Risk of Recurrent Stroke and Mortality Among Black and White Patients With Poststroke Depression.

BACKGROUND: Poststroke depression (PSD) is a treatable and common complication of stroke that is underdiagnosed and undertreated in minority populations. We compared outcomes of Black and White patients with PSD in the United States to assess whether race is independently associated with the risk of recurrent stroke and mortality. METHODS: We used deidentified Medicare data from inpatient, outpatient, and subacute nursing facilities for Black and White US patients from January 1, 2016, to December 31, 2019, to perform this retrospective cohort analysis. International Classification of Diseases, Tenth Revision codes were used to identify patients diagnosed with depression within 6 months of index stroke with no depression diagnosis 1-year preceding index stroke. We performed an unadjusted Kaplan-Meier analysis of the cumulative risk of recurrent stroke up to 3 years after index acute ischemic stroke admission and all-cause mortality following acute ischemic stroke stratified by Black and White race. We performed adjusted and reduced Cox regression to calculate hazard ratios for the main predictor of race (Black versus White), for recurrent stroke and all-cause mortality, adjusting for sociodemographic characteristics, comorbidities, characteristics of the hospitalization, and acute stroke interventions. RESULTS: Of 474 770 Medicare patients admitted with acute index stroke, 443 486 were categorized as either Black or White race and 35 604 fulfilled our criteria for PSD. Within the PSD cohort, 25 451 (71.5%) had no death or recurrent stroke within 6 months and 5592 (15.7%) had no death or readmission of any cause within 6 months. Black patients with PSD had a persistently elevated cumulative risk of recurrent stroke compared with White patients with PSD up to 3 years following acute ischemic stroke (log-rank P=0.0011). In our reduced multivariable model, Black patients had a 19.8% (hazard ratio, 1.198 [95% CI, 1.022-1.405]; P=0.0259) greater risk of recurrent stroke than White patients. The unadjusted cumulative risk of all-cause mortality was higher in this cohort of older White patients with PSD compared with Black patients; however, this difference disappeared with adjustment for age and other cofactors. CONCLUSIONS: Black patients with PSD face a persistently elevated risk of recurrent stroke compared with White patients but a similar risk of all-cause mortality. Our findings support that black race is an independent predictor of recurrent stroke in patients with PSD and highlight the need to address social determinants of health and systemic racism that impact poststroke outcomes among racial minorities.

In-hospital outcomes in patients with and without epilepsy diagnosed with COVID-19-A cohort study.

OBJECTIVES: Coronavirus disease 2019 (COVID-19) is associated with mortality in persons with comorbidities. The aim of this study was to evaluate in-hospital outcomes in patients with COVID-19 with and without epilepsy. METHODS: We conducted a retrospective study of patients with COVID-19 admitted to a multicenter health system between March 15, 2020, and May 17, 2021. Patients with epilepsy were identified using a validated International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)/ICD-10-CM case definition. Logistic regression models and Kaplan-Meier analyses were conducted for mortality and non-routine discharges (i.e., not discharged home). An ordinary least-squares regression model was fitted for length of stay (LOS). RESULTS: We identified 9833 people with COVID-19 including 334 with epilepsy. On univariate analysis, people with epilepsy had significantly higher ventilator use (37.70% vs 14.30%, p < .001), intensive care unit (ICU) admissions (39.20% vs 17.70%, p < .001) mortality rate (29.60% vs 19.90%, p < .001), and longer LOS (12 days vs 7 days, p < .001). and fewer were discharged home (29.64% vs 57.37%, p < .001). On multivariate analysis, only non-routine discharge (adjusted odds ratio [aOR] 2.70, 95% confidence interval [CI] 2.00-3.70; p < .001) and LOS (32.50% longer, 95% CI 22.20%-43.60%; p < .001) were significantly different. Factors associated with higher odds of mortality in epilepsy were older age (aOR 1.05, 95% CI 1.03-1.08; p < .001), ventilator support (aOR 7.18, 95% CI 3.12-16.48; p < .001), and higher Charlson comorbidity index (CCI) (aOR 1.18, 95% CI 1.04-1.34; p = .010). In epilepsy, admissions between August and December 2020 or January and May 2021 were associated with a lower odds of non-routine discharge and decreased LOS compared to admissions between March and July 2020, but this difference was not statistically significant. SIGNIFICANCE: People with COVID-19 who had epilepsy had a higher odds of non-routine discharge and longer LOS but not higher mortality. Older age (≥65), ventilator use, and higher CCI were associated with COVID-19 mortality in epilepsy. This suggests that older adults with epilepsy and multimorbidity are more vulnerable than those without and should be monitored closely in the setting of COVID-19.

Treatment Patterns for Sickle Cell Disease among Those with Cerebrovascular Disease in the USA.

BACKGROUND: New treatments and guidelines in sickle cell disease (SCD) have improved the quality and lifespan of SCD patients. Over 90% of people with SCD will live into adulthood, and the majority will live past 50 years of age. However, data on comorbidities and treatments among SCD patients with and without cerebrovascular disease (CVD) are limited. OBJECTIVES: The objective of this study was to describe the outcomes and preventive treatments used on SCD patients with and without CVD, based on a dataset of over 11,000 SCD patients. METHODS: We identified SCD patients with and without CVD from the MarketScan administrative database using validated International Classification of Diseases, 10th Revision, Clinical Modification codes from January 1, 2016, to December 31, 2017. We summarized treatments received (iron chelation, blood transfusion, transcranial Doppler, and hydroxyurea) and tested for differences by CVD status using the t test for continuous variables and the χ2 for categorical variables. We also tested for differences among SCD, stratifying by age (<18 years vs. ≥18 years). RESULTS: Of the 11,441 SCD patients, 833 (7.3%) had CVD. SCD patients with CVD were more likely to have diabetes mellitus (32.4% among those with CVD vs. 13.8% without CVD), congestive heart failure (18.3 vs. 3.4%), hypertension (58.6 vs. 24.7%), chronic kidney disease (17.9 vs. 4.9%), and coronary artery disease (21.3 vs. 4.0%). SCD patients with CVD were more likely to receive a blood transfusion (15.3 vs. 7.2%) and hydroxyurea (10.5 vs. 5.6%). Fewer than 20 patients with SCD were given iron chelation therapy, and none received transcranial Doppler ultrasound. Hydroxyurea was prescribed among a greater percentage of children (32.9%) than adults (15.9%). CONCLUSIONS: There appears to be an underutilization overall of treatment options among SCD patients with CVD. Further research would confirm these trends and explore ways to increase utilization of standard treatments among SCD patients.

Patterns in the number of interventionalists for endovascular treatment of acute ischemic stroke in the US.

BACKGROUND: Endovascular thrombectomy (ET) has become the standard of stroke care for large vessel occlusion acute ischemic stroke (AIS) involving the anterior circulation. With continued eligibility expansion, the demand for neuro-intervention is growing. Current estimates indicate inadequate supply of interventionalists. However, there is limited data describing the number of interventionalists per hospital in the US, and correlations with outcomes. METHODS: We used Medicare 100% sample datasets and included all AIS admissions from 2018 to 2019, using validated International Classification of Diseases, 10th Revision, Clinical Modification codes to identify AIS and comorbidities. We utilized National Provider Identifier codes to identify distinct interventionalists at the hospital. We examined outcomes at the hospital level, including percent of AIS treated with thrombolysis, percent of AIS with inpatient mortality, percent of AIS with discharge home, and percent of AIS with death within 30 days. RESULTS: Among 471,427 AIS admissions, 16,253 received ET over the 2-year period of the study. Only 683 of 4576 AIS-treating institutions provided ET (14.9%). These ET centers most frequently only had one interventionalist performing ET and were clustered in large metropolitan areas with high AIS volumes. As AIS volumes, ET volumes, and mean NIHSS scores increased, so did the number of interventionalists. With each additional interventionalist, there was an increased likelihood of poor outcomes including inpatient mortality, discharge home, and 30-day mortality. CONCLUSIONS: We confirmed a relative lack of neuro-interventionalists among US hospitals, with a concentration of interventionalists in urban, high-volume centers. The greater likelihood of poor outcomes associated with increasing number of interventionalists is likely due to increasing complexity and severity of cases at high-volume ET centers, but further study is needed.

Patterns and outcomes of weekend admission for acute ischemic stroke.

BACKGROUND AND OBJECTIVES: The "weekend effect" describes worse care delivery during off-hours or weekends and has been demonstrated in multiple sub-specialties. Off-hours care for acute ischemic stroke (AIS) has been associated with poorer outcomes. However, there is less data about the "weekend effect" on endovascular thrombectomy (ET) outcomes. METHODS: We used Medicare 100% sample datasets and included all AIS admissions from 2018-2019, using validated International Classification of Diseases, 10th Revision, Clinical Modification codes to identify AIS and comorbidities. Medicare provides the date of admission for all hospitalizations, and the day of the week was determined and assigned to weekend (Saturday or Sunday) or weekday (Monday through Friday). We defined 3 major outcomes: inpatient mortality, discharge home (vs. other destination), and 30-day mortality. RESULTS: Among 471427 AIS admissions,13.0% and 12.9% of all AIS admissions occurred on a Saturday and Sunday, respectively, less than the expected 14.3% occurring on any given day (p-value <0.0001). AIS admissions on a weekend were less likely to receive IV thrombolysis (13.6% on Saturday and 12.9% on Sunday) and ET (13.1% on Saturday and 13.2% on Sunday), p-value <0.0001. Among all AIS admissions, weekend admission was associated with worse outcomes, including higher odds of inpatient mortality (adjusted OR 1.04 [95% CI 1.01-1.08, p<0.0001]), lower odds of discharge home (0.94 [0.93-0.96, p<0.0001]), and higher odds of 30-day mortality (1.06 [1.04-1.08, p<0.0001]). However, among AIS patients treated with ET, there was no association of weekend admission with outcomes. CONCLUSIONS: In this national and contemporary dataset, we observed that the proportion of thrombolysis and ET cases was less over the weekend, and outcomes (inpatient mortality, 30-day mortality and odds of discharge home) were worse overall. We did not observe this association among AIS patients undergoing ET on a weekend vs. weekday.

Relationships among hospital acute ischemic stroke volumes, hospital characteristics, and outcomes in the US.

BACKGROUND AND OBJECTIVES: Prior research on volume-based patient outcomes related to acute ischemic stroke (AIS) have demonstrated contradictory results and fail to reflect recent advances in stroke care. We sought to examine contemporary relationships between hospital AIS volumes and outcomes. METHODS: We used complete Medicare datasets in a retrospective cohort study using validated International Classification of Diseases Tenth Revision codes to identify patients admitted with AIS from January 1, 2016 through December 31, 2019. AIS volume was calculated as the total number of AIS admissions per hospital during the study period. We examined several hospital characteristics by AIS volume quartile. We performed adjusted logistic regressions testing associations of AIS volume quartiles with: inpatient mortality, receipt of tissue plasminogen activator (tPA) and endovascular therapy (ET), discharge home, and 30-day outpatient visit. We adjusted for sex, age, Charlson comorbidity score, teaching hospital status, MDI, hospital urban-rural designation, stroke certification status and ICU and neurologist availability at the hospital. RESULTS: There were 952400 AIS admissions among 5084 US hospitals; AIS 4-year volume quartiles were: 1st: 1-8 AIS admissions; 2nd: 9-44; 3rd: 45-237; 4th: 238+. Highest quartile hospitals more often were stroke-certified (49.1% vs 8.7% in lowest quartile, p<0.0001), with ICU bed availability (19.8% vs 4.1%, p<0.0001) and with neurologist expertise (91.1% vs 3%, p<0.0001). In the highest AIS quartile (compared to the lowest quartile), there was lower inpatient mortality (odds ratio [OR] 0.71 [95%CI 0.57-0.87, p<0.0001]), lower 30-day mortality (0.55 [0.49-0.62], p<0.0001), greater receipt of tPA (6.60 [3.19-13.65], p<0.0001) and ET (16.43 [10.64-25.37], p<0.0001, and greater likelihood of discharge home (1.38 [1.22-1.56], p<0.0001). However, when the highest quartile hospitals were examined separately, higher volumes were associated with higher mortality despite higher rates of tPA and ET receipt. CONCLUSIONS: High AIS-volume hospitals have greater utilization of acute stroke interventions, stroke certification and availability of neurologist and ICU care. These features likely play a role in the better outcomes observed at such centers, including inpatient and 30-day mortality and discharge home. However, the highest volume centers had higher mortality despite greater receipt of interventions. Further research is needed to better understand volume-outcome relationships in AIS to improve care at lower volume centers.

Depression readmission risk is elevated in multiple sclerosis compared to other chronic illnesses.

OBJECTIVE: Assess readmissions for depression or suicide attempt (SA) after MS admission versus other chronic inflammatory illnesses. METHODS: This retrospective cohort study identified MS, asthma, rheumatoid arthritis (RA), depression, and SA in the 2013 National Readmissions Database by International Classification of Diseases codes. Index admissions (MS, n = 7698; asthma, n = 93,590; RA, n = 3685) and depression or SA readmission rates were analyzed. Hazard ratios (HRs) estimated 1-year depression/SA readmission hazard, comparing MS to asthma or RA, adjusting for age, sex, psychiatric comorbidity, substance abuse, tobacco use, income, and index hospitalization characteristics. RESULTS: MS had more baseline depression (24.7%) versus asthma (15.6%) and RA (14.6%). Ninety-day depression readmission rate was higher in MS (0.5%) than asthma (0.3%) and RA (0.03%). Depression readmission HR was higher after MS admission versus asthma (HR = 1.37, 95% confidence interval (CI) = 1.00-1.86, p = 0.0485) and RA (HR = 4.68, 95% CI = 1.60-13.62, p = 0.0047). HR was not different for SA readmission across groups. Depression readmission HR was more than double in MS patients with psychiatric disease or substance abuse versus RA or asthma patients with either comorbidity. CONCLUSION: Depression readmission risk after MS hospitalization was elevated versus asthma/RA. Substance use and baseline psychiatric comorbidity were more strongly associated with depression readmission in MS patients.

Triptan medication use among patients with migraine with contraindications in the US.

OBJECTIVE: We sought to investigate the prevalence of triptan use among patients with migraine who have contraindications to triptan usage, and to explore specifics of the medication prescribed, dosage, and route of administration. BACKGROUND: Triptan medications are a mainstay of acute migraine therapy, but little is known about prevalence and patterns of triptan prescribing among patients with contraindications in the United States. METHODS: In this retrospective cohort study, we used data from the IBM Marketscan database to identify patients aged ≥ 18 years with migraine from January 1, 2016, to December 31, 2017, using International Classification of Diseases, Clinical Modification 10 codes. Contraindications to triptan medications were identified by review of package labels as listed on the US Food and Drug Administration website. Triptan medications were identified from the IBM Micromedex Redbook linked to prescription claims along with route of administration and dosage. RESULTS: Of 1,038,472 individuals diagnosed with migraine, 400,112 (38.5%) were prescribed triptan medication, and of those who were prescribed a triptan, 55,707 (13.9%) had at least one contraindication, with the most common contraindication being cardiac arrhythmia (33,696/400,112 individuals, 8.4%) followed by cerebrovascular disease (14,787/400,112, 3.7%) and coronary artery disease (10,236/400,112, 2.6%). Sumatriptan was the most prescribed triptan (261,736/1,038,472, 25.2%), and the subcutaneous and intranasal routes were more commonly prescribed among those with contraindications compared with those without contraindications. DISCUSSION: A substantial proportion of patients with migraine with contraindications were prescribed triptan medications. These findings call for further research on the outcomes of patients with medical contraindications who are prescribed triptan medications, and for greater clarity in prescribing guidelines about the optimal approach for acute therapy among patients with migraine.

SUBRETINAL DRUSENOID DEPOSITS AND SOFT DRUSEN: Are They Markers for Distinct Retinal Diseases?

PURPOSE: Soft drusen and subretinal drusenoid deposits (SDDs) characterize two pathways to advanced age-related macular degeneration (AMD), with distinct genetic risks, serum risks, and associated systemic diseases. METHODS: One hundred and twenty-six subjects with AMD were classified as SDD (with or without soft drusen) or non-SDD (drusen only) by retinal imaging, with serum risks, genetic testing, and histories of cardiovascular disease (CVD) and stroke. RESULTS: There were 62 subjects with SDD and 64 non-SDD subjects, of whom 51 had CVD or stroke. SDD correlated significantly with lower mean serum high-density lipoprotein (61 ± 18 vs. 69 ± 22 mg/dL, P = 0.038, t-test), CVD and stroke (34 of 51 SDD, P = 0.001, chi square), ARMS2 risk allele (P = 0.019, chi square), but not with CFH risk allele (P = 0.66). Non-SDD (drusen only) correlated/trended with APOE2 (P = 0.032) and CETP (P = 0.072) risk alleles (chi square). Multivariate independent risks for SDD were CVD and stroke (P = 0.008) and ARMS2 homozygous risk (P = 0.038). CONCLUSION: Subjects with subretinal drusenoid deposits and non-SDD subjects have distinct systemic associations and serum and genetic risks. Subretinal drusenoid deposits are associated with CVD and stroke, ARMS2 risk, and lower high-density lipoprotein; non-SDDs are associated with higher high-density lipoprotein, CFH risk, and two lipid risk genes. These and other distinct associations suggest that these lesions are markers for distinct diseases.

Racial differences in persistence to secondary prevention medication regimens after ischemic stroke.

BACKGROUND: Prior stroke is one of the biggest risk factors for future stroke events. Effective secondary prevention medication regimens can dramatically reduce recurrent stroke risk. Guidelines recommend the use of antithrombotic, antihypertensive and lipid-lowering medications after stroke. Medication adherence is known to be better in the presence of a caregiver but long-term adherence after stroke is unknown and disparities may persist. METHODS: We examined the effects of race and sex on baseline prescription and maintenance of secondary prevention regimens in the presence of a caregiver using the Caring for Adults Recovering from the Effects of Stroke (CARES) study, an ancillary study of the national REasons for Geographic and Racial Differences in Stroke (REGARDS). RESULTS: Incident ischemic stroke survivors (N = 172; 36% Black) with family caregivers had medications recorded at hospital discharge and on average 9.8 months later during a home visit. At discharge, antithrombotic prescription (95.9%), lipid-lowering medications (78.8%) and antihypertensives (89.9%) were common and there were no race or sex differences in discharge prescription rates. One year later, medication persistence had fallen to 86.6% for antithrombotics (p = 0.002) and 69.8% for lipid lowering (p = 0.008) but increased to 93.0% for antihypertensives (p = 0.30). Blacks were more likely to have discontinued antithrombotics than Whites (18.3% v 7.7%, p = 0.04). No significant differences in persistence were seen with age, sex, income, depression, or cognitive impairment. CONCLUSIONS: Medication persistence was high in this sample, likely due to the presence of a caregiver. In our cohort, despite similar prescription rates at the time of hospital discharge, Black stroke survivors were more than twice as likely to stop antithrombotics than Whites. The effect of changes in patterns of medication usage on health outcomes in Black stroke survivors warrants continued investigation.

Variability in Intensive Care Utilization for Intracerebral Hemorrhage in the United States: Retrospective Cohort Study.

OBJECTIVES: There are urban-rural geographic health disparities in intracerebral hemorrhage (ICH) outcomes. However, there is limited data regarding the relationship between intensive care (ICU) availability and ICH outcomes. We examined whether ICU availability was a significant contributor to ICH outcomes by US geographic region. MATERIALS AND METHODS: We used de-identified Medicare inpatient datasets from January 2016 to December 2019 and identified all index ICH admissions, stratifying by ICU care received during the hospitalization. Distributions of teaching hospital status, quartile of ICH volume, hospital urban-rural designation, and ICU availability were obtained using chi-square test. Propensity-score matching was utilized to compare outcomes of more favorable outcome, inpatient mortality, and 30-day all-cause readmissions by ICU availability at each hospital. RESULTS: Out of a total of 119,891 hospitalizations for ICH, 66,306 (55.3%) received ICU-level care. Of hospitals that treated at least one ICH, 42.6% did not provide ICU level care for any ICH admission during the study period. Teaching hospitals (48.0% vs 7.0%; p<0.0001), hospitals with higher ICH case volumes (p<0.0001) and in larger metropolitan areas (p<0.0001) were more likely to have an ICU available. Propensity score-matched models showed that hospital ICU availability was associated with a lower likelihood of inpatient mortality (29.4% vs 33.7%; p=0.0016) CONCLUSIONS: Rural-urban disparities in ICH outcomes are likely multifactorial, but ICU availability likely contributes to the disparity. Additional studies are necessary to elucidate other contributing mechanisms.

Correlations Between Physician and Hospital Stroke Thrombectomy Volumes and Outcomes: A Nationwide Analysis.

Background and Purpose: Despite the Joint Commission's certification requirement of ≥15 stroke thrombectomy (ST) cases per center and proceduralist annually, the relationship between ST case volumes and outcomes is uncertain. We sought to determine whether a proceduralist or hospital volume threshold exists that is associated with better outcomes among Medicare beneficiaries. Methods: Retrospective cohort study using validated International Classification of Diseases, Tenth Revision, Clinical Modification codes to identify admissions with acute ischemic stroke and treatment with ST. We used de-identified, national 100% inpatient Medicare data sets from January 1, 2016, to December 31, 2017 for US individuals aged ≥65 years. We calculated total procedures by proceduralist and hospital. We performed adjusted logistic regression of total cases as a predictor of inpatient mortality, good outcome (defined by dichotomized discharge disposition of inpatient rehabilitation or better), and 30-day readmission. We adjusted for sex, age, Charlson Comorbidity Index, availability of neurocritical care, teaching hospital status, socioeconomic status, 2-year stroke volume, and urban versus rural hospital location. We dichotomized case numbers incrementally to determine a volume threshold for better outcomes. Results: Thirteen thousand three hundred thirty-five patients were treated with ST by 2754 proceduralists at 641 hospitals. For every 10 more proceduralist cases, patients had 4% lower adjusted odds of inpatient mortality (adjusted odds ratio, 0.96 [95% CI, 0.95­0.98], P<0.0001) and 3% greater adjusted odds of good outcome (adjusted odds ratio, 1.03 [95% CI, 1.02­1.04], P<0.0001). For every 10 more hospital cases, patients had 2% lower odds of inpatient mortality (adjusted odds ratio, 0.98 [95% CI, 0.98­0.99], P=0.0003) and 2% greater odds of good outcome (adjusted odds ratio, 1.02 [95% CI, 1.01­1.02], P<0.0001). With increasing volumes, there were higher odds of better outcomes. Conclusions: Nationally, higher proceduralist and hospital ST case volumes were associated with reduced inpatient mortality and better outcome. These data support volume requirements in guidelines for ST training and certification.

Acute Cerebrovascular Events With COVID-19 Infection.

BACKGROUND AND PURPOSE: Coronavirus disease 2019 (COVID-19) has been associated with an increased incidence of thrombotic events, including stroke. However, characteristics and outcomes of COVID-19 patients with stroke are not well known. METHODS: We conducted a retrospective observational study of risk factors, stroke characteristics, and short-term outcomes in a large health system in New York City. We included consecutively admitted patients with acute cerebrovascular events from March 1, 2020 through April 30, 2020. Data were stratified by COVID-19 status, and demographic variables, medical comorbidities, stroke characteristics, imaging results, and in-hospital outcomes were examined. Among COVID-19-positive patients, we also summarized laboratory test results. RESULTS: Of 277 patients with stroke, 105 (38.0%) were COVID-19-positive. Compared with COVID-19-negative patients, COVID-19-positive patients were more likely to have a cryptogenic (51.8% versus 22.3%, P<0.0001) stroke cause and were more likely to suffer ischemic stroke in the temporal (P=0.02), parietal (P=0.002), occipital (P=0.002), and cerebellar (P=0.028) regions. In COVID-19-positive patients, mean coagulation markers were slightly elevated (prothrombin time 15.4±3.6 seconds, partial thromboplastin time 38.6±24.5 seconds, and international normalized ratio 1.4±1.3). Outcomes were worse among COVID-19-positive patients, including longer length of stay (P<0.0001), greater percentage requiring intensive care unit care (P=0.017), and greater rate of neurological worsening during admission (P<0.0001); additionally, more COVID-19-positive patients suffered in-hospital death (33% versus 12.9%, P<0.0001). CONCLUSIONS: Baseline characteristics in patients with stroke were similar comparing those with and without COVID-19. However, COVID-19-positive patients were more likely to experience stroke in a lobar location, more commonly had a cryptogenic cause, and had worse outcomes.

Stroke and HIV-associated neurological complications: A retrospective nationwide study.

There is an increased risk of stroke and other neurological complications in human immunodeficiency virus (HIV) infected patients with no large population-based studies in the literature. We aim to evaluate the prevalence of stroke, HIV-associated neurological complications, and identify risk factors associated with poor outcomes of stroke among HIV admissions in the United States. In the nationwide inpatient sample with adult HIV hospitalizations, patients with primary cerebrovascular disease (CeVDs) and HIV-associated neurological complications were identified by ICD-9-CM codes. We performed a retrospective study with weighted analysis to evaluate the prevalence of stroke and neurological complications and outcomes of stroke among HIV patients. We included 1,559,351 HIV admissions from 2003 to 2014, of which 22470 (1.4%) patients had CeVDs (transient ischemic attack [TIA]: 3240 [0.2%], acute ischemic stroke [AIS]: 14895 [0.93%], and hemorrhagic stroke [HS]: 4334 [0.27%]), 7781 (0.49%) had neurosyphilis, 29,925 (1.87%) meningitis, 39,190 (2.45%) cytomegalovirus encephalitis, 4699 (0.29%) toxoplasmosis, 9964 (0.62%) progressive multifocal leukoencephalopathy, and 142,910 (8.94%) epilepsy. There is increased overall prevalence trend for CeVDs (TIA: 0.17%-0.24%; AIS: 0.62%-1.29%; HS: 0.26%-0.31%; pTrend < .0001) from 2003 to 2014. Among HIV admissions, variables associated with AIS were neurosyphilis (odds ratio: 4.38; 95% confidence interval: 3.21-5.97), meningitis (4.87 [4.10-5.79]), and central nervous system tuberculosis (6.72 [3.85-11.71]). Toxoplasmosis [4.27 [2.34-7.76]), meningitis (2.91 [2.09-4.06)], and cytomegalovirus encephalitis (1.62 [1.11-2.37]) were associated with higher odds of HS compared to patients without HS. There was an increasing trend of CeVDs over time among HIV hospitalizations. HIV-associated neurological complications were associated with the risk of stroke, together with increased mortality, morbidity, disability, and discharge to long-term care facilities. Further research would clarify stroke risk factors in HIV patients to mitigate adverse outcomes.

Postpartum psychiatric readmissions: A nationwide study in women with and without epilepsy.

OBJECTIVE: To assess whether epilepsy is associated with increased odds of 30-day readmission due to psychiatric illness during the postpartum period. METHODS: The 2014 Nationwide Readmissions Database and the International Classification of Disease, Ninth Revision, Clinical Modification codes were used to identify postpartum women up to 50 years old in the United States, including the subgroup with epilepsy. The primary outcome was 30-day readmission and was categorized as (1) readmission due to psychiatric illness, (2) readmission due to all other causes, or (3) no readmission. Secondary outcome was diagnosis at readmission. The association of the primary outcome and presence of epilepsy was examined using multinomial logistic regression. RESULTS: Of 1 558 875 women with admissions for delivery identified, 6745 (.45%) had epilepsy. Thirteen of every 10 000 women had 30-day psychiatric readmissions in the epilepsy group compared to one of every 10 000 in the no-epilepsy group (p < .0001). Of every 10 000 women with epilepsy, 256 had 30-day readmissions due to other causes compared to 115 of every 10 000 women in the no-epilepsy group (p < .0001). The odds ratio for readmission due to psychiatric illness was 10.13 (95% confidence interval = 5.48-18.72) in those with epilepsy compared to those without. Top psychiatric causes for 30-day readmissions among women with epilepsy were mood disorders, schizophrenia and other psychotic disorders, and substance-related disorders. SIGNIFICANCE: This large-scale study demonstrated that postpartum women with epilepsy have higher odds of readmission due to a psychiatric illness compared to women without epilepsy. Postpartum treatment strategies and interventions to prevent psychiatric readmissions are necessary in this vulnerable population.

Seizures and status epilepticus may be risk factor for cardiac arrhythmia or cardiac arrest across multiple time frames.

OBJECTIVE: To determine if Emergency Department (ED) or inpatient encounters for epilepsy or status epilepticus are associated with increased odds of cardiac arrhythmia or cardiac arrest over successively longer time frames. METHODS: The State Inpatient and ED Databases (from New York, Florida, and California) are statewide datasets containing data on 97% of hospitalizations and ED encounters from these states. In this retrospective, case-crossover study, we used International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify index cardiac arrhythmia encounters. Exposures were inpatient or ED encounters for epilepsy or status epilepticus. The case-crossover analysis tested whether an epilepsy or status epilepticus encounter within various case periods (1, 3, 7, 30, 60, 90, and 180 days prior to index encounter) was associated with subsequent ED or inpatient encounter for cardiac arrhythmia, as compared to control periods of equal length one year prior. RESULTS: The odds ratio (OR) for cardiac arrhythmia after an epilepsy encounter was significant at all time intervals (OR range 2.37-3.36), and highest at 1 day after epilepsy encounter (OR 3.63, 95% confidence interval [CI] 1.66-7.93, p = 0.0013). The OR after status epilepticus was significant at 7- to 180-day intervals (OR range 2.25-2.74), and highest at 60 days (OR 2.74, CI 2.09-3.61, p < 0.0001). SIGNIFICANCE: Epilepsy and status epilepticus events are associated with increased odds of subsequent cardiac arrhythmia or cardiac arrest over multiple chronic timeframes. Increased cardiac surveillance may be warranted to minimize morbidity and mortality in patients with epilepsy.

Hospital readmissions in older adults with epilepsy in the US - A population-based study.

OBJECTIVE: Our objective was to determine proportions, causes, and predictors of 30-day readmissions among older adults with epilepsy. Understanding predictors of readmissions may inform future interventions aimed at reducing avoidable hospitalizations in this vulnerable population. METHODS: Individuals 65 years or older with epilepsy were identified using previously validated ICD-9-CM codes in any diagnostic position in the 2014 Nationwide Readmissions Database. Proportions of 30-day readmissions and causes of readmissions in older adults with epilepsy were compared to both older adults without and younger adults (18-64 years old) with epilepsy. We identified predictors of readmission in older adults with epilepsy using logistic regression. RESULTS: There were 92,030 older adults with, 3,166,852 older adults without, and 168,622 younger adults with epilepsy. Proportions of readmissions were higher in older adults with (16.2%) than older adults without (12.5%) and younger adults with epilepsy (15.1%). The main cause of readmission for older adults with and without epilepsy was septicemia, and epilepsy/seizure in younger adults with epilepsy. Predictors of 30-day readmissions in older adults with epilepsy were: non-elective admissions (OR 1.37, 95%CI 1.27-1.48), public insurance (Medicaid vs. private insurance OR 1.19, 95%CI 1.02-1.39; Medicare vs. private insurance OR 1.11, 95%CI 1.00-1.22), lower median household income for patient's zip code ($1-$39,999 vs. $66,000 + OR 1.15, 95% CI 1.08-1.22), hospital location in large metropolitan areas (OR 1.22, 95%CI 1.05-1.42), higher Charlson-Deyo comorbidity index (OR 1.11, 95%CI 1.10-1.02), and male sex (OR 1.04, 95%CI 1.00-1.09). SIGNIFICANCE: Our findings suggest that targeted interventions to reduce the risk of infection may potentially reduce readmission in older people with epilepsy, similarly to those without. Provision of coordinated care and appropriate discharge planning may reduce readmissions particularly in those who are males, are of lower socioeconomic status and with more comorbidities.

Readmission for cardiac and non-cardiac causes among adults with epilepsy or multiple sclerosis - A nationwide analysis.

PURPOSE: The aim of this study was to determine proportions of 30-day cardiac readmissions in adults with epilepsy compared to multiple sclerosis (MS) or those with neither condition. Predictors and causes of readmissions were also examined. METHODS: We used the 2014 Nationwide Readmissions Database and ICD-9-CM codes to identify people with epilepsy, MS, and without epilepsy or MS. Multinomial logistic regressions were fitted to: (1) examine association between 30-day readmissions and epilepsy, MS or neither, and (2) to describe causes and predictors of 30-day readmission for cardiac readmissions in epilepsy. RESULTS: Out of 6,870,508 adults admitted in 2014, 202,938 (2.98%) had epilepsy and 29,556 (0.45%) had MS. The proportion of 30-day readmission for epilepsy and MS were, respectively: (1) due to cardiac causes (0.17% vs. 0.13%); (2) due to other causes (13.89% vs. 10.61%). The odds of 30-day cardiac readmission in those with epilepsy and MS were lower compared to those without either condition (OR = 0.64, 95% CI 0.57-0.73, p < 0.0001; OR = 0.60, 95% CI 0.43-0.84, p = 0.003). Among those with epilepsy, increasing age (OR = 1.03, 95% CI 1.02-1.04, p < 0.0001) and a Charlson comorbidity index ≥1 (OR = 1.79, 95% CI 1.24-2.60, p = 0.002) were associated with higher odds of 30-day cardiac readmission. A higher proportion of those with epilepsy readmitted within 30-days due to cardiac causes died in hospital (10.09%) compared to those with MS (not reportable due to cell frequency <10) or without epilepsy or MS (5.61%). CONCLUSION: Those admitted to a hospital and living with epilepsy had a higher proportion of cardiac readmissions and death in hospital when compared to those living with MS, and the determinants are likely multifactorial. These findings are important and need to be further explored to identify strategies to prevent readmissions due to any cause and treatments that could reduce mortality.

Characteristics and outcomes of hospitalizations and readmissions for opioid dependence and overdose: nationally representative data.

Background: Despite the increasing rates of morbidity, mortality, and costs from the opioid addiction crisis, there is a paucity of literature on nationwide patterns of opioid abuse and dependence admissions and readmissions. We sought to investigate common comorbidities, readmission rates, and variables associated with readmission following index admission for opioid overdose or dependence. Methods: The 2013 Nationwide Readmission Database is a national database including data on more than 14 million US admissions. We used International Classification of Disease, Ninth Revision, Clinical Modification codes to identify index opioid abuse or dependence admissions, readmissions, and medical co-morbidities. We summarized all-cause readmission rates and reasons for readmission following index opioid dependence or overdose admission. We performed multivariable logistic regression, testing the association between characteristics of index admission and readmission. Results: 64,426 individuals were admitted for drug overdose or dependence during 2013. Of those, 30.1% were readmitted for all causes within one year and 8.7% were readmitted for opioid overdose or dependence within that year. The most common primary diagnoses on the readmission record were infection, kidney failure, drug related admission, and psychiatric admission. Predictors of readmission were smoking, male sex, younger age, alcohol, bipolar disorder, non-opioid drug use, admission to teaching hospitals in metropolitan areas, and discharge against medical advice. Conclusion: There is a high all-cause readmission rate following index admission for opioid overdose or dependence and a greater likelihood of readmission among young males with psychiatric comorbidities in metropolitan areas. Targeted interventions to address psychiatric comorbidities and transitions of care may be needed for the high-risk opioid dependence and overdose population.

Healthcare Utilization for Stroke Patients at the End of Life: Nationally Representative Data.

Objectives Stroke and post-stroke complications are associated with high morbidity, mortality, and cost. Our objective was to examine healthcare utilization and hospice enrollment for stroke patients at the end of life. Materials and methods The 2014 Nationwide Readmissions Database is a national database of > 14 million admissions. We used validated ICD-9 codes to identify fatal ischemic stroke, summarized demographics and hospitalization characteristics, and examined healthcare use within 30 days before fatal stroke admission. We used de-identified 2014 Medicare hospice data to identify stroke and non-stroke patients admitted to hospice. Results Among IS admissions in 2014 (n = 472,969), 22652 (4.8%) had in-hospital death. 28.2% with fatal IS had two or more hospitalizations in 2014. Among those with fatal IS admission, 13.0% were admitted with cerebrovascular disease within 30 days of fatal IS admission. Half of stroke patients discharged to hospice from the Medicare dataset were hospitalized with cerebrovascular disease within the thirty days prior to hospice enrollment. Within the study year, 6.9% of hospice enrollees had one or more emergency room visits, 31.7% had one or more inpatient encounters, and 5.2% had one or more nursing facility encounters (compared to 21.4%, 70.6%, and 27.2% respectively in the 30-day period prior to enrollment). Conclusions High rates of readmission prior to fatal stroke may indicate opportunity for improvement in acute stroke management, secondary prevention, and palliative care involvement as encouraged by AHA/ASA guidelines. For patients who are expected to survive 6 months or less, hospice may offer goal-concordant services for patients and caregivers who desire comfort-focused care.