Abstract P191: A Large Cohort Study Predicting the Temporal Course and Rate of Improvement in Stroke Patients Admitted to Inpatient Rehabilitation Facilities

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Shayandokht Taleb ◽  
Dorothea Parker ◽  
Billie Hsieh ◽  
Mohammad H Rahbar ◽  
Joseph Wozny ◽  
...  
Keyword(s):  
Goodness Of Fit ◽  
Statistical Significance ◽  
Age At Onset ◽  
Inpatient Rehabilitation ◽  
Change Score ◽  
Large Cohort ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Rehabilitation Facilities ◽  
Stroke Type

Introduction: We sought to predict the course and rate of functional improvement and length of stay (LOS) in patients with ischemic and hemorrhagic strokes admitted to inpatient rehabilitation facilities(IRF). Aim: To study the course and associating factors affecting functional outcomes among a large cohort of stroke patients admitted to IRFs. Methods: The cohort consists of stroke patients admitted to 5 IRFs in Houston, between 4/17-8/19. Higher order polynomial (quartic, cubic, quadratic) regressions were fitted to predict the temporal relationship between FIM score improvement and LOS, and based on goodness of fit statistics, cubic polynomial fit was selected. Effects of interactions were tested and later dropped from the final model because of non-statistical significance. Models were adjusted for age, gender, stroke type (hemorrhagic vs ischemic), and stroke severity based on NIHSS. Results: The demographics of patients are presented in table 1. Among 679 patients, the univariate analyses reflected that age (F=24.2, p <0.001), admission NIHSS score (F=67, p<0.001), stroke type (F=25.2, p <0.001), and admission FIM (F=283, P<0.001) were significant factors predicting IRF LOS. History of previous stroke, diabetes, hypertension, and hyperlipidemia did not have any significant effects on LOS. In multiple regression model, age at onset (β=-0.18, p<0.001), hemorrhagic vs ischemic stroke (β=3.02, p <0.01) were significant predictors of total FIM change score when adjusting for stroke severity and gender. Total FIM change score was positively correlated with LOS at IRF with a steep improvement in the first 15 days of IRF stay which plateaued afterwards in patients with 1-30 days of IRF stay (Fig. 2). Conclusion: Patient’s age, ischemic vs hemorrhagic stroke were the most significant predictors when deriving the relationship between total FIM score and LOS while adjusting for stroke severity and patient’s gender, which plateaued after 2 weeks of IRF stay.

Abstract P220: Hemorrhagic Stroke Patients Admitted to Inpatient Rehabilitation Facilities Improve Differently Based on Their Involvement of Corticospinal Tract

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Shayandokht Taleb ◽  
Dorothea Parker ◽  
Lamya Ibrahim ◽  
Billie Hsieh ◽  
Muhammad E Haque ◽  
...  
Keyword(s):  
Corticospinal Tract ◽  
Statistical Significance ◽  
Univariate Analysis ◽  
Inpatient Rehabilitation ◽  
Functional Improvement ◽  
Volume Estimate ◽  
Factors Affecting ◽  
Rehabilitation Facilities ◽  
And Gender ◽  
Time Of Admission

Introduction: We asked whether intracerebral hemorrhage (ICH) patients admitted to inpatient rehabilitation facilities(IRF) improve differently based on their involvement of the corticospinal tract(CST). Aim: To predict associating radiological factors affecting discharge FIM score. Methods: We reviewed the patients’ characteristics and their respective imaging findings presenting with ICH between 4/17 to 8/19. The ICH volume and edema around the ICH were measured using analyze software. The main outcome measure was FIM score at time of discharge. Statistical significance was set at 0.05. Results: Among the 53 patients included, 49% were female. The median age of the patients was 62 years (IQR 25,89). The median length of stay at IRF was 22days (IQR 14,26). In univariate analysis, FIM score at the time of discharge FIM score at the time of discharge admission were significantly associated with NIHSS (estimate -1.26, p<0.001), and ICH volume (estimate -3.45, p=0.01). However, the univariate analysis did not reveal an association of age (estimate -0.15, p=0.4) and gender (estimate 0.207, p=0.97) with FIM score at the time of discharge.Multiple regression analysis reflected that the CST involvement had a decrement in functional improvement on FIM in comparison with patients with intact CST when adjusting for age ( p = 0.008), gender ( p <0.01), NIHSS at the time of admission ( p <0.01), and the ICH volume ( p =0.02). Conclusion: This preliminary study suggests that functional improvement declines in ICH patients with CST involvement.

Abstract TP160: What Matters Most? Predictors of Poststroke Functional Outcomes From Inpatient Rehabilitation Facilities Across the United States

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
James J García ◽  
Karlita L Warren ◽  
Fengmei Gong ◽  
Honggang Wang
Keyword(s):  
United States ◽  
Length Of Stay ◽  
Functional Outcomes ◽  
Inpatient Rehabilitation ◽  
The United States ◽  
Sociodemographic Factors ◽  
Administrative Database ◽  
Cross Sectional ◽  
Rehabilitation Facilities ◽  
Stroke Type

Introduction: Stroke is one of the leading cause of disability and death in the United States (Benjamin et al., 2018). Inpatient rehabilitation is the gold standard treatment for post-acute care (Weinstein et al., 2016). Data indicate a discharge to inpatient rehabilitation facilities (IRFs) following the acute stroke phase has increased (Buntin, Colla, & Escarce, 2009). The inpatient milieu provides a unique opportunity to examine predictors of functional outcomes using a captive sample. Thus, the current study aim is to identify factors associated with poststroke functional outcomes throughout inpatient rehabilitation. Method: This is a cross-sectional and retrospective analysis of data extracted from an administrative database during years 2005-2016 from 244,286 stroke patients across 30% of IRFs in the U.S. Inclusion criteria were patients at or above the age 18 with stroke as an admitting diagnosis using ICD 9/10 codes 430-438/I60-I69. Dependent variables were: admission Total FIM, Total FIM efficiency, discharge Total FIM, and length of stay (LOS). Results: Using separate regression analyses, marital status, admit year, type of admission, race/ethnicity, insurance type, sex, age, number of complications, number of comorbidities, and stroke type, emerged as significant predictors of functional outcomes throughout inpatient rehabilitation. Moreover, those with greater comorbidities and complications were associated with lower admission FIM total score, less total FIM efficiency, lower discharge FIM total score, and a longer LOS. Compared to NHWs, racial/ethnic people were associated with lower FIM scores throughout inpatient rehabilitation and a longer length of stay. Discussion: In this robust national dataset, data indicate clinical and sociodemographic factors are significantly associated with poststroke functional outcomes throughout inpatient rehabilitation. Implications are discussed within a framework of social determinants of health.

scholarly journals The Stroke Unit Story: Where Have We Been and Where Are We Going?

2021 ◽  
pp. 1-8
Author(s):  
Peter Langhorne
Keyword(s):  
Collaborative Research ◽  
Stroke Unit ◽  
Final Section ◽  
Evidence Base ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Stroke Units ◽  
History Of ◽  
Stroke Unit Care ◽  
Stroke Type

<b><i>Background:</i></b> The concept of stroke unit care has been discussed for over 50 years, but it is only in the last 25 years that clear evidence of its effectiveness has emerged to inform these discussions. <b><i>Summary:</i></b> This review outlines the history of the concept of stroke units to improve recovery after stroke and their evaluation in clinical trials. It describes the first systematic review of stroke unit trials published in 1993, the establishment of a collaborative research group (the Stroke Unit Trialists’ Collaboration), the subsequent analyses and updates of the evidence base, and the efforts to implement stroke unit care in routine settings. The final section considers some of the remaining challenges in this area of research and clinical practice. <b><i>Key Messages:</i></b> Good quality evidence confirms that stroke patients who are looked after in a stroke unit are more likely to survive and be independent and living at home 1 year after their stroke. The apparent benefits are independent of patient age, sex, stroke type, or initial stroke severity. The benefits are most obvious in units based in a discrete ward (stroke ward). The current challenges include integrating effective stroke units with more recent systems to deliver hyper-acute stroke interventions and implementing stroke units in lower resource regions.

Abstract T P117: Impact of Medicaid Coverage on Utilization of Inpatient Rehabilitation Facilities

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Lesli Skolarus ◽  
James F Burke ◽  
Lewis B Morgenstern ◽  
Will Meurer ◽  
Eric Adelman ◽  
...  
Keyword(s):  
Acute Care ◽  
Private Insurance ◽  
Inpatient Rehabilitation ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Medicaid Coverage ◽  
Random Intercept ◽  
Working Age ◽  
Medicaid Population ◽  
Post Acute Care

Objective: Optimal post-acute care is associated with improved stroke outcomes. Among working age stroke patients discharged to institutional post-acute care, those with Medicaid are less likely to be discharged to an inpatient rehabilitation facility (IRF) than those with private insurance, a finding which may be influenced by state Medicaid coverage. We hypothesized that stroke patients residing in states where Medicaid does not cover IRFs would be less likely to be discharged to an IRF than patients residing in states where Medicaid covers IRFs. Methods: Working age ischemic stroke patients with Medicaid were identified from the 2010 Nationwide Inpatient Sample (NIS) using ICD-9 CM codes 433.x1, 434.x1 and 436. Medicaid coverage of IRFs (yes versus no) was ascertained for 45 states with NIS data by review of state Medicaid websites. The primary outcome was discharge to IRF (versus other discharge destinations). We fit a hierarchical logistic regression model that included patient-level factors (demographics and stroke severity measures (length of stay, t-PA use and Charlson comorbidity score)), and a state policy variable representing whether a State’s Medicaid pays for IRF, with a random intercept for hospital. Based on this model, we estimated the probability of utilization of IRFs in states with Medicaid coverage of IRFs compared to those without. Results: Medicaid did not cover IRFs in 4 (TN, TX, SC, WV) out of 45 states. Compared to stroke patients residing in states with Medicaid coverage of IRF, stroke patients hospitalized in states without Medicaid coverage of IRF were less likely to be discharged to an IRF (12.8% (7.5-18.0%) vs. 19.4% (17.0-21.8%), p=0.02) after adjusting for patient and hospital factors. Conclusion: Working age stroke patients with Medicaid who reside in states where Medicaid does not cover IRFs have less utilization of IRFs than patients residing in states where Medicaid covers IRFs. As the Medicaid population expands under the Patient Protection and Affordable Care Act and the number of working age stroke patients increase, careful attention to state Medicaid policy for post-acute care and analysis of its effects are warranted.

scholarly journals Harboring Cnm-Expressing Streptococcus Mutans In The Oral Cavity Relates To Both Deep and Lobar Cerebral Microbleeds

2021 ◽  
Author(s):  
Shuhei Ikeda ◽  
Satoshi Saito ◽  
Satoshi Hosoki ◽  
Shuichi Tonomura ◽  
Yumi Yamamoto ◽  
...  
Keyword(s):  
Streptococcus Mutans ◽  
Statistical Significance ◽  
Cerebral Microbleeds ◽  
National Institutes Of Health ◽  
Amyloid Angiopathy ◽  
Imaging Data ◽  
Stroke Patients ◽  
Cariogenic Bacterium ◽  
Stroke Type ◽  
Risk Ratios

Abstract Streptococcus mutans, a major cariogenic bacterium, expressing the collagen-binding protein Cnm induces cerebrovascular inflammation, resulting in the impairment of blood brain barrier integrity followed by cerebral bleeding. We here examined the association of Cnm-positive S. mutans with cerebral microbleeds (CMBs) in acute stroke patients selected from a single-center registry database. Of 428 patients who received oral bacterial examinations among 3154 stroke patients, 326 patients who harbored S. mutans were identified. After excluding four patients without imaging data, we compared 72 patients with Cnm-positive S. mutans and 250 with Cnm-negative S. mutans. Deep, lobar and infratentorial CMBs were observed in 46 (63.9%), 36 (50.0%), 25 (34.7%) patients with Cnm-positive S. mutans and 144 (57.6%), 114 (45.6%), 101 (40.4%) with Cnm-negative S. mutans. Possession of Cnm-positive S. mutans was related to higher numbers of both deep and lobar, but not infratentorial, CMBs (risk ratios 1.57 [1.07‒2.30], deep; 5.44 [2.50‒11.85], lobar). Statistical significance persisted after adjusting for age, sex, hypertension, stroke type, National Institutes of Health Stroke Scale score, and cerebral amyloid angiopathy (risk ratios 1.61 [1.14‒2.27], deep; 5.14 [2.78‒9.51], lobar). Our study indicated that reduction of Cnm-positive S. mutans may serve as a therapeutic approach for improving the prognosis of stroke patients.

Abstract 3563: Ischemic Stroke with Early AM Onset is More Severe but Less Frequent

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
M. Carter Denny ◽  
Karen C Albright ◽  
Amelia K Boehme ◽  
T. Mark Beasley ◽  
Sheryl Martin-Schild
Keyword(s):  
Ischemic Stroke ◽  
Statistical Significance ◽  
Inpatient Rehabilitation ◽  
Stroke Onset ◽  
Time Interval ◽  
Stroke Severity ◽  
Large Artery ◽  
Clotting Factors ◽  
Discharge Disposition ◽  
Iv Tpa

Background: Diurnal fluctuations in clotting factors, occurrence of thrombosis, and stroke have been reported. We sought to evaluate the distribution of stroke occurrence and differences in stroke characteristics and outcomes in a biracial population. Methods: Patients presenting to our center with acute ischemic stroke of known symptom onset were identified by retrospective chart review. Patients were grouped into one of four onset periods: 00:01-06:00, 06:01-12:00, 12:01-18:00, and 18:01-00:00. We compared demographics, baseline stroke severity, blood pressure and glucose levels, IV tPA treatment rates, stroke etiology, complications, and early clinical outcomes. Results: The 244 patients with a known time of onset were included in analyses; the distribution of stroke onset and comparison of other collected variables are demonstrated in the figure and table , respectively. Stroke onset 00:01-06:00 was less frequent, but associated with significantly higher median NIHSS score (p=0.005). Patients with stroke onset 00:01-06:00 were more often African-American, had atherothrombotic mechanisms (large artery or small artery infarctions), received IV tPA, and had reduced frequency of good mRS, though statistical significance was not achieved. Time interval of stroke onset was not an independent predictor of death, good outcome (mRS 0-2), or favorable discharge disposition (home or inpatient rehabilitation). Discussion: The most severe ischemic strokes occurred in early AM hours, but were less common than stroke onset during other time intervals. A larger sample is required to determine why ischemic stroke is more severe with early AM onset, if blacks are more susceptible to early AM stroke, and if early AM stroke is less responsive to tPA.

Abstract T P298: Impact of Accurate Weight Based Dosing of IV tPA in Acute Ischemic Stroke Patients

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Vishal B Jani ◽  
Sopan Lahewala ◽  
Shilpkumar Arora ◽  
Erin Shell ◽  
Anmar Razak ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Statistical Significance ◽  
Categorical Variables ◽  
Stroke Severity ◽  
Fisher Exact Test ◽  
Weight Estimation ◽  
Stroke Patients ◽  
Significant Difference ◽  
Iv Tpa

Background: Accurate weight-based dosing is essential for efficacy and safety of thrombolysis in acute ischemic stroke (AIS). Stroke patients may be unable to communicate correct body weight (BW). Dosing may be estimated which can lead to error. Objective: To assess accuracy of weight estimation and the effect of weight and dosing discrepancy on outcome of patients with AIS Methods: 94 patients receiving IV tpa for AIS in a CSC registry between Feb, 2013 and Jul, 2014 were reviewed. All were given estimated weight based tPA- per patient input or agreement of 2 providers in ER. Accurate weights were obtained and recorded later. Actual weight was used to calculate the ideal TPA doses and compared to the weights and doses used. The cohort was separated into two groups based on weight discrepancy to those 10 kg (non forgiven) discrepancy. Rate of hemorrhage, NIHSS and hospice/mortality were assessed. Difference between categorical variables was tested using the chi-square and Fisher’ Exact Test. Differences between continuous variables were tested using Wilcoxon Rank Sum test and presented with median and IQ range. Results: 86.1% (forgiven cohort) were given the optimal tPA dose despite estimation. There was a significant difference in stroke severity based on admission NIHSS between the cohorts (33.3% in forgiven vs. 69.2% non-forgiven. P=0.04). Stroke severity based on discharge NIHSS did not reach statistical significance (mild: 71.8% vs 63.6%, moderate: 16.9% vs 9.1% and severe: 11.3% vs 27.3%, p = 0.32). 30 days modified Rankin Scale (mRS) was available for 52 pts without any significant difference (good outcome 44.4% vs 57.1%, poor outcome 35.6 % vs 28.6 %, p = 0.82). Statistically non significance toward higher rate of hemorrhagic conversion (6.4% vs 7.7%, p = 0.41), and higher mortality in non-forgiven group (7.41% vs 15.38%, p= 0.33). Conclusion: Accurate BW measurement prior tPA still remains challenging. In this study, weight estimation by 2 providers is fairly accurate. 14 % of the patients with discrepancy of > 10 kg had higher rate of mortality and hemorrhage although this was not statistically significant. Further studies with larger sample sizes are needed to examine the safety of weight estimation in AIS patients who receive IV tpa

Abstract 2224: The Relationship Between Process and Outcomes for Stroke Post Prospective Payment in Inpatient Rehabilitation Facilities

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Suzanne R O'Brien ◽  
Gail Ingersoll ◽  
Ying Xue ◽  
Adam Kelly ◽  
Din Chen
Keyword(s):  
Inpatient Rehabilitation ◽  
Functional Independence ◽  
Assessment Instrument ◽  
Discharge Destination ◽  
Medicare Beneficiaries ◽  
Prospective Payment ◽  
Rehabilitation Facilities ◽  
Race Ethnicity ◽  
Stroke Type ◽  
The Relationship

Background and Objective: Previous studies have reported decreasing length of stay (LOS) for inpatient rehabilitation facilities (IRFs), with conflicting effects on discharge Functional Independence Measure (FIM) scores and discharge destination (DD). This study was the first to examine the post prospective payment system (PPS) period using Medicare data drawn from the national Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) database. The purposes were to examine trends over time for process and outcome factors, and to describe the relationships between process, LOS, and outcomes (discharge FIM scores and DD), for Medicare patients with stroke. Methods: The study included 371,211 Medicare Part A beneficiaries aged 65 and older with stroke, admitted to United States (US) IRFs between January 1, 2002 and June 30, 2007. Descriptive statistics and generalized estimating equations (GEE) modeling for clustered data were used for analysis. Continuous GEE evaluated LOS and discharge FIM scores, and binomial GEE evaluated LOS and DD (community verses institution). Covariates in models were: admission FIM scores, age, gender, race/ethnicity, comorbidities, complications, and stroke type. Time interactions with admission FIM scores, LOS, and discharge FIM scores (binomial model only) were examined. Results: During the study period, mean LOS decreased from 17.9 (SD=9.9) to 16.1(SD=8.3) days (p<. 0001), mean discharge FIM scores decreased from 80.1 (SD=24.5) to 76.5 (SD=24.5) points (p<. 0001), and rate of community discharge decreased from 66.6% to 61.2% (p<. 0001). LOS predicted discharge FIM scores (95% CI, .48, .52, p<.0001), but the relationship to community discharge was weak (OR .997, p=.007). Discharge FIM scores predicted discharge destination (OR 1.07, p<.0001). Covariates of admission FIM scores, age, gender, race/ethnicity, comorbidities, complications, and stroke type also predicted outcomes. Time interactions were present for LOS, admission FIM scores, and discharge FIM scores. Conclusions: During the first 5.5 years of PPS, declining trends were found for LOS, discharge FIM scores, and rate of community discharge for Medicare beneficiaries with stroke. LOS was a strong predictor for discharge FIM scores, but weak for DD. Discharge FIM scores were a better predictor of DD than LOS. Effects of covariates on discharge FIM scores and DD have clinical implications for IRF stroke rehabilitation in the US. Because of the reduced time for treatment, dose of IRF rehabilitation for Medicare beneficiaries may not be achieving expected results in the post-PPS period.

Abstract T P119: Challenges Associated with Access to Stroke Rehabilitation for Patients with Cognitive Impairment in Toronto

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Elizabeth Linkewich ◽  
Nicola Tahair ◽  
Michelle Donald ◽  
Sylvia Quant
Keyword(s):  
Cognitive Impairment ◽  
Cognitive Rehabilitation ◽  
Stroke Rehabilitation ◽  
Best Practice ◽  
Inpatient Rehabilitation ◽  
Rehabilitation Services ◽  
Cognitive Screening ◽  
Stroke Patients ◽  
Referral Decisions ◽  
Rehabilitation Facilities

Background: Cognitive Impairment (CI) affects up to 60% of stroke survivors and is associated with poorer recovery and decreased function. Toronto clinicians report limited access to inpatient rehabilitation for stroke patients with CI. Purpose: To inform system planning that aligns with best practice for stroke patients with CI, the Toronto Stroke Networks examined: 1) access to inpatient rehabilitation services for stroke patients with CI; 2) facility differences with respect to referral decisions; and 3) the frequency of documented standardized cognitive screening (SCS) in inpatient rehabilitation referrals. Methods: Data were abstracted from the E-Stroke Rehab Referral System for fiscal years 2012-2014. Initial high intensity rehabilitation (HIR) referrals for 5 rehabilitation facilities in Toronto were analyzed to examine: percentage of referrals accepted, declined, and declined due to CI, and percentage of referrals reporting SCS in referral documentation. These data were further stratified by facility. A survey of cognitive rehabilitation was completed across 6 rehabilitation facilities. Results: There are no cognitive rehabilitation services that cater specifically to stroke patients reported in Toronto. Of the total number of HIR referrals (n=5005), 68.3% of initial referrals were accepted and 18.2% declined. Of the declined referrals (n=910), 17.5% were declined due to CI with variability across the 5 rehabilitation facilities ranging from 0.6 to 46.5%. Further, when examining referrals that were pending a decision or declined due to CI (n=508), 78.5% (range 48-100%) of these referrals across, 10 referring acute care facilities, had no documented SCS. Conclusions: Stroke patients with CI do not have adequate or consistent access to stroke rehabilitation across sites within Toronto. Additionally, there is a lack of documented SCS in rehabilitation referrals, which could impact access to rehabilitation. This work will further inform educational initiatives that support increased access to inpatient rehabilitation for persons with stroke and CI.

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