Association Between Early Outpatient Visits and Readmissions After Ischemic Stroke

Abstract

Background: Reducing hospital readmission is an important goal to optimize poststroke care and reduce costs. Early outpatient follow-up may represent one important strategy to reduce readmissions. We examined the association between time to first outpatient contact and readmission to inform postdischarge transitions.

Methods and results: We performed a retrospective cohort study of all Medicare fee-for-service patients discharged home after an acute ischemic stroke in 2012 identified by the InternationalClassification of Diseases, Ninth Revision, Clinical Modification codes. Our primary predictor variable was whether patients had a primary care or neurology visit within 30 days of discharge. Our primary outcome variable was all-cause 30-day hospital readmission. We used separate multivariable Cox models with primary care and neurology visits specified as time-dependent covariates, adjusted for numerous patient- and systems-level factors. The cohort included 78 345 patients. Sixty-one percent and 16% of patients, respectively, had a primary care and neurology visit within 30 days of discharge. Visits occurred a median (interquartile range) 7 (4-13) and 15 (5-22) days after discharge for primary care and neurology, respectively. Thirty-day readmission occurred in 9.4% of patients. Readmissions occurred a median 14 (interquartile range, 7-21) days after discharge. Patients who had a primary care visit within 30 days of discharge had a slightly lower adjusted hazard of readmission than those who did not (hazard ratio, 0.98; 95% confidence interval, 0.97-0.98). The association was nearly identical for 30-day neurology visits (hazard ratio, 0.98; 95% confidence interval, 0.97-0.98).

Conclusions: Thirty-day outpatient follow-up was associated with a small reduction in hospital readmission among elderly patients with stroke discharged home. Further work should assess how outpatient care may be improved to further reduce readmissions.

Keywords: aged; confidence intervals; humans; outcome and process assessment (health care); primary health care.

Figure 1

Patient flowchart. Exclusions are displayed.

Figure 2

Time distribution of primary covariates and outcome. The denominator of these graphs is the entire cohort. A) Distribution of days to first neurology visit B) Distribution of days to first primary care visit C) Distribution of days to first readmission

Figure 2

Time distribution of primary covariates and outcome. The denominator of these graphs is the entire cohort. A) Distribution of days to first neurology visit B) Distribution of days to first primary care visit C) Distribution of days to first readmission

Figure 2

Time distribution of primary covariates and outcome. The denominator of these graphs is the entire cohort. A) Distribution of days to first neurology visit B) Distribution of days to first primary care visit C) Distribution of days to first readmission