Abstract WMP95: A Transition of Care Program to Reduce Stroke Related Hospital Readmissions

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Heather Khan ◽  
Hebah M Hefzy
Keyword(s):  
Risk Factors ◽  
Readmission Rate ◽  
Stroke Risk ◽  
Community Hospital ◽  
Hospital Readmissions ◽  
Care Program ◽  
Transition Of Care ◽  
Stroke Risk Factors ◽  
Risk Patients

Introduction: Readmission to the hospital after discharge following a stroke or TIA remains a nation-wide problem. While the CMS national benchmark was approximately 12% in 2015, our hospital Medicare stroke readmission rate rose from approximately 12% at the end of 2014 to 28.6% in February 2015. Our goal was a reduction in stroke readmission rates to below the national benchmark of 12% by December 2015. Hypothesis: We hypothesized that implementing a transition of care program at our 200 bed community hospital would reduce hospital stroke-related readmissions. Methods: In March 2015, a random sample of forty stroke/TIA patients that were discharged home between December of 2014 and February of 2015 were interviewed. The patients were asked about barriers to discharge, what could have improved the discharge experience, and what problems they encountered that could have resulted in a readmission. Based on their answers, risk factors were identified using an inverse Pareto graph and a transition of care program was implemented which included the following work flow: 1) daily rounding to query patients regarding insight into stroke risk factors, environmental concerns, and social impacts to discharge in the stroke unit by the stroke coordinator (a registered nurse); 2) a discharge telephone call within two business days to high risk patients identified during rounds focusing on review of the discharge summary, re-education regarding stroke risk factors, and ensuring that follow-up appointments were in place; 3) an outpatient follow-up appointment with a board certified vascular neurologist within two weeks of discharge. Results: Our transition of care program resulted in an improvement of 82.5%, with a Medicare stroke re-admission rate of 5% in December 2015. As of May 2016, our year-to-date hospital stroke readmission rate is 8.1%, while the current CMS national average is 12.7%. Conclusions: A transition of care program is implementable in a community hospital setting, and results in reduced stroke-related hospital readmissions. Its success emphasizes the importance of identifying high risk patients and assessing individual drivers of readmission risk.

scholarly journals Anticoagulant Therapy in Initially Low‐Risk Patients With Nonvalvular Atrial Fibrillation Who Develop Risk Factors

2020 ◽  
Vol 9 (16) ◽  
Author(s):  
Sun Young Choi ◽  
Moo Hyun Kim ◽  
Kwang Min Lee ◽  
Young‐Rak Cho ◽  
Jong Sung Park ◽  
...  
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Low Risk ◽  
Composite Outcome ◽  
Stroke Risk Factor ◽  
Stroke Risk Factors ◽  
Risk Patients

Background The CHA 2 DS 2 ‐VASc score has been validated for stroke risk prediction in patients with atrial fibrillation (AF). Antithrombotic therapy is not recommended for low‐risk patients with AF (CHA 2 DS 2 ‐VASc 0 [male] or 1 [female]). We studied a cohort of initially low‐risk patients with AF in relation to their development of incident comorbidities and their treatment on oral anticoagulation therapy. Methods and Results We assessed data from 14 441 low‐risk patients with AF (CHA 2 DS 2 ‐VASc score of 0 [male] or 1 [female]) using the Korean National Health Insurance Service database, in relation to their development of incident stroke risk factors and adverse outcomes. The clinical end point was the occurrence of ischemic stroke, major bleeding, all‐cause death, or the composite outcome (ischemic stroke + major bleeding + all‐cause death). In our cohort, 2615 (29.1%) male and 1650 (30.3%) female patients acquired at least 1 new stroke risk factor during a mean follow‐up of 2.0 years. Among the patients with an increasing CHA 2 DS 2 ‐VASc score ≥1, male and female patients treated with oral anticoagulants had a significantly lower risk of ischemic stroke (male: hazard ratio [HR], 0.62 [95% CI, 0.44–0.82; P =0.003]; female: HR, 0.65 [95% CI, 0.47–0.84; P =0.007]), all‐cause death (male: HR, 0.67 [95% CI, 0.49–0.88; P =0.009]; female: HR, 0.82 [95% CI, 0.63–1.02; P =0.185]), and composite outcomes (male: HR, 0.78 [95% CI, 0.61–0.95; P =0.042]; female: HR, 0.79 [95% CI, 0.62–0.96; P =0.045]) than patients not treated with oral anticoagulants. Conclusions Approximately 30% of patients acquired ≥1 stroke risk factor over a 2‐year follow‐up period. Low‐risk patients with AF should be regularly reassessed to adequately identify those with incident stroke risk factors that would merit thromboprophylaxis for the prevention of stroke and the composite outcome.

scholarly journals The Risk of Stroke Using CHA2 DS2 -VASc Score in Hemodialysis Patients at a Tertiary Hospital in Riyadh, Saudi Arabia

2019 ◽  
Vol 4 (7) ◽  
Keyword(s):  
Risk Factors ◽  
High Risk ◽  
Stroke Risk ◽  
Hemodialysis Patients ◽  
Low Risk ◽  
High Risk Patients ◽  
Stroke Risk Factors ◽  
Increased Risk ◽  
Risk Patients ◽  
History Of

Introduction: Patients undergoing hemodialysis are at increased risk of stroke. However, less known about the impact of some of the stroke risk factors, and the value of stroke risk scores in determining the risk in those patients. Our main goal. To assess the risk factors for stroke in hemodialysis patients and the use of the new CHA2DS2-VASc score for stroke assessment. Methods: Single center, retrospective cohort study of 336 patients undergoing hemodialysis from June 24, 2018, to September 6, 2018, was recruited. Baseline demographics, clinical, and laboratory data were collected. We calculated the CHA2 DS2 -VASc score for stroke assessment in all patients and categorized them into high, moderate and low risk patients according to CHA2 DS2 - VASc score and subcategorized them to two groups atrial fibrillation (AFib) and Non- Atrial fibrillation (Non AFib) patients. Results: 336 patients were included in our study; the majority of patients were at high risk with a CHA2 DS2 -VASc Score mean of 2.9± 1.5, although history of stroke was observed only in 15 patients (4.46%). According to CHA2 DS2 - VASc score, 280 patients were at high risk, 172 (51.19%) were high-risk patients on treatment (anticoagulant or antiplatelet) and 108(32.14%) patients were high risk patients not on treatment 48 were at moderate risk (14.28%) and 8 were at low risk (2.38 %). Patients were divided into subgroups as non-AFib and AFib. In non-AFib patients 320 (95.23%), high-risk patients 103 (32.18%) were not treated; high-risk patients with treatment are 162 (50.62%), moderate patients were 47 (14.68%), 8(2.5%) was in low risk. AFib patients were 16 with a mean CHA2 DS2 -VASc score of 4.4±1.1. Patients with AFib were all at high risk except 1 was at moderate risk (6.25%). There were 11 (68.75%) patients on treatment and 5 (31.25%) patients not on treatment. The risk factors for stroke that were statistically significant in increasing score risk for all patients were: age > 65 (95% CI, -2.04– -1.29; p = 0.000), being female (95% CI, -1.36– -0.68; p = 0.000) hypertension (95% CI, -2.59– -1.37; p = 0.000), diabetes (95% CI, -2.10– -1.50; p = 0.000), CVD (95% CI, -2.07– -1.24; p=0.000), history of stroke or TIA (95% CI, -3.70– -2.03; p = 0.000), CHF or LVEF (95% CI, -2.28– - 0.91; p = 0.000). Conclusions: The risk of stroke in hemodialysis patients is significant according to the use of CHA2 DS2 -VASc score in Non-AFib hemodialysis patients shows supportive evidence of increased risk of stroke in those patients, which suggest the importance of close monitoring of patients with stroke risk factors by the nephrologist and the stroke team which will lead to the initiation of early prophylaxis in those patients.

scholarly journals Pneumonia in patients with stroke: risk factors, identification of at-risk patients, and methods of prevention

2020 ◽  
Vol 20 (2) ◽  
pp. 88-96
Author(s):  
Michał Turlakiewicz ◽  
◽  
Anna Piekarska ◽  
Keyword(s):  
Risk Factors ◽  
Acute Phase ◽  
Stroke Risk ◽  
Early Stage ◽  
Scoring Systems ◽  
Stroke Risk Factors ◽  
Risk Of Death ◽  
Risk Patients ◽  
Clinically Significant ◽  
Expert Recommendations

Stroke-associated pneumonia (SAP) is the most common complication of the early stage of ischaemic stroke. The prevalence of SAP is difficult to determine precisely, but it is estimated to affect 2–22% of patients in the acute phase of stroke. Strokeassociated pneumonia is a clinically significant problem, as it markedly increases the risk of death compared to the population of acute stroke patients without pneumonia. In addition, SAP is associated with poorer final functional status, greater dependence on other people’s help after hospital discharge, extended hospital stay, and higher treatment costs. The paper presents the risk factors for stroke-related pneumonia, including the two best documented: dysphagia and stroke-induced immunodepression syndrome (SIDS). An attempt is made to identify patients in the acute phase of stroke who should be evaluated for the risk of developing pneumonia, and tools useful in the identification of such patients (A2DS2, ISAN scoring systems) are discussed. Also, based on expert recommendations, measures to minimise the risk of stroke-related pneumonia are proposed, and the recommended therapeutic regimen is described.

Non-valvular atrial fibrillation patients with none or one additional risk factor of the CHA2DS2-VASc score

2015 ◽  
Vol 114 (10) ◽  
pp. 826-834 ◽  
Author(s):  
Flemming Skjøth ◽  
Peter Nielsen ◽  
Torben Bjerregaard Larsen ◽  
Gregory Lip
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Stroke Risk ◽  
Additional Risk Factor ◽  
Stroke Risk Factor ◽  
Stroke Risk Factors ◽  
Long Run ◽  
One Year ◽  
Net Clinical Benefit

SummaryOral anticoagulation (OAC) to prevent stroke has to be balanced against the potential harm of serious bleeding, especially intracranial haemorrhage (ICH). We determined the net clinical benefit (NCB) balancing effectiveness and safety of no antithrombotic therapy, aspirin and warfarin in AF patients with none or one stroke risk factor. Using Danish registries, we determined NCB using various definitions intrinsic to our cohort (Danish weights at 1 and 5 year follow-up), with risk weights which were derived from the hazard ratio (HR) of death following an event, relative to HR of death after ischaemic stroke. When aspirin was compared to no treatment, NCB was neutral or negative for both risk strata. For warfarin vs no treatment, NCB using Danish weights was neutral where no risk factors were present and using five years follow-up. For one stroke risk factor, NCB was positive for warfarin vs no treatment, for one year and five year follow-up. For warfarin vs aspirin use in patients with no risk factors, NCB was positive with one year follow-up, but neutral with five year follow-up. With one risk factor, NCB was generally positive for warfarin vs aspirin. In conclusion, we show a positive overall advantage (i.e. positive NCB) of effective stroke prevention with OAC, compared to no therapy or aspirin with one additional stroke risk factor, using Danish weights. ‘Low risk’ AF patients with no additional stroke risk factors (i.e. CHA2DS2-VASc 0 in males, 1 in females) do not derive any advantage (neutral or negative NCB) with aspirin, nor with warfarin therapy in the long run.Note: The review process for this manuscript was fully handled by Christian Weber, Editor in Chief.

scholarly journals Stroke Risk Factors Beyond the CHA2DS2-VASc Score: Can We Improve Our Identification of “High Stroke Risk” Patients With Atrial Fibrillation?

2015 ◽  
Vol 116 (11) ◽  
pp. 1781-1788 ◽  
Author(s):  
Filip M. Szymanski ◽  
Gregory Y.H. Lip ◽  
Krzysztof J. Filipiak ◽  
Anna E. Platek ◽  
Anna Hrynkiewicz-Szymanska ◽  
...  
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Stroke Risk ◽  
Stroke Risk Factors ◽  
Risk Patients

Abstract P357: Trajectories of Stroke Risk Factors Before Stroke Onset With a 24-year Follow-up of Japanese People Living in an Urban Area: The Suita Study

Circulation ◽  
2018 ◽  
Vol 137 (suppl_1) ◽  
Author(s):  
Soshiro Ogata ◽  
Fumiaki Nakamura ◽  
Kunihiro Nishimura ◽  
Makoto Watanabe ◽  
Yoshihiro Kokubo ◽  
...  
Keyword(s):  
Risk Factors ◽  
Blood Glucose ◽  
Blood Glucose Level ◽  
Glucose Level ◽  
Stroke Risk ◽  
Hdl Cholesterol ◽  
Stroke Onset ◽  
Stroke Risk Factors ◽  
Mean Differences

Introduction: Many studies investigated associations of stroke risk factors assessed at one point in time with stroke onset. However, few studies investigated growth curves (trajectories) of the stroke risk factors assessed at multiple points in time before stroke onset. Hypothesis: We assessed the hypothesis that people with stroke, compared with their controls, would have higher values of the stroke risk factors at multiple points in time and higher change rates by year (slopes) of those factors before stroke onset. Methods: The present study used a nested case-control design based on the Suita study that is a cohort study launched in 1989 with 15,746 community-dwelling participants in an urban city, Suita, Japan. During a 24-year follow-up, 201 cases (43.8% in women) were identified. Corresponding to the cases, 2010 controls (51.5% in women) matched by age (± 4 years) were identified by incidence density sampling. As the stroke risk factors, we included systolic blood pressure (SBP), diastolic BP (DBP), blood glucose level, body mass index, waist circumference, non-HDL cholesterol, and triglyceride assessed every two years on health check-ups. Linear mixed models were performed to investigate adjusted mean differences in the stroke risk factors between the stroke cases and the controls at 20, 15, 10, 5 years and the last assessment before stroke onset. Mean differences in slopes of the stroke risk factors before stroke onset were also investigated. Results: The linear mixed models showed that SBP and DBP were significantly higher in the cases than the controls at any points in time before stroke onset (the adjusted mean differences [95% CI] at the last assessment before stroke onset: 4.52 [1.4, 7.64] mmHg for SBP and 2.93 [1.23, 4.63] mmHg for DBP). However, slopes of SBP and DBP were not significantly different between the cases and the controls. We observed no significant difference between the cases and the controls in blood glucose level at 20 years before stroke onset (the adjusted mean difference: 2.24 [-0.26, 4.74] mg/dl). However, compared with the controls, the cases significantly had a steeper slop of blood glucose increase (the adjusted mean difference in the slope per year: 0.21 [0.02, 0.40] mg/dl; and the adjusted mean differences at 15, 10, and 5 years and the last assessment before stroke onset: 3.29 [1.31, 5.26], 4.34 [2.51, 6.16], 5.39 [3.25, 7.52], 6.44 [3.69, 9.19] mg/dl, respectively). We observed no significant differences of means and slopes in BMI, waist circumference, non-HDL cholesterol, and triglyceride between the cases and the controls. Conclusions: In conclusions, multiple assessments of the stroke risk factors on health check-ups can be useful to early identify people who will be likely to develop stroke by observing SBP and DBP at any points in time, and the trajectory of blood glucose level.

Dynamic Changes of CHA2DS2-VASc Score and the Risk of Ischaemic Stroke in Asian Patients with Atrial Fibrillation: A Nationwide Cohort Study

2018 ◽  
Vol 118 (07) ◽  
pp. 1296-1304 ◽  
Author(s):  
Minjae Yoon ◽  
Pil-Sung Yang ◽  
Eunsun Jang ◽  
Hee Yu ◽  
Tae-Hoon Kim ◽  
...  
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Ischaemic Stroke ◽  
Stroke Risk ◽  
Low Risk ◽  
Dynamic Changes ◽  
Risk Patients ◽  
Changes Over Time ◽  
Over Time

Background Stroke risk in atrial fibrillation (AF) is often assessed at initial presentation, and risk stratification performed as a ‘one off’. In validation studies of risk prediction, baseline values are often used to ‘predict’ events that occur many years later. Many clinical variables have ‘dynamic’ changes over time, as the patient is followed up. These dynamic changes in risk factors may increase the CHA2DS2-VASc score, stroke risk category and absolute ischaemic stroke rate. Objective This article evaluates the ‘dynamic’ changes of CHA2DS2-VASc variables and its effect on prediction of stroke risk. Patients and Methods From the Korea National Health Insurance Service database, a total of 167,262 oral anticoagulant-naive non-valvular AF patients aged ≥ 18 years old were enrolled between January 1, 2002, and December 31, 2005. These patients were followed up until December 31, 2015. Results At baseline, the proportions of subjects categorized as ‘low’, ‘intermediate’ or ‘high risk’ by CHA2DS2-VASc score were 15.4, 10.6 and 74.0%, respectively. Mean CHA2DS2-VASc score increased annually by 0.14, particularly due to age and hypertension. During follow-up of 10 years, 46.6% of ‘low-risk’ patients and 72.0% of ‘intermediate risk’ patients were re-classified to higher stroke risk categories. Among the original ‘low-risk’ patients, annual ischaemic stroke rates were significantly higher in the re-classified ‘intermediate’ (1.17 per 100 person-years, p < 0.001) or re-classified ‘high-risk’ groups (1.44 per 100 person-years, p = 0.048) than consistently ‘low-risk’ group (0.29 per 100 person-years). The most recent CHA2DS2-VASc score and the score change with the longest follow-up had the best prediction for ischaemic stroke. Conclusion In AF patients, stroke risk as assessed by the CHA2DS2-VASc score is dynamic and changes over time. Rates of ischaemic stroke increased when patients accumulated risk factors, and were re-classified into higher CHA2DS2-VASc score categories. Stroke risk assessment is needed at every patient contact, as accumulation of risk factors with increasing CHA2DS2-VASc score translates to greater stroke risks over time.

scholarly journals 0589 Arrhythmia Detection in Obstructive Sleep Apnea (ADIOS)

SLEEP ◽  
2020 ◽  
Vol 43 (Supplement_1) ◽  
pp. A225-A226
Author(s):  
E S Geil ◽  
A R Ramos ◽  
A R Abreu ◽  
L K Lambrasko ◽  
S I Dib ◽  
...  
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Obstructive Sleep Apnea ◽  
High Risk ◽  
Stroke Risk ◽  
Vascular Risk ◽  
Stroke Risk Factors ◽  
Obstructive Sleep ◽  
The Mean

Abstract Introduction Obstructive sleep apnea (OSA) is a recognized risk factor for ischemic stroke; however, there is a paucity of studies devoted to modifying stroke risk factors in patients with OSA. We aimed to evaluate the prevalence and treatment of stroke risk factors in newly diagnosed OSA patients. Methods We evaluated consecutive patients with an OSA diagnosis made within 12 months and CHADS2 score of &gt;2, consistent with high risk for atrial fibrillation. The patients completed polysomnography, sleep questionnaires, and systematic assessments for demographic variables, vascular risk factors, and medication use. Participants also completed up to four weeks of ambulatory cardiac monitoring. A six-month follow-up visit screened for new hospitalizations associated to vascular events and use of new anticoagulants or antiplatelet therapy. Results The sample consisted of 87 patients, mean age 59±8 years, 53% women, and 69% of Hispanic/Latino background. The mean BMI was 35±9. Hypertension was seen in 57% and diabetes mellitus in 33% of the sample. The mean apnea-hypopnea index was 41±27 events/hour. Atrial fibrillation was detected in 3% of the sample through prolonged monitoring. At six-month follow-up, 9% of the sample was hospitalized due to stroke, transient ischemic attack, or coronary artery disease, while 13% reported use of anticoagulants and 38% antiplatelet therapy. Conclusion In this high risk sample of OSA patients, there was a high prevalence of cerebrovascular events and use of medical treatment for secondary stroke prevention. Future studies evaluating the treatment of vascular risk factors in OSA can provide strategies to minimize stroke occurrence. Support Boehringer Ingelheim

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