The Effect of Improved Dysphagia Care on Outcome in Patients with Acute Stroke: Trends from 8-Year Data of a Large Stroke Register.

BACKGROUND: Early dysphagia screening and appropriate management are recommended by current guidelines to reduce complications and case fatality in acute stroke. However, data on the potential benefit of changes in dysphagia care on patient outcome are limited. Our objective was to assess the degree of implementation of dysphagia guidelines and determine the impact of modifications in dysphagia screening and treatment practices on disease complications and outcome in stroke patients over time. METHODS: In this prospective register-based study ("Stroke Register of Northwestern Germany"), all adult stroke patients admitted to 157 participating hospitals between January, 2008 and December, 2015 were included (n = 674,423). Dysphagia incidence upon admission, the proportion of patients receiving a standardized swallowing screening, and the percentage of dysphagic patients being referred to a speech language therapist (SLT) for treatment were obtained per year. Pneumonia rate, modified Rankin Scale (mRS) at discharge, and in-hospital mortality were compared between groups of dysphagic vs. non-dysphagic patients over time. RESULTS: Screening proportions continuously increased from 47.2% in 2008 to 86.6% in 2015. But the proportion diagnosed with dysphagia remained stable with about 19%. The number of dysphagic patients receiving SLT treatment grew from 81.6 up to 87.0%. Pneumonia incidence was higher in dysphagic stroke cases (adjusted OR 5.4 [5.2-5.5], p < 0.001), accompanied by a worse mRS at discharge (adjusted OR for mRS ≥3: 3.1 [3.0-3.1], p < 0.001) and higher mortality (adjusted OR 3.1 [3.0-3.2], p < 0.001). The order of magnitude of these end points did not change over time. CONCLUSION: Although advances have been made in dysphagia care, prevalent screening and treatment practices remain insufficient to reduce pneumonia rate, improve functional outcome, and decrease case fatality in dysphagic stroke patients. More research is urgently needed to develop more effective swallowing therapies.

The influence of neighborhood unemployment on mortality after stroke.

BACKGROUND: Few studies have investigated the impact of neighborhood characteristics on mortality after stroke. Aim of our study was to analyze the influence of district unemployment as indicator of neighborhood socioeconomic status (SES-NH) on poststroke mortality, and to compare these results with the mortality in the underlying general population. METHODS: Our analyses involve 2 prospective cohort studies from the city of Dortmund, Germany. In the Dortmund Stroke Register (DOST), consecutive stroke patients (N=1883) were recruited from acute care hospitals. In the Dortmund Health Study (DHS), a random general population sample was drawn (n=2291; response rate 66.9%). Vital status was ascertained in the city's registration office and information on district unemployment was obtained from the city's statistical office. We performed multilevel survival analyses to examine the association between district unemployment and mortality. RESULTS: The association between neighborhood unemployment and mortality was weak and not statistically significant in the stroke cohort. Only stroke patients exposed to the highest district unemployment (fourth quartile) had slightly higher mortality risks. In the general population sample, higher district unemployment was significantly associated with higher mortality following a social gradient. After adjustment for education, health-related behavior and morbidity was made the strength of this association decreased. CONCLUSIONS: The impact of SES-NH on mortality was different for stroke patients and the general population. Differences in the association between SES-NH and mortality may be partly explained by disease-related characteristics of the stroke cohort such as homogeneous lifestyles, similar morbidity profiles, medical factors, and old age.

Development of a clinical score (A2DS2) to predict pneumonia in acute ischemic stroke.

BACKGROUND AND PURPOSE: Poststroke pneumonia is a potentially preventable complication after stroke associated with poor outcome. We developed and externally validated a prognostic score for predicting risk of pneumonia after ischemic stroke. METHODS: The prognostic score was developed based on clinical data routinely collected after admission from the Berlin Stroke Register, Germany. The association of demographics, comorbidities, and clinical characteristics with poststroke pneumonia was investigated using multivariable logistic regression analyses. Independent predictors of poststroke pneumonia were translated into a point scoring system based on the corresponding regression coefficients. The predictive properties of the developed prognostic score were externally validated using an independent data set from the Stroke Register Northwest-Germany. RESULTS: Between 2007 and 2009, 15 335 patients with ischemic stroke were registered within the Berlin Stroke Register. The observed rate of pneumonia in hospital was 7.2%. A 10-point score was derived for prediction of poststroke pneumonia (Age ≥ 75 years=1, Atrial fibrillation=1, Dysphagia=2, male Sex=1, stroke Severity, National Institutes of Health Stroke Scale 0-4=0, 5-15=3, ≥ 16=5; A(2)DS(2)). The proportion of pneumonia varied between 0.3% in patients with a score of 0 point to 39.4% in patients with a score of 10 points. The score demonstrated excellent discrimination (C-statistic 0.84; 95% CI, 0.83-0.85) and calibration (McFadden R(2)=0.21). Prediction, discrimination, and calibration properties were reproduced in the validation cohort consisting of 45 085 patients with ischemic stroke. CONCLUSIONS: The A(2)DS(2) score is a valid tool for predicting poststroke pneumonia based on routinely available data. A(2)DS(2) might be useful for guiding monitoring of high-risk patients or prophylactic pneumonia management in clinical routine.

Who receives rehabilitation after stroke?: Data from the quality assurance project "Stroke Register Northwest Germany".

BACKGROUND: Neurological rehabilitation after stroke lowers rates of death, dependency, and institutionalization. Little research has yet addressed the factors affecting the selection of ischemic stroke patients for rehabilitative treatment. METHOD: The database for this study consisted of all cases of ischemic stroke (ICD-10 code I63) that occurred in 2010 and 2011 in the neurological inpatient care facilities participating in the "Stroke Register Northwest Germany" quality assurance project. A primary target group for rehabilitation was defined a priori (Barthel Index at discharge ≤ 65, no premorbid nursing dependency, no transfer to another acute-care hospital after initial treatment of stroke). Among these patients, factors potentially affecting the provision of rehabilitative treatment were studied with binary logistic regression and multilevel logistic regression. RESULTS: There were 96 955 cases of ischemic stroke in the 127 participating hospitals. 40.8% and 11.4% of these patients underwent neurological and geriatric rehabilitation, respectively. The primary target group for rehabilitation contained 14 486 patients, 14.9% of whom underwent no rehabilitation after their acute treatment. The chances of undergoing subsequent rehabilitation were higher for patients with paresis and dysarthria on admission. Female sex, older age, impaired consciousness at admission, prior history of stroke, and lack of counseling by the hospital social services were all associated with a lower probability of undergoing rehabilitation. CONCLUSION: In this study, 54.4% of all ischemic stroke patients and 85.1% of all patients in a primary target group for rehabilitation that was defined a priori underwent rehabilitation after acute care for stroke. Older patients and those who had had a previous stroke were less likely to undergo rehabilitation. Counseling by hospital social services increased the probability of rehabilitation. The potential exclusion of stroke patients from rehabilitation because of old age should be critically examined in every relevant case.