Even when accounting for patients residing in an institution before stroke, new institutionalization after stroke was more common in patients with prestroke disability. This is in line with other population‐based data that showed ~30% of those with prestroke disability required new institutionalization after stroke. 7 The economic and societal consequences of this are staggering, with accumulated disability after stroke in those with prestroke disability associated with an additional $30 011 in 5‐year health care and institutionalization costs per patient compared with patients without preexisting disability. 7 It should be noted that intensive inpatient rehabilitation that accounts for a portion of this poststroke institutionalization likely mitigates some long‐term disability after stroke. 40 Thus, a proportion of short‐term institutionalization may be cost effective in the long term. Nevertheless, the striking rates of institutionalization do highlight the need for further research and efforts to reduce disparities in stroke care for patients with prestroke disability that will have a significant impact on reducing the economic and societal downstream consequences of ischemic stroke in the United States.
It is important to consider the implications of our results as they relate to patient groups other than those with prestroke disability. Older people and women comprised a large proportion of patients with prestroke disability in our study. This is consistent with other population‐based and registry studies outside the United States. 7 , 14 These demographic groups are known to suffer from significant disparities across the continuum of stroke care. 15 , 41 , 42 Thus, it is possible that the differences in ischemic stroke care for patients with prestroke disability may further exacerbate well‐established disparities in stroke care for these patient populations as well.
A strength of this work is its use of the GCNKSS, which is one of the larger population‐based studies of incident stroke in the United States. Our study adds to the limited population‐based data assessing differences in ischemic stroke care across phases of the care continuum between patients with and without prestroke disability. The large, diverse patient population from the GCNK region also allowed for reliable description of the population with prestroke disability in the United States. Our study has important limitations as well. We included patients only hospitalized for ischemic stroke and we did not include patients that were managed exclusively in the outpatient setting. Reperfusion therapy decision‐making (IVT and EVT) for acute ischemic stroke is directed by a central team in the GCNK region and thus may not reflect US practice patterns. Generalizability of the findings may be limited due to differences in health care system structures, insurance policies, and care access in other US regions and countries outside the GCNK region. The methodology for deriving poststroke mRS status from the medical records was internally validated by the GCNKSS study team with good agreement between medical record derived poststroke mRS and poststroke mRS status derived through direct patient contact. 43 Although a similar approach was used to determine prestroke mRS status by medical record review, this process has not been validated. The study period includes a period of evolving EVT practice for acute ischemic stroke due to large vessel occlusion, as clinical trials showing efficacy of EVT were published in 2015 44 , 45 , 46 , 47 (our study period) but adoption of interventions into clinical practice tends to lag evidence generation. Additionally, there was a small number of patients who received EVT in our data set. Thus, no definitive conclusions can be drawn from our analysis of differences in the provision of EVT and these results should be further investigated using more contemporary data sets. Lastly, there may be unmeasured confounding that contributed to patients with prestroke disability not receiving full stroke cause evaluation testing and secondary stroke prevention treatment. We did not capture reasons for limited testing or withholding therapy, some of which may be justified, such as patient preferences, testing that was already completed previously, and bleeding risk associated with multimorbidity in patients with prestroke disability.
CONCLUSIONS
This population‐based study demonstrated that prestroke disability is common among a sample of patients with ischemic stroke in the United States and there are differences in acute ischemic stroke reperfusion therapies and stroke cause evaluation testing between patients with and without prestroke disability. Further research is needed to understand the underlying reasons for these differences, as improving ischemic stroke care for patients with prestroke disability represents an opportunity to significantly reduce the societal impact of disability related to ischemic stroke.
Sources of Funding
This study was funded by the National Institute of Neurological Disorders and Stroke (R01NS030678‐26). Dr Mistry's effort is supported by Patient‐Centered Outcomes Research Institute (AD‐2022C1‐25 624).
Disclosures
Dr Mistry: Consultant for AbbVie and RAPID AI. Drs Robinson, Stanton, Sucharew, Mackey, Ferioli, Slavin, Walsh, Kleindorfer, and Kissela: Received funding from the National Institute of Neurological Disorders and Stroke (R01NS030678‐26). The other authors have no relevant disclosures.
Supporting information
Tables S1–S9
This article was sent to Fadar Oliver Otite, MD, SM, Associate Editor, for review by expert referees, editorial decision, and final disposition.
Supplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/JAHA.124.040499
For Sources of Funding and Disclosures, see page 10.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Tables S1–S9