Variation in US acute ischemic stroke treatment by hospital regions: limited endovascular access despite evidence.

BACKGROUND: Although national organizations recognize the importance of regionalized acute ischemic stroke (AIS) care, data informing expansion are sparse. We assessed real-world regional variation in emergent AIS treatment, including growth in revascularization therapies and stroke center certification. We hypothesized that we would observe overall growth in revascularization therapy utilization, but observed differences would vary greatly regionally. METHODS: A retrospective cross-sectional analysis was carried out of de-identified national inpatient Medicare Fee-for-Service datasets from 2016 to 2019. We identified AIS admissions and treatment with thrombolysis and endovascular thrombectomy (ET) with International Classification of Diseases, 10th Revision, Clinical Modification codes. We grouped hospitals in Dartmouth Atlas of Healthcare Hospital Referral Regions (HRR) and calculated hospital, demographic, and acute stroke treatment characteristics for each HRR. We calculated the percent of hospitals with stroke certification and AIS cases treated with thrombolysis or ET per HRR. RESULTS: There were 957 958 AIS admissions. Relative mean (SD) growth in percent of AIS admissions receiving revascularization therapy per HRR from 2016 to 2019 was 13.4 (31.7)% (IQR -6.1-31.7%) for thrombolysis and 28.0 (72.0)% (IQR 0-56.0%) for ET. The proportion of HRRs with decreased or no difference in ET utilization was 38.9% and the proportion of HRRs with decreased or no difference in thrombolysis utilization was 32.7%. Mean (SD) stroke center certification proportion across HRRs was 45.3 (31.5)% and this varied widely (IQR 18.3-73.4%). CONCLUSIONS: Overall growth in AIS treatment has been modest and, within HRRs, growth in AIS treatment and the proportion of centers with stroke certification varies dramatically.

Provider care segregation and hospital-region racial disparities for carotid interventions in the USA.

BACKGROUND: Reasons for racial disparities in the utilization and outcomes of carotid interventions (carotid endarterectomy (CEA) and carotid artery stenting (CAS)) are not well understood, especially segregation of care associated with carotid intervention. We examined patterns of geographic and provider care segregation in carotid interventions and outcomes. METHOD: We used de-identified Medicare datasets to identify CEA and CAS interventions between January 1, 2016 and December 31, 2019 using validated ICD-10 codes. For patients who underwent carotid intervention, we calculated (1) the proportion of White patients at the hospital, (2) the proportional difference in the proportion of White patients between hospital patients and the county, and (3) provider care segregation by the dissimilarity index for carotid intervention cases. We examined associations between measures of segregation and outcomes. RESULTS: Despite higher proportions of Black patients in counties with hospitals that provide carotid intervention, lower proportions of Black patients received intervention. The difference in the proportion of White patients comparing CEA patients to the county race distribution was 0.143 (SD 0.297) at the hospital level (for CAS, 0.174 (0.315)). The dissimilarity index for CEA providers was high, with mean (SD) 0.387 (0.274) averaged across all hospitals and higher among CAS providers at 0.472 (0.288). Black patients receiving CEA and CAS (compared with Whites) had reduced odds of discharge home. Better outcomes (inpatient mortality and 30-day mortality) were independently associated with higher proportion of White CAS patients. CONCLUSION: In this national study with contemporary data on carotid intervention, we found evidence for segregation of care of both CEA and CAS.

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.

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.

Risk Factors and Incidence of Acute Ischemic Stroke: A Comparative Study Between Young Adults and Older Adults.

Introduction Approximately 5-10% of strokes occur in adults of less than 45 years of age. The rising prevalence of stroke risk factors may increase stroke rates in young adults (YA). We aimed to compare risk factors and outcomes of acute ischemic stroke (AIS) among YA. Methods Adult hospitalizations for AIS and concurrent risk factors were found in the Nationwide Inpatient Sample database. Weighted analysis using chi-square and multivariable survey logistic regression was performed to evaluate AIS-related outcomes and risk factors among YA (18-45 years) and older patients. Results A total of 4,224,924 AIS hospitalizations were identified from 2003 to 2014, out of which 198,378 (4.7%) were YA. Prevalence trend of YA with AIS showed incremental pattern over time (2003: 4.36% to 2014: 4.7%; pTrend<0.0001). In regression analysis, the risk factors associated with AIS in YA were obesity (adjusted odds ratio {aOR}: 2.26; p<0.0001), drug abuse (aOR: 2.56; p<0.0001), history of smoking (aOR: 1.20; p<0.0001), infective endocarditis (aOR: 2.08; p<0.0001), cardiomyopathy (aOR: 2.11; p<0.0001), rheumatic fever (aOR: 4.27; p=0.0014), atrial septal disease (aOR: 2.46; p<0.0001), ventricular septal disease (aOR: 4.99; p<0.0001), HIV infection (aOR: 4.36; p<0.0001), brain tumors (aOR: 7.89; p<0.0001), epilepsy (aOR: 1.43; p<0.0001), end stage renal disease (aOR: 2.19; p<0.0001), systemic lupus erythematous (aOR: 3.76; p<0.0001), polymyositis (aOR: 2.72; p=0.0105), ankylosis spondylosis (aOR: 2.42; p=0.0082), hypercoagulable state (aOR: 4.03; p<0.0001), polyarteritis nodosa (aOR: 5.65; p=0.0004), and fibromuscular dysplasia (aOR: 2.83; p<0.0001). Conclusion There is an increasing trend in AIS prevalence over time among YA. Both traditional and non-traditional risk factors suggest that greater awareness is needed, with prevention strategies for AIS among young adults.

Decompressive Hemicraniectomy for Acute Ischemic Stroke in the US: Characteristics and Outcomes.

OBJECTIVES: Decompressive hemicraniectomy can be life-saving for malignant middle cerebral artery acute ischemic stroke (AIS). However, utilization and outcomes for hemicraniectomy in the US are not known. We sought to analyze baseline characteristics and outcomes of patients receiving hemicraniectomy for AIS in the US. MATERIALS AND METHODS: We identified adults who received hemicraniectomy for AIS, identified with validated International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9) code in the Nationwide Readmissions Database 2014. We calculated 30-day readmission rates, reasons for readmission, and procedures performed. RESULTS: 2850 of 531,896 AIS patients (0.54%) received hemicraniectomy. Although patients receiving hemicraniectomy were more likely to be younger (57.0, 95% CI 56.0-58.0; vs 70.9, 95% CI 70.6-71.2; p < 0.0001) and male (40% vs 51.2% female; p<0.0001), 46.3% of patients who received hemicraniectomy were age 60 years and older. Patients 60 years or older receiving hemicraniectomy were more likely to die (29.9% vs 21.9%, p = 0.0081). Hemicraniectomy was more frequently performed at large hospitals (75.3% vs 57.7%; p < 0.0001) in urban areas (99.1% vs 90.3%; p < 0.0001) designated as metropolitan teaching hospitals (88.3% vs 63.4%; p < 0.0001). 30-day readmissions were most commonly due to infection (31.5%), non-infectious medical complications (17.7%), and surgical complications (13.8%). These readmissions were critical. CONCLUSIONS: Although hemicraniectomy is used more frequently in the treatment of younger, male, ischemic stroke patients, only half of the patients receiving hemicraniectomy in 2014 were <60 years old. Regardless of age, hemicraniectomy is a geographically segregated procedure, only being performed in large metropolitan teaching hospitals.

Sex Differences in Ischemic Stroke Readmission Rates and Subsequent Outcomes After Coronary Artery Bypass Graft Surgery.

BACKGROUND AND PURPOSE: Prior studies examining sex-related risk of readmission for ischemic stroke (IS) after coronary artery bypass grafting (CABG) did not adjust for preoperative comorbidities and used small study samples that were single-center or otherwise poorly generalizable. We assessed risk of readmission for IS after CABG for females compared to males in a nationwide sample. METHODS: The 2013 Nationwide Readmissions Database contains data on 49% of all U.S. hospitalizations. We used population weighting to determine national estimates. Using all follow-up data up to 1 year after discharge from CABG hospitalization, we estimated Kaplan-Meier cumulative risk of IS, stratified by sex, using the log-rank test for significance. We created Cox proportional hazard models to calculate hazard ratios (HR) and 95% confidence intervals (CI) for IS readmission, with sex as the main independent variable. We ran unadjusted models and models adjusted for age, vascular risk factors, estimated severity of illness and risk of mortality, hospital characteristics, and income quartile of patient's zip code. RESULTS: An estimated 53,270 females and 147,396 males survived index CABG admission in 2013. There was a consistently elevated cumulative risk of readmission for IS after CABG for females versus males (log-rank p-value = 0.0014). In the unadjusted Cox model, the HR of IS in females vs. males was 1.35 (95% CI 1.12-1.62, p = 0.0015). The elevated risk for females remained after adjusting for severity of illness (1.30 [1.08-1.56], p = 0.0056) and risk of mortality (1.28 [1.07-1.54], p = 0.0086). This elevated risk persisted after adjusting for multiple vascular risk factors, hospital characteristics, and income quartile of patient's zip code (1.23 [1.02-1.48], p = 0.03). CONCLUSIONS: We found a 23% increased risk of readmission for IS up to 1 year after CABG for females compared to males in a fully adjusted model utilizing a large, contemporary, nationwide database. Further research would clarify mechanisms of this increased risk among women.

Recovery From Mobility Limitation in Middle-Aged African Americans: The Jackson Heart Study.

BACKGROUND: Despite evidence that African Americans shoulder a high burden of mobility limitation, little is known about factors associated with recovery. METHOD: Participants from the Jackson Heart Study underwent 3 in-person exams from 2000 to 2013. Mobility limitations were assessed over this period by self-reported limitations in walking half a mile or climbing stairs during annual phone calls. The outcome of interest, recovery from mobility limitation, was defined as no mobility limitation the year following an incident event. Candidate predictor variables were assessed in logistic regression models, including sociodemographic, psychosocial, and health measures. Inverse probability weights were used to address missing data in the outcome. RESULTS: Among 4526 participants (mean [SD] age = 54.5 (12.8) years) without a mobility limitation at baseline, 1445 (32%) had an incident mobility limitation over 12 years of follow-up, and 709 (49%) reported recovery from mobility limitation by 1 year later. Low income and daily discrimination were associated with a lower likelihood of recovery even after adjustment for covariates. In adjusted models, greater comorbidity was associated with a lower likelihood of recovering (p-value for trend = .05). History of heart failure and cancer were associated with a lower likelihood of recovering from mobility limitation (OR: 0.52, 95% CI: 0.29, 0.94 and OR: 0.74, 95% CI: 0.55, 1.00). Adiposity, smoking status, and physical activity were not associated with recovery from mobility limitation. CONCLUSION: Half of incident mobility limitations in this population of middle-aged African Americans were transient. Adverse sociodemographic factors and comorbidities were associated with lower likelihood of recovery.

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.

Nationwide Analysis of Endovascular Thrombectomy Provider Specialization for Acute Stroke.

BACKGROUND AND PURPOSE: Determine the extent of cerebrovascular expertise among the specialties of proceduralists providing endovascular thrombectomy (ET) for emergent large vessel occlusion stroke in the modern era of acute stroke 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 ET. We identified proceduralist specialty by linking the National Provider Identifier provided by Medicare to the specialty listed in the National Provider Identifier database, grouping into radiology, neurology, neurosurgery, other surgical, and internal medicine. We calculated the number of proceduralists and hospitals who performed ET, ET team specialty composition by hospital, and number of proceduralists who performed ET at multiple hospitals. RESULTS: Forty-two percent (n=5612) of ET were performed by radiology-background proceduralists, with unclear knowledge of how many were cerebrovascular specialists. Neurosurgery- and neurology-background interventionalists performed fewer but substantial numbers of cases, accounting for 24% (n=3217) and 23% (n=3124) of total cases, respectively. ET teams included a neurology- or neurosurgery-background proceduralist at 65% (n=407) of hospitals that performed ET and included both in 26% (n=160) of teams. CONCLUSIONS: Almost two-thirds of ET teams nationwide include a neurology- or neurosurgery-background proceduralist and higher volume centers in urban areas were more likely to have neurology- or neurosurgery-background proceduralists with cerebrovascular expertise on their team. It is unclear how many radiology-background interventionalists are cerebrovascular specialists versus generalists. Significant work remains to be done to understand the impact of proceduralist specialty, training, and cerebrovascular expertise on ET outcomes.

Early epidemiological indicators, outcomes, and interventions of COVID-19 pandemic: A systematic review.

BACKGROUND: Coronavirus disease-2019 (COVID-19), a pandemic that brought the whole world to a standstill, has led to financial and health care burden. We aimed to evaluate epidemiological characteristics, needs of resources, outcomes, and global burden of the disease. METHODS: Systematic review was performed searching PubMed from December 1, 2019, to March 25, 2020, for full-text observational studies that described epidemiological characteristics, following MOOSE protocol. Global data were collected from the JHU-Corona Virus Resource Center, WHO-COVID-2019 situation reports, KFF.org, and Worldometers.info until March 31, 2020. The prevalence percentages were calculated. The global data were plotted in excel to calculate case fatality rate (CFR), predicted CFR, COVID-19 specific mortality rate, and doubling time for cases and deaths. CFR was predicted using Pearson correlation, regression models, and coefficient of determination. RESULTS: From 21 studies of 2747 patients, 8.4% of patients died, 20.4% recovered, 15.4% were admitted to ICU and 14.9% required ventilation. COVID-19 was more prevalent in patients with hypertension (19.3%), smoking (11.3%), diabetes mellitus (10%), and cardiovascular diseases (7.4%). Common complications were pneumonia (82%), cardiac complications (26.4%), acute respiratory distress syndrome (15.7%), secondary infection (11.2%), and septic shock (4.3%). Though CFR and COVID-19 specific death rates are dynamic, they were consistently high for Italy, Spain, and Iran. Polynomial growth models were best fit for all countries for predicting CFR. Though many interventions have been implemented, stern measures like nationwide lockdown and school closure occurred after very high infection rates (>10cases per 100 000population) prevailed. Given the trend of government measures and decline of new cases in China and South Korea, most countries will reach the peak between April 1-20, if interventions are followed. CONCLUSIONS: A collective approach undertaken by a responsible government, wise strategy implementation and a receptive population may help contain the spread of COVID-19 outbreak. Close monitoring of predictive models of such indicators in the highly affected countries would help to evaluate the potential fatality if the second wave of pandemic occurs. The future studies should be focused on identifying accurate indicators to mitigate the effect of underestimation or overestimation of COVID-19 burden.

Index Admission Characteristics and All-Cause Readmissions Analysis in Younger and Older Adults with Intracerebral Hemorrhage.

INTRODUCTION: Intracerebral hemorrhage (ICH) comprises 15-20% of all strokes with debilitating consequences. Data regarding characteristics and outcomes of primary ICH in the young are lacking, given its rarity, making comparisons between younger and older cohorts difficult to perform. Nationally representative administrative databases enable analysis of such rare events. OBJECTIVE: To determine the baseline characteristics, all-cause readmission rates, and reasons for primary ICH in younger and older adults using a nationally representative database. METHODS: A retrospective cohort analysis was performed using the Nationwide Readmissions Database 2013. Validated ICD-9-CM codes identified index ICH admissions, comorbidities, demographics, behavioral risk factors, procedures, and Elixhauser and Charlson Comorbidity indices. We compared "younger" (age ≤ 45 years) and "older" (age > 45) index ICH admissions by weighted 30-day all-cause readmission rates, primary diagnosis code for 30-day readmissions, most common comorbidities during the index hospitalization, and Kaplan-Meier cumulative risk of readmission up to 1 year. RESULTS: Older admissions had higher comorbidity scores and mortality, but both groups had similar total comorbidities. Younger admissions exhibited longer length of stay with more procedures performed. Vascular anomalies (aneurysm 7.2 vs. 4.6% and arteriovenous malformation 5.9 vs. 0.8%) and behavioral risk factors (smoking 26.5 vs. 23.0%, alcohol abuse 6.7 vs. 4.6%, and substance use 13.5 vs. 2.9%) were more prevalent in younger admissions, while older patients had more cardiovascular comorbidities. All-cause 30-day readmission rates (13.1 vs. 13.0%) and 1-year cumulative risk of readmission (log-rank p value 0.7209) were similar. Readmissions in the younger cohort were primarily for neurological conditions, and those in the older cohort were for systemic conditions. CONCLUSIONS: Adults <45 years with ICH had similar total comorbidities as older adults but more procedures, longer hospital stay, and more behavioral risk factors. Readmission rates were similar though reasons differed; younger patients were more for neurological reasons than for other systemic causes.

Readmissions for Depression and Suicide Attempt following Stroke and Myocardial Infarction.

BACKGROUND AND PURPOSE: Rates of depression after ischemic stroke (IS) and myocardial infarction (MI) are significantly higher than in the general population and associated with morbidity and mortality. There is a lack of nationally representative data comparing depression and suicide attempt (SA) after these distinct ischemic vascular events. METHODS: The 2013 Nationwide Readmissions Database contains >14 million US admissions for all payers and the uninsured. Using International Classification of Disease, 9th Revision, Clinical Modification Codes, we identified index admission with IS (n = 434,495) or MI (n = 539,550) and readmission for depression or SA. We calculated weighted frequencies of readmission. We performed adjusted Cox regression to calculate hazard ratio (HR) for readmission for depression and SA up to 1 year following IS versus MI. Analyses were stratified by discharge home versus elsewhere. RESULTS: Weighted depression readmission rates were higher at 30, 60, and 90 days in patients with IS versus MI (0.04%, 0.09%, 0.12% vs. 0.03%, 0.05%, 0.07%, respectively). There was no significant difference in SA readmissions between groups. The adjusted HR for readmission due to depression was 1.49 for IS versus MI (95% CI 1.25-1.79, p < 0.0001). History of depression (HR 3.70 [3.07-4.46]), alcoholism (2.04 [1.34-3.09]), and smoking (1.38 [1.15-1.64]) were associated with increased risk of depression readmission. Age >70 years (0.46 [0.37-0.56]) and discharge home (0.69 [0.57-0.83]) were associated with reduced hazards of readmission due to depression. CONCLUSIONS: IS was associated with greater hazard of readmission due to depression compared to MI. Patients with a history of depression, smoking, and alcoholism were more likely to be readmitted with depression, while advanced age and discharge home were protective. It is unclear to what extent differences in type of ischemic tissue damage and disability contribute, and further investigation is warranted.

COVID-19 and Decompressive Hemicraniectomy for Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Young patients with malignant cerebral edema have been shown to benefit from early decompressive hemicraniectomy. The impact of concomitant infection with coronavirus disease 2019 (COVID-19) and how this should weigh in on the decision for surgery is unclear. METHODS: We retrospectively reviewed all COVID-19-positive patients admitted to the neuroscience intensive care unit for malignant edema monitoring. Patients with >50% of middle cerebral artery involvement on computed tomography imaging were considered at risk for malignant edema. RESULTS: Seven patients were admitted for monitoring of whom 4 died. Cause of death was related to COVID-19 complications, and these were either seen both very early and several days into the intensive care unit course after the typical window of malignant cerebral swelling. Three cases underwent surgery, and 1 patient died postoperatively from cardiac failure. A good outcome was attained in the other 2 cases. CONCLUSIONS: COVID-19-positive patients with large hemispheric stroke can have a good outcome with decompressive hemicraniectomy. A positive test for COVID-19 should not be used in isolation to exclude patients from a potentially lifesaving procedure.

Discharge against medical advice among neurological patients: Characteristics and outcomes.

OBJECTIVE: To study characteristics and outcomes of patients with stroke, traumatic brain injury (TBI), and epilepsy with discharge against medical advice (DAMA). DATA SOURCES/STUDY SETTING: Retrospective analysis of the 2013 Nationwide Readmissions Database, a nationally representative inpatient administrative dataset. STUDY DESIGN: Associations between predictors and DAMA at index admission were analyzed using adjusted logistic models. We examined 30-day all-cause readmissions. DATA COLLECTION METHODS: Patients aged ≥18 years at index admission for International Classification of Diseases-9 diagnosis code of epilepsy, TBI, or stroke were included. PRINCIPAL FINDINGS: Discharge against medical advice occurred in 1998/58278 patients (3.43 percent) in the epilepsy group, 1762/211 213 (0.83 percent) in the stroke group, and 1289/74 652 (1.73 percent) in the TBI group. Factors consistently associated with increased likelihood of DAMA included lower age, male sex, non-Medicare and nonprivate insurance, lower socioeconomic status, and behavioral risk factors (smoking history, alcohol history, and drug use). The crude 30-day all-cause readmission rate for those with DAMA from their index admission was 16.4 percent for the stroke cohort, 13.9 percent for epilepsy, and 13.4 percent for TBI. DAMA at index admission was significantly associated with increased risk of 30-day all-cause readmission among all groups (adjusted odds ratio 1.79, 95% CI: 1.65-1.94, P < .0001). CONCLUSIONS: Age, sex, insurance status, socioeconomic status, and behavioral factors were associated with DAMA in neurological patients. Further research is needed to develop interventions to reduce DAMA in high-risk groups.

Risk of thrombotic events after inpatient intravenous immunoglobulin or plasma exchange for neurologic disease: A case-crossover study.

INTRODUCTION: Our aim in this study was to determine whether intravenous immunoglobulin (IVIg) or plasma exchange (PLEx) for treatment of neurologic disease is a trigger for thrombotic events. METHODS: Using administrative data from 2005 to 2014, we identified index admissions for thrombotic events. We performed case-crossover analyses for these admissions with previous admissions for neurologic disease with IVIg or PLEx using exposure periods of between 7 and 120 days. RESULTS: We identified 1.9 million admissions for venous thrombosis embolism, myocardial infarction, or acute ischemic stroke. The odds ratio for venous thrombosis embolism within a 30-day window after exposure to IVIg was 3.33 (1.34-8.30, P = .0097) and for PLEx was 4.29 (1.88-9.76, P = .0005). Myocardial infarction and acute ischemic stroke admissions were not associated with exposure to either therapy. DISCUSSION: Patients admitted for venous thrombosis embolism (but not acute ischemic stroke or myocardial infarction) were more likely exposed to either IVIg or PLEx during previous admission for neurologic disease.

Characteristics and Outcomes of Retinal Artery Occlusion: Nationally Representative Data.

Background and Purpose- There are few large studies examining comorbidities, outcomes, and acute interventions for patients with retinal artery occlusion (RAO). RAO shares pathophysiology with acute ischemic stroke (AIS); direct comparison may inform emergent treatment, evaluation, and secondary prevention. Methods- The National Readmissions Database contains data on ≈50% of US hospitalizations from 2013 to 2015. We used International Classification of Diseases, Ninth Revision, codes to identify and compare index RAO and AIS admissions, comorbidities, and interventions and Clinical Comorbidity Software codes to identify readmissions causes, using survey-weighted methods when possible. Cumulative risk of all-cause readmission after RAO ≤1 year was estimated by Kaplan-Meier analysis. Results- Among 4871 RAO and 1 239 963 AIS admissions, patients with RAO were less likely (P<0.0001) than patients with AIS to have diabetes mellitus (RAO, 24.3% versus AIS, 36.8%), congestive heart failure (9.1% versus 14.8%), atrial fibrillation (15.5% versus 25.2%), or hypertension (62.2% versus 67.6%) but more likely to have valvular disease (13.3% versus 10.5%) and tobacco usage (38.6% versus 32.9%). In RAO admissions, thrombolysis was administered in 2.9% (5.8% in central RAO subgroup, versus 8.0% of AIS), therapeutic anterior chamber paracentesis in 1.0%, thrombectomy in none; 1.4% received carotid endarterectomy during index admission, 1.6% within 30 days. Nearly 1 in 10 patients with RAO were readmitted within 30 days and were more than twice as likely as patients with AIS to be readmitted for dysrhythmia or endocarditis. Readmission for stroke after RAO was the highest within the first 150 days after index admission, and risk was higher in central RAO than in branch RAO. Conclusions- Patients with RAO had high prevalence of many stroke risk factors, particularly valvular disease and smoking, which can be addressed to minimize subsequent risk. Despite less baseline atrial fibrillation, RAO patients were more likely to be readmitted for atrial fibrillation/dysrhythmias. A variety of interventions was administered. AIS risk is the highest shortly after RAO, emphasizing the importance of urgent, thorough neurovascular evaluation.

Readmission after neurosurgical intervention in epilepsy: A nationwide cohort analysis.

OBJECTIVE: Hospital readmissions result in increased health care costs and are associated with worse outcomes after neurosurgical intervention. Understanding factors associated with readmissions will inform future studies aimed at improving quality of care in those with epilepsy. METHODS: Patients of all ages with epilepsy who underwent a neurosurgical intervention were identified in the 2014 Nationwide Readmissions Database, a nationally representative dataset containing data from roughly 17 million US hospital discharges. Diagnosis of epilepsy was based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)-based case definitions. Neurosurgical interventions for epilepsy: resective/disconnective surgery, responsive neurostimulation/deep brain stimulation, vagus nerve stimulation, radiosurgery, and intracranial electroencephalography were identified using ICD-9-CM procedure codes. Primary outcome was all-cause 30-day readmission following discharge from the index hospitalization. RESULTS: There were a total of 2284 index surgical admissions. Overall, 10.83% (n = 251) of patients following an index epilepsy surgery admission were readmitted within 30 days. Factors independently associated with 30-day readmission for all epilepsy surgery admissions were: Medicare insurance (P < .01), discharge disposition that was not home (P < .01), higher Elixhauser comorbidity indexes (P < .01), longer length of stay (P < .01), and adverse events of surgical and medical care during index stay (P = .04). In the multivariate model, Medicare insurance (hazard ratio [HR] 1.81 [1.29-2.53], P < .01) and length of stay (HR 1.02 [1.01-1.04], P < .01) remained significant independent predictors for 30-day readmission. The most common primary reason for readmissions was epilepsy/convulsions accounting for 22.85%. SIGNIFICANCE: Our results suggest that careful management of postoperative seizures and discharge planning after epilepsy surgery may be important to optimize outcomes and reduce the risk of readmission, particularly for patients on Medicare.

National trends in endovascular therapy for acute ischemic stroke: utilization and outcomes.

OBJECTIVE: Following widespread acceptance of endovascular therapy (ET) for large vessel occlusion stroke in 2015, we assessed nationwide utilization of revascularization for acute ischemic stroke (AIS). METHODS: We utilized the 2013-2016 Healthcare Cost and Utilization Project Nationwide Readmissions Database. We identified AIS admissions, treatment with intravenous thrombolysis (IVT), ET, and vascular risk factors using International Classification of Disease Clinical Modification codes. Main predictor of outcome was the time period of index admission ('pre-endovascular era (pre-EA)' January 2013-January 2015 and 'endovascular era (EA)' February 2015- December 2016). We calculated the proportion of AIS admissions in which, first, VT and second, ET was performed. Among patients treated with ET, we examined the association between era and discharge disposition, in-hospital mortality during index admission, and 30-day readmission. RESULTS: There were 925 363 index AIS admissions before the EA and 857 347 during. A higher proportion of AIS patients received IVT (8.4% vs 7.8%) and ET (2.6% vs 1.3%) in the EA. Although length of stay (LOS) was shorter in the EA (5.70 vs 6.80 days), total charges were greater ($56 691 vs $53 878), and admissions were more often to a metropolitan hospital (65.2% vs 57.2%). Among those treated with ET, a smaller proportion received IVT (29.7% vs 44.9%), LOS was substantively shorter (9.75 vs 12.76 days), and patients had a lower odds of discharge home. CONCLUSIONS: The utilization of ET has doubled in the EA but ET remains underutilized. ET is predominantly provided at metropolitan teaching hospitals and associated with higher charges despite shorter LOS and unchanged in-hospital mortality.

Interleukin-6 and lipoprotein-associated phospholipase A2 are associated with functional trajectories.

BACKGROUND/OBJECTIVES: Inflammatory biomarkers have been associated with stroke and mortality, but inflammation may also have detrimental effects beyond acute events. We hypothesized that serum concentrations of interleukin-6 (IL6) and lipoprotein-associated phospholipase A2 (LpPLA2) were inversely associated with long-term functional decline independently of vascular risk factors, stroke and myocardial infarction (MI) occurring during follow-up. DESIGN: Prospective population based cohort study. SETTING: The Northern Manhattan Study. PARTICIPANTS (INCLUDING THE SAMPLE SIZE): Race/ethnically diverse stroke-free individuals in northern Manhattan aged ≥40 years (n = 3298). INTERVENTION: None. MEASUREMENTS: Annual functional assessments with the Barthel index (BI), for a median of 13 years. BI was analyzed as a continuous variable (range 0-100). Baseline demographics, risk factors, and laboratory studies were collected, including IL6 (n = 1679), LpPLA2 mass (n = 1912) and activity (n = 1937). Separate mixed models estimated standardized associations between each biomarker and baseline functional status and change over time, adjusting for demographics, vascular risk factors, social variables, cognition, and depression measured at baseline, and stroke and MI occurring during follow-up. RESULTS: Mean age was 69 (SD 10) years, 35% were male, 53% Hispanic, 74% hypertensive, and 16-24% diabetic. LogIL6 was associated with decline in BI over time (-0.13 points per year, 95% CI -0.24, -0.02) and marginally with baseline BI (-0.20, 95% CI -0.40, 0.01). LpPLA2 activity levels were associated with baseline BI (-0.36, 95% CI -0.68, -0.04) but not change over time, and LpPLA2 mass levels were not associated with either. CONCLUSION: In this large population-based study, higher serum inflammatory biomarker levels were associated with disability, even when adjusting for baseline covariates and stroke and MI occurring during follow-up.