Hospital Discharge and Readmissions Before and During the COVID-19 Pandemic for California Acute Stroke Inpatients

Abstract

Background: Acute stroke therapy and rehabilitation declined during the COVID-19 pandemic. We characterized changes in acute stroke disposition and readmissions during the pandemic.

Methods: We used the California State Inpatient Database in this retrospective observational study of ischemic and hemorrhagic stroke. We compared discharge disposition across a pre-pandemic period (January 2019 to February 2020) to a pandemic period (March to December 2020) using cumulative incidence functions (CIF), and re-admission rates using chi-squared.

Results: There were 63,120 and 40,003 stroke hospitalizations in the pre-pandemic and pandemic periods, respectively. Pre-pandemic, the most common disposition was home [46%], followed by skilled nursing facility (SNF) [23%], and acute rehabilitation [13%]. During the pandemic, there were more home discharges [51%, subdistribution hazard ratio 1.17, 95% CI 1.15-1.19], decreased SNF discharges [17%, subdistribution hazard ratio 0.70, 95% CI 0.68-0.72], and acute rehabilitation discharges were unchanged [CIF, p<0.001]. Home discharges increased with increasing age, with an increase of 8.2% for those ≥85 years. SNF discharges decreased in a similar distribution by age. Thirty-day readmission rates were 12.7 per 100 hospitalizations pre-pandemic compared to 11.6 per 100 hospitalizations during the pandemic [p<0.001]. Home discharge readmission rates were unchanged between periods. Readmission rates for discharges to SNF (18.4 vs. 16.7 per 100 hospitalizations, p=0.003) and acute rehabilitation decreased (11.3 vs. 10.1 per 100 hospitalizations, p=0.034).

Conclusions: During the pandemic a greater proportion of patients were discharged home, with no change in readmission rates. Research is needed to evaluate the impact on quality and financing of post-hospital stroke care.

Keywords: Acute stroke; COVID-19 pandemic; hospital discharge; intracerebral hemorrhage; ischemic stroke; readmissions; rehabilitation; subarachnoid hemorrhage.

Fig. 1

Acute stroke discharge disposition before and during the COVID-19 pandemic. Abbreviations: LTCH – long-term acute care hospital Percentages of discharges to each disposition among discharges within the period specified for (A) all stroke patients and (B) by age group. The pre-pandemic period is from January 1, 2019 to February 29, 2020 and the pandemic period is March 1, 2020 to December 31, 2020.

Fig. 2

Cumulative incidence for acute stroke disposition before and during the COVID-19 pandemic. Abbreviations: AR/LTCH – Acute rehabilitation/long-term acute care hospital; SNF – skilled nursing facility Cumulative incidence functions (CIF) representing incidence of disposition as a function of length of stay, accounting for each possible disposition as a competing risk. Length of stay was truncated at 30 days for visualization purposes only. The pre-pandemic period is from January 1, 2019 to February 29, 2020 and the pandemic period is March 1, 2020 to December 31, 2020. CIF is displayed for (A) all stroke, and by individual disposition: (B) home, (C) SNF, (D) transfer, (E) AR/LTCH, and (F) Died

Fig. 3

Multivariate logistic regression predicting odds of readmission within 30 days of index hospitalization discharge. Abbreviations: SNF – skilled nursing facility; LTCH – long-term acute care hospital; ICH – intracerebral hemorrhage; SAH – subarachnoid hemorrhage Home, SNF, Transfer, Acute Rehab/LTCH indicate the discharge disposition for the index acute stroke hospitalization. For example, acute stroke patients discharged to SNF during the pandemic period compared to pre-pandemic had lower odds of being readmitted within 30 days following discharge, while those discharged to home during the pandemic compared to pre-pandemic had no difference in odds of 30-day readmission. The pre-pandemic period is from January 1, 2019 to February 29, 2020 and the pandemic period is March 1, 2020 to December 31, 2020.