Abstract
BackgroundFew studies have focused on post-discharge ambulatory care for stroke patients and subsequent differences in readmission and mortality rates. Identifying groups at higher risk according to services received is important when planning post-discharge follow-up in ambulatory care. According to a recent Whitepaper by the Norwegian Government, patients receiving ambulatory care should have follow-up with a general practitioner (GP) within 14 days of hospital discharge.MethodsAll home discharged stroke cases occurring in Oslo from 2009 to 2014 were included. 90- and 365-day all-cause readmissions and mortality were compared separately for patients categorized based on services received (no services, home nursing, ambulatory rehabilitation and home nursing with ambulatory rehabilitation) and early GP follow-up within 14 days following discharge. Variables used to adjust for differences in health status and demographics at admission included inpatient days and comorbidities the year prior to admission, calendar year, sex, age, income, education and functional score. Cox regression reporting hazard ratios (HR) was used.ResultsThere were no significant differences in readmission rates for early GP follow-up. Patients receiving home nursing and/or rehabilitation had higher unadjusted 90- and 365-day readmission rates than those without services (HR from 1.87 to 2.63 depending on analysis, p < 0.001), but the 90-day differences disappeared after risk adjustment, except for patients receiving only rehabilitation. There were no significant differences in mortality rates according to GP follow-up after risk adjustment. Patients receiving rehabilitation had higher mortality than those without services, even after adjustment (HR from 2.20 to 2.69, p < 0.001), whereas the mortality of patients receiving only home nursing did not differ from those without services.ConclusionsOur results indicate that the observed differences in unadjusted readmission and mortality rates according to GP follow-up and home nursing were largely due to differences in health status at admission, likely unrelated to the stroke. On the other hand, mortality for patients receiving ambulatory rehabilitation was twice as high compared to those without, even after adjustment and irrespective of also receiving home nursing. Hence, assessing the needs of these patients during discharge planning and providing careful follow-up after discharge seems important.
Highlights
Few studies have focused on post-discharge ambulatory care for stroke patients and subsequent differences in readmission and mortality rates
Death date was acquired from the national cause of death register (DÅR, Dødsårsaksregisteret) and GP visits were identified from the national general practitioner reimbursement register (KUHR, Kontroll og Utbetaling av HelseRefusjon)
Activities of daily living (ADL) scores valid 30 days prior to admission were identified from the Oslo municipal health and care service register (Oslo kommunes fagsystem for omsorgstjenestene), as well as any home nursing services, ambulatory rehabilitation or stays in long-term care before and after hospitalization
Summary
Few studies have focused on post-discharge ambulatory care for stroke patients and subsequent differences in readmission and mortality rates. Stroke is a leading cause of mortality and disability globally with many patients receiving rehabilitation services [1, 2] These patients are sensitive to readmissions [3,4,5,6] and have high mortality rates [7], making the post-discharge period crucial. Coordination and vertical integration of care among primary and secondary (specialist) care is a persistent issue challenging many healthcare systems worldwide [8, 9]. Trends such as shorter hospital lengths of stay (LOS), expanded outpatient care and reducing hospital beds have led to the need for increasing more cost-effective ambulatory follow-up options such as home nursing and ambulatory rehabilitation services to substitute more extensive inpatient treatments. Appropriate coordination between care levels, often referred to as transitional care, is imperative [8, 10, 11]
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