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. 2012 Feb;1(1):42-50.
doi: 10.1161/JAHA.111.000034. Epub 2012 Feb 20.

Relationship of national institutes of health stroke scale to 30-day mortality in medicare beneficiaries with acute ischemic stroke

Gregg C Fonarow  1 , Jeffrey L Saver, Eric E Smith, Joseph P Broderick, Dawn O Kleindorfer, Ralph L Sacco, Wenqin Pan, Daiwai M Olson, Adrian F Hernandez, Eric D Peterson, Lee H Schwamm
Affiliations

Relationship of national institutes of health stroke scale to 30-day mortality in medicare beneficiaries with acute ischemic stroke

Gregg C Fonarow et al. J Am Heart Assoc. 2012 Feb.

Abstract

Background: The National Institutes of Health Stroke Scale (NIHSS), a well-validated tool for assessing initial stroke severity, has previously been shown to be associated with mortality in acute ischemic stroke. However, the relationship, optimal categorization, and risk discrimination with the NIHSS for predicting 30-day mortality among Medicare beneficiaries with acute ischemic stroke has not been well studied.

Methods and results: We analyzed data from 33102 fee-for-service Medicare beneficiaries treated at 404 Get With The Guidelines-Stroke hospitals between April 2003 and December 2006 with NIHSS documented. The 30-day mortality rate by NIHSS as a continuous variable and by risk-tree determined or prespecified categories were analyzed, with discrimination of risk quantified by the c-statistic. In this cohort, mean age was 79.0 years and 58% were female. The median NIHSS score was 5 (25th to 75th percentile 2 to 12). There were 4496 deaths in the first 30 days (13.6%). There was a strong graded relation between increasing NIHSS score and higher 30-day mortality. The 30-day mortality rates for acute ischemic stroke by NIHSS categories were as follows: 0 to 7, 4.2%; 8 to 13, 13.9%; 14 to 21, 31.6%; 22 to 42, 53.5%. A model with NIHSS alone provided excellent discrimination whether included as a continuous variable (c-statistic 0.82 [0.81 to 0.83]), 4 categories (c-statistic 0.80 [0.79 to 0.80]), or 3 categories (c-statistic 0.79 [0.78 to 0.79]).

Conclusions: The NIHSS provides substantial prognostic information regarding 30-day mortality risk in Medicare beneficiaries with acute ischemic stroke. This index of stroke severity is a very strong discriminator of mortality risk, even in the absence of other clinical information, whether used as a continuous or categorical risk determinant. (J Am Heart Assoc. 2012;1:42-50.).

Keywords: National Institutes of Health Stroke Scale; ischemic stroke; mortality; registries.

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Figures

Figure 1.
Figure 1.
Distribution of NIHSS scores among Medicare beneficiaries in GTWG-Stroke hospitals with acute ischemic stroke patients alive at 30 days are shown in green and patients dead by 30 days shown in red. NIHSS indicates National Institutes of Health Stroke Scale; GWTG, Get With The Guidelines.
Figure 2.
Figure 2.
Acute ischemic stroke 30-day mortality rates by NIHSS. Standard error bars are displayed. NIHSS indicates National Institutes of Health Stroke Scale.
Figure 3.
Figure 3.
Calibration plot of observed and predicted 30-day mortality by NIHSS as a continuous variable.
See this image and copyright information in PMC

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