Impact of transfer status on hospitalization cost and discharge disposition for acute ischemic stroke across the US

Abstract

OBJECT In this study, the authors used information provided in the Nationwide Inpatient Sample (NIS) to study the impact of transferring stroke patients from one facility to a center where they received some form of active stroke intervention (intravenous tissue plasminogen activator, thrombectomy, or a combination of both therapies). METHODS Patient demographic characteristics and hospital factors obtained from the 2008-2010 acute stroke NIS data were analyzed. Discharge disposition, hospitalization cost, and mortality were the dependent variables studied. Univariate analysis and multivariate binary logistic regression analysis were performed. Data analysis focused on the cohort of acute stroke patients who received some form of active intervention (55,913 of 1,311,511 patients in the NIS). RESULTS When overall outcome was considered, transferred patients had a significantly higher number of other-than-routine (OTR, i.e., other than discharge to home without home health care) discharge dispositions (p < 0.0001). In multivariate regression analysis including pertinent patient and hospital factors, transfer-in patients had significantly worse OTR discharge disposition (p < 0.0001, odds ratio [OR] 2.575, 95% CI 2.341-2.832). Mean hospitalization cost including an intervention was $70,325.11 for direct admissions and $97,546.92 for transferred patients. Transfer from another facility (p < 0.001, OR 1.677, 95% CI 1.548-1.817) was associated with higher hospitalization cost. CONCLUSIONS The study showed that hospital cost for acute stroke intervention is significantly higher for a transferred patient than for a direct admission. Moreover, the frequency of OTR discharge was significantly higher among transferred patients than direct admissions. Future strategies should focus on ways and means of transporting patients appropriately and directly to stroke centers.

Keywords: APR-DRG = All Patient Refined Diagnosis-Related Group; CAD = coronary artery disease; CCS = Clinical Classifications Software; DVT = deep venous thrombosis; ESCAPE = Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times; HCUP = Healthcare Cost and Utilization Project; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; LOS = length of stay; MR CLEAN = Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands; NIHSS = National Institutes of Health Stroke Scale; NIS = Nationwide Inpatient Sample; Nationwide Inpatient Sample; OR = odds ratio; OTR = other than routine; SD = standard deviation; UTI = urinary tract infection; acute ischemic stroke; discharge disposition; hospitalization cost; mRS = modified Rankin Scale; nos = not otherwise specified; tPA = tissue plasminogen activator; thrombectomy; thrombolysis; vascular disorders.