Regaining pre-fracture basic mobility status after hip fracture and association with post-discharge mortality and readmission-a nationwide register study in Denmark.

BACKGROUND: early mobilization after hip fracture (HF) is an important predictor of outcome, but knowledge of the consequences of not achieving the pre-fracture basic mobility status in acute hospital recovery is sparse. OBJECTIVE: we examined whether the regain of pre-fracture basic mobility status evaluated with the cumulated ambulation score (CAS) at hospital discharge was associated with 30-day post-discharge mortality and readmission. DESIGN: this is a population-based cohort study. MEASURES: using the nationwide Danish Multidisciplinary HF Database from January 2015 through December 2015, 5,147 patients 65 years or older undergoing surgery for a first-time HF were included. The pre-fracture and discharge CAS score (0-6 points with six points indicating an independent basic mobility status) were recorded. CAS was dichotomized as regained or not and entered into adjusted Cox regression overall analysis and stratified by sex, age, body mass index, Charlson comorbidity index, type of fracture, residential status and length of acute hospital stay. Outcome measures were 30-day post-discharge mortality and readmission. RESULTS: overall mortality and readmission were 8.3% (n = 425) and 17.1% (n = 882), respectively. Mortality was 3.5% (n = 71) among patients who regained their pre-fracture CAS score compared with 11.4% (n = 354) among those who did not. Adjusted hazard ratios for 30-day mortality and readmission were 2.76 (95% confidence interval [CI] = 2.01-3.78) and 1.26 (95% CI = 1.07, 1.48), respectively, for patients who did not regain their pre-fracture CAS compared with those who did. CONCLUSIONS: we found that the loss of pre-fracture basic mobility level upon acute hospital discharge was associated with increased 30-day post-discharge mortality and readmission after a first time HF.

Lifestyle Factors and Early Clinical Outcome in Patients With Acute Stroke: A Population-Based Study.

BACKGROUND AND PURPOSE: We examined the associations of individual and combined lifestyle factors with early adverse stroke outcomes. METHODS: A total of 82 597 patients were identified from nationwide registries. Lifestyle factors at the time of stroke admission included body mass index (kg/m2), smoking habits, and alcohol intake, which were grouped (healthy, moderately healthy, moderately unhealthy, and unhealthy). The associations between lifestyle and outcomes were examined using multivariable regression. RESULTS: A total of 18.3% had a severe stroke, 7.8% pneumonia, 12.5% urinary tract infection, and 9.9% died within 30 days. The association between lifestyle, stroke severity, and mortality, respectively, differed according to sex. Unhealthy lifestyle was associated with lower risk of severe stroke (adjusted odds ratio [OR], 0.73; 95% confidence interval [CI], 0.63-0.84) and 30-day mortality among men (adjusted OR, 0.71; 95% CI, 0.58-0.87), but not among women (severe stroke: adjusted OR, 1.14; 95% CI, 0.85-1.55, and mortality: adjusted OR, 1.34; 95% CI, 0.90-1.99). No sex differences were found for pneumonia and urinary tract infection. Unhealthy lifestyle was not associated with a statistically significant increased risk of developing in-hospital pneumonia (adjusted OR, 1.30; 95% CI, 0.98-1.73) or urinary tract infection (adjusted OR, 0.98; 95% CI, 0.72-1.33). Underweight was associated with a higher 30-day mortality (men: adjusted OR, 1.71; 95% CI, 1.50-1.96, and women: adjusted OR, 1.46; 95% CI, 1.34-1.60). CONCLUSIONS: Healthy lifestyle was not associated with a lower risk of adverse stroke outcomes, in particularly among men. However, underweight may be a particular concern being associated with an increased risk of adverse outcomes among both sexes.

The Danish Stroke Registry.

AIM OF DATABASE: The aim of the Danish Stroke Registry is to monitor and improve the quality of care among all patients with acute stroke and transient ischemic attack (TIA) treated at Danish hospitals. STUDY POPULATION: All patients with acute stroke (from 2003) or TIA (from 2013) treated at Danish hospitals. Reporting is mandatory by law for all hospital departments treating these patients. The registry included >130,000 events by the end of 2014, including 10,822 strokes and 4,227 TIAs registered in 2014. MAIN VARIABLES: The registry holds prospectively collected data on key processes of care, mainly covering the early phase after stroke, including data on time of delivery of the processes and the eligibility of the individual patients for each process. The data are used for assessing 18 process indicators reflecting recommendations in the national clinical guidelines for patients with acute stroke and TIA. Patient outcomes are currently monitored using 30-day mortality, unplanned readmission, and for patients receiving revascularization therapy, also functional level at 3 months poststroke. DESCRIPTIVE DATA: Sociodemographic, clinical, and lifestyle factors with potential prognostic impact are registered. CONCLUSION: The Danish Stroke Registry is a well-established clinical registry which plays a key role for monitoring and improving stroke and TIA care in Denmark. In addition, the registry is increasingly used for research.

Processes of early stroke care and hospital costs.

BACKGROUND: The relationship between processes of early stroke care and hospital costs remains unclear. AIMS: We therefore examined the association in a population based cohort study. METHODS: We identified 5909 stroke patients who were admitted to stroke units in a Danish county between 2005 and 2010.The examined recommended processes of care included early admission to a stroke unit, early initiation of antiplatelet or anticoagulant therapy, early computed tomography/magnetic resonance imaging (CT/MRI) scan, early physiotherapy and occupational therapy, early assessment of nutritional risk, constipation risk and of swallowing function, early mobilization,early catheterization, and early thromboembolism prophylaxis.Hospital costs were assessed for each patient based on the number of days spent in different in-hospital facilities using local hospital charges. RESULTS: The mean costs of hospitalization were $23 352 (standard deviation 27 827). The relationship between receiving more relevant processes of early stroke care and lower hospital costs followed a dose­response relationship. The adjusted costs were $24 566 (95% confidence interval 19 364­29 769) lower for patients who received 75­100% of the relevant processes of care compared with patients receiving 0­24%. All processes of care were associated with potential cost savings, except for early catheterization and early thromboembolism prophylaxis. CONCLUSIONS: Early care in agreement with key guidelines recommendations for the management of patients with stroke may be associated with hospital savings.

Registration of acute stroke: validity in the Danish Stroke Registry and the Danish National Registry of Patients.

BACKGROUND: The validity of the registration of patients in stroke-specific registries has seldom been investigated, nor compared with administrative hospital discharge registries. The objective of this study was to examine the validity of the registration of patients in a stroke-specific registry (The Danish Stroke Registry [DSR]) and a hospital discharge registry (The Danish National Patient Registry [DNRP]). METHODS: Assuming that all patients with stroke were registered in either the DSR, DNRP or both, we first identified a sample of 75 patients registered with stroke in 2009; 25 patients in the DSR, 25 patients in the DNRP, and 25 patients registered in both data sources. Using the medical record as a gold standard, we then estimated the sensitivity and positive predictive value of a stroke diagnosis in the DSR and the DNRP. Secondly, we reviewed 160 medical records for all potential stroke patients discharged from four major neurologic wards within a 7-day period in 2010, and estimated the sensitivity, specificity, positive predictive value, and negative predictive value of the DSR and the DNRP. RESULTS: Using the first approach, we found a sensitivity of 97% (worst/best case scenario 92%-99%) in the DSR and 79% (worst/best case scenario 73%-84%) in the DNRP. The positive predictive value was 90% (worst/best case scenario 72%-98%) in the DSR and 79% (worst/best case scenario 62%-88%) in the DNRP. Using the second approach, we found a sensitivity of 91% (95% confidence interval [CI] 81%-96%) and 58% (95% CI 46%-69%) in the DSR and DNRP, respectively. The negative predictive value was 91% (95% CI 83%-96%) in the DSR and 72% (95% CI 62%-80%) in the DNRP. The specificity and positive predictive value did not differ among the registries. CONCLUSION: Our data suggest a higher sensitivity in the DSR than the DNRP for acute stroke diagnoses, whereas the positive predictive value was comparable in the two data sources.

Higher stroke unit volume associated with improved quality of early stroke care and reduced length of stay.

BACKGROUND AND PURPOSE: Specialized stroke unit care improves outcome among patients with stroke, but it is unclear whether there are any scale advantages in costs and clinical outcome from treating a larger number of patients. We examined whether the case volume in stroke units was associated with quality of early stroke care, mortality, and hospital bed-day use. METHODS: In a nationwide population-based cohort study, we identified 63 995 patients admitted to stroke units in Denmark between 2003 and 2009. Data on exposure, outcome, and covariates were collected prospectively. Comparisons were clustered within stroke units and adjusted for patient and hospital characteristics. RESULTS: Patients in high-volume stroke units overall had a better prognostic profile than patients in low-volume stroke units. Patients in high-volume stroke units also received more processes of care in the early phase of stroke compared with patients in low-volume stroke units (unadjusted difference, 9.84 percentage points; 95% CI, 3.98-15.70). High stroke unit volume was associated with shorter length of the initial hospital stay (adjusted ratio, 0.49; 95% CI, 0.41-0.59) and reduced bed-day use in the first year after stroke (adjusted ratio, 0.79; 95% CI, 0.70-0.87). No association between volume and mortality was found. CONCLUSIONS: Patients admitted to high-volume stroke units received a higher quality of early stroke care and spent fewer days in the hospital compared with patients in low-volume units. We observed no association between volume and mortality.

Use of secondary medical prophylaxis and clinical outcome among patients with ischemic stroke: a nationwide follow-up study.

BACKGROUND AND PURPOSE: Although secondary medical prevention strategies in patients with stroke are well established, only sparse data exist regarding their effectiveness in routine care. We examined the effectiveness in a nationwide, population-based follow-up study. METHODS: Using data from the Danish National Indicator Project (DNIP), 28,612 patients hospitalized for ischemic stroke in 2003 to 2006 were identified. Information on drug use and outcomes was by individual-level record linkage with national medical databases. Hazard ratios were computed for death, myocardial infarction, and recurrent stroke according to drug use after hospital discharge. RESULTS: Treatment with antiplatelets, oral anticoagulants, antihypertensives, or statins was associated with a lower risk of the combined end point of death, myocardial infarction, or recurrent stroke during a mean follow-up period of 2.7 years (adjusted hazard ratios [HRs] from 0.44 [95% CI, 0.39-0.49] to 0.94 [95% CI, 0.89-0.99]). All drug classes were associated with lower risk of death (adjusted HRs from 0.36 [95% CI, 0.32-0.41] to 0.85 [95% CI, 0.80-0.90]), with oral anticoagulant treatment in patients with atrial fibrillation being particularly effective in elderly women (>80 years; adjusted HR, 0.35; 95% CI, 0.28-0.45). Oral anticoagulant treatment was associated with a lower risk of recurrent stroke (adjusted HR, 0.58; 95% CI, 0.47-0.73), and statins were associated with a lower risk of myocardial infarction (adjusted HR, 0.84; 95% CI, 0.73-0.97) and recurrent stroke (adjusted HR, 0.86; 95% CI, 0.79-0.92). CONCLUSIONS: Secondary medical prophylaxis after ischemic stroke was associated with improved outcome in routine settings. Although these findings are of an observational nature, they tend to support the results from previous randomized trials.

In-hospital medical complications, length of stay, and mortality among stroke unit patients.

BACKGROUND AND PURPOSE: The relationship between in-hospital stroke-related medical complications and clinical outcome remains unclear. We examined whether medical complications were associated with length of stay (LOS) and mortality among stroke unit patients. METHODS: Using population-based Danish medical registries, we performed a follow-up study among all patients with acute stroke admitted to stroke units in 2 counties between 2003 and 2009 (n=13 721). Data regarding in-hospital medical complications, including pneumonia, urinary tract infection, pressure ulcer, falls, deep venous thrombosis, pulmonary embolism, and severe constipation together with LOS and mortality were prospectively registered. RESULTS: Overall, 25.2% of patients (n=3453) experienced 1 or more medical complications during hospitalization. The most common complications were urinary tract infection (15.4%), pneumonia (9.0%), and constipation (6.8%). Median LOS was 13 days (25th and 75th quartiles, 5 and 33). All medical complications were associated with longer LOS. The adjusted relative LOS extension ranged from 1.80 (95% CI, 1.54-2.11) for pneumonia to 3.06 (95% CI, 2.67-3.52) for falls. Patients with 1 or more complications had an increased 1-year mortality rate (adjusted mortality rate ratio [MRR], 1.20; 95% CI, 1.04-1.39). The association was mainly because of pneumonia, which was associated with higher mortality both after 30 days (adjusted MRR, 1.59; 95% CI, 1.31-1.93) and 1 year (adjusted MRR, 1.76; 95% CI, 1.45-2.14). CONCLUSIONS: In-hospital medical complications were associated with longer LOS and some, in particular pneumonia, also with an increased mortality among patients with acute stroke.

Socioeconomic differences in quality of care and clinical outcome after stroke: a nationwide population-based study.

BACKGROUND AND PURPOSE: The association among socioeconomic status, quality of care, and clinical outcome after stroke remains poorly understood. In a Danish nationwide follow-up study, we examined whether socioeconomic-related differences in acute stroke care occur and, if so, whether they explain socioeconomic differences in case-fatality and readmission risk. METHODS: Using population-based public registries, we identified and followed all patients aged≤65 years admitted with stroke from 2003 to 2007 (n=14,545). We compared the proportion of patients receiving 7 specific processes of care according to income, educational attainment, and employment status. Furthermore, we computed 30-day and 1-year hazard ratios for death and readmission adjusted for patient characteristics and received processes of acute stroke care. RESULTS: For low-income patients and disability pensioners, the relative risk of receiving all of the relevant processes of care was 0.82 (95% CI, 0.78 to 0.86) and 0.83 (95% CI, 0.79 to 0.87), respectively, compared with high-income patients and employed patients. Adjusted 30-day and 1-year hazard ratios for death for unemployed patients were 1.57 (95% CI, 1.25 to 1.97) and 1.58 (1.32 to 1.88), respectively, compared with employed patients. Unemployed patients also had a higher risk of readmission. The differences in mortality and readmission risk remained after controlling for received processes of acute stroke care. CONCLUSIONS: Low socioeconomic status was associated with a lower chance of receiving optimal acute stroke care. However, the differences in acute care did not appear to explain socioeconomic differences in mortality and readmission risk.

Quality of care and patient outcome in stroke units: is medical specialty of importance?

BACKGROUND: Specialized stroke unit care improves outcome in stroke patients. However, it is uncertain whether the units should be placed in a neurological or non-neurological (eg, internal medicine or geriatric) setting. OBJECTIVES: To assess whether stroke unit setting (neurological/non-neurological) is associated with quality of care and outcome among patients with stroke, and whether these associations depend on the severity of comorbidity. METHODS: In a nationwide population-based follow-up study, we identified 45,521 patients admitted to stroke units in Denmark between 2003 and 2008. Outcomes were quality of care (whether patients received evidence-based processes of acute stroke care), mortality, length of stay, and readmission. Charlson comorbidity index was used to assess comorbidity, and comparisons were adjusted for patient and hospital characteristics. RESULTS: Patients admitted to stroke units in neurological settings had higher odds for early antiplatelet therapy (odds ratio, 1.68; 95% confidence interval, 1.10-2.56) and early computed tomographic scan or magnetic resonance imaging (odds ratio, 1.77; 95% confidence interval, 1.29-2.45) compared with patients in non-neurological settings. No other differences were found when studying quality of care and patient outcomes. However, patients with moderate comorbidity admitted to stroke units in neurological settings had higher odds for 1-year mortality, but comparisons across strata of comorbidity were not statistical significant. CONCLUSIONS: Except for early antiplatelet therapy and early computed tomographic scan or magnetic resonance imaging, the medical setting was not associated with differences in processes of acute stroke care and patient outcome. No medical setting related differences were found according to comorbidity, although indications of a worse outcome in patients with moderate comorbidity in neurological settings warrant further investigation.

Processes of care and medical complications in patients with stroke.

BACKGROUND AND PURPOSE: the relationship between processes of care and the risk of medical complications in patients with stroke remains unclear. We therefore examined the association in a population-based follow-up study. METHODS: we identified 11 757 patients admitted for stroke to stroke units in 2 Danish counties in 2003 to 2008. The examined processes of care included early admission to a stroke unit, early initiation of antiplatelet or oral anticoagulant therapy, early CT/MRI scan, and early assessment by a physiotherapist and an occupational therapist of nutritional risk and of swallowing function and early mobilization. RESULTS: overall, 25.3% (n=2969) of the patients experienced ≥ 1 medical complications during hospitalization. The most common medical complications were urinary tract infection (15.5%), pneumonia (8.8%), and constipation (7.0%). We found indications of an inverse dose-response relationship between the number of processes of care that the patients received and the risk of medical complications. The lowest risk of complications was found among patients who received all relevant processes of care compared with patients who failed to receive any of the processes (ie, adjusted ORs ranged from 0.42 [95% CI, 0.24 to 0.74] for pressure ulcer to 0.64 [95% CI, 0.44 to 0.93] for pneumonia). Of the individual processes of care, early mobilization was associated with the lowest risk of complications. CONCLUSIONS: higher quality of acute stroke care was associated with a lower risk of medical complications.

Medical prophylaxis following hospitalization for ischemic stroke: age- and sex-related differences and relation to mortality.

BACKGROUND: The extent and implications of age- and sex-related differences in prophylaxis following ischemic stroke are unknown. We examined differences in the use of medical prophylaxis across age and sex groups in stroke patients after hospital discharge in Denmark and estimated the possible impact on age- and sex-related differences in mortality. METHODS: A nationwide population-based follow-up study was conducted involving 28,634 patients hospitalized for ischemic stroke in 2003-2006 who survived 30 days after discharge. The proportion of patients who filled prescriptions for cardiovascular drugs within 0-6 and 12-18 months after discharge was determined. Mortality rates were compared across age and sex groups with and without controlling for use of medical prophylaxis. RESULTS: Increasing age was associated with lower prophylaxis. Adjusted odds ratios for the use of a combination of a platelet inhibitor, an antihypertensive and a statin were 0.45 [95% confidence interval (CI): 0.38-0.54] and 0.52 (95% CI: 0.43-0.62) for men and women >80 years, respectively, compared with men ≤65 years. No systematic sex-related differences were identified. Continued drug use ranged from 66.1 to 91.9% for different drugs 12-18 months after discharge, with the lowest rate of continued use found among patients >80 years. Controlling for use of medical prophylaxis was associated with lower mortality rate ratios for elderly compared with younger patients. CONCLUSIONS: Continuous efforts are warranted to ensure implementation of evidence-based secondary prophylaxis among elderly patients with ischemic stroke.

Medical complications in patients with stroke: data validity in a stroke registry and a hospital discharge registry.

BACKGROUND: Stroke patients frequently experience medical complications; yet, data on incidence, causes, and consequences are sparse. OBJECTIVE: To examine the data validity of medical complications among patients with stroke in a population-based clinical registry and a hospital discharge registry. METHODS: We examined the predictive values, sensitivity and specificity of medical complications among patients admitted to specialized stroke units and registered in the Danish National Indicator Project (DNIP) and the Danish National Registry of Patients (NRP) between January 2003 and December 2006 (n = 8,024). We retrieved and reviewed medical records from a random sample of patients (n = 589, 7.3%). RESULTS: We found substantial variation in the data quality of stroke-related medical complication diagnoses both within the specific complications and between the registries. The positive predictive values ranged from 39.0%-87.1% in the DNIP, and from 0.0%-92.9% in the NRP. The negative predictive values ranged from 71.6%-98.9% in the DNIP and from 63.3% to 97.4% in the NRP. In both registries the specificity of the diagnoses was high. The sensitivity ranged from 23.5% (95% confidence interval [CI]: 14.9-35.4) for falls to 62.9% (95% CI: 54.9-70.4) for urinary infection in the DNIP, and from 0.0 (95% CI: 0.0-4.99) for falls to 18.1% (95% CI: 2.3-51.8) for pressure ulcer in the NRP. CONCLUSION: The DNIP may be useful for studying medical complications among patients with stroke.

Quality of care and 30 day mortality among patients with hip fractures: a nationwide cohort study.

BACKGROUND: We examined the association between quality of care and 30 day mortality in a nationwide cohort of patients hospitalized with hip fracture. METHODS: We used data from The Danish National Indicator Project, a quality improvement initiative with participation of more than 90% of Danish hospital departments caring for patients with hip fracture between August 16, 2005 and August 15, 2006. Quality of care was measured in terms of meeting five specific criteria: early assessment of the patient's nutritional risk, systematic pain assessment during mobilization, assessment of Activities of Daily Living (ADL) before the fracture, assessment of ADL before discharge, and initiation of treatment to prevent future osteoporotic fractures. The association between meeting each of the quality of care criteria for the patient and 30 day mortality was examined using logistic regression to adjust for potential confounders. RESULTS: 6,266 patients hospitalized with an incident episode of hip fracture were included in the study. For four of the five quality of care criteria, patients who met the criterion had substantially lower 30 day mortality after hip fracture. The adjusted mortality odds ratios (ORs) ranged from 0.42 (95% CI, 0.30 to 0.58) for assessment of ADL before discharge (excluding deaths during hospitalization) to 0.72 (95% CI, 0.52 to 1.00) for systematic pain assessment. We found an inverse dose-response relationship between the number of quality of care criteria met and 30 day mortality; the lowest mortality was found among patients for whom all five quality of care criteria were met, as compared with patients for whom no quality of care criteria were met: adjusted mortality OR 0.18 (95% CI, 0.09 to 0.36). CONCLUSION: Higher quality of care during hospitalization with hip fracture was associated with lowered 30 day mortality.

Sex-related differences in quality of care and short-term mortality among patients with acute stroke in Denmark: a nationwide follow-up study.

BACKGROUND AND PURPOSE: Sex may predict level of care and successive outcome among patients with stroke. We examined fulfillment of quality of care criteria according to sex and possible impact of any sex-related differences on short-term mortality in a population-based nationwide follow-up study in Denmark. METHODS: We identified 29 549 patients admitted with stroke between January 2003 and October 2005 in the Danish National Indicator Project. Data on 30- and 90-day mortality were obtained from The Civil Registration System. We compared proportions of patients receiving adequate care between sexes, as measured by admission to a specialized stroke unit, administration of antiplatelet or anticoagulant therapy, examination with CT/MRI scan, and assessment by a physiotherapist, an occupational therapist, and of nutritional risk. Further, we computed 30- and 90-day mortality rate ratios (MRR), adjusted for patient characteristics, fulfillment of quality of care criteria, and department. RESULTS: The proportion of patients who received adequate care was either slightly lower or similar among women when compared to men. The relative risks (RR) of receiving specific components of care ranged from 0.84 (95% confidence interval [CI]:0.74 to 0.96) to 1.01 (95% CI:0.96 to 1.06) when comparing sexes. The adjusted mortality rate ratios were lower among women and adjustment for fulfillment of quality of care criteria had only marginal impact. CONCLUSIONS: There appear not to be any substantial sex-related differences in acute hospital care among patients with stroke in Denmark. The lower female short-term mortality is therefore most likely explained by other factors.

Quality of care and mortality among patients with stroke: a nationwide follow-up study.

BACKGROUND: The relationship between process and outcome measures among patients with stroke is unclear. OBJECTIVES: To examine the association between quality of care and mortality among patients with stroke in a nationwide population-based follow-up study. METHODS: Using data from The Danish National Indicator Project, a quality improvement initiative with participation of all Danish hospital departments caring for patients with stroke, we identified 29,573 patients hospitalized with stroke between January 13, 2003 and October 31, 2005. Quality of care was measured in terms of 7 specific criteria: early admission to a stroke unit, early initiation of antiplatelet or oral anticoagulant therapy, early examination with computed tomography/magnetic resonance imaging scan, and early assessment by a physiotherapist, an occupational therapist, and of nutritional risk. Data on 30- and 90-day mortality rates were obtained through the Danish Civil Registration System. RESULTS: Six of 7 of these criteria were associated with lower 30- and 90-day mortality rates. Adjusted mortality rate ratios corrected for clustering by department ranged from 0.41 to 0.83. We found indication of an inverse dose-response relationship between the number of quality of care criteria met and mortality; the lowest mortality rate was found among patients whose care met all criteria compared with patients whose care failed to meet any criteria (ie, adjusted 30-day mortality rate ratios: 0.45, 95% confidence interval: 0.24-0.66). When analyses were stratified by age and sex, the dose-response relationship was found in all subgroups. CONCLUSIONS: Higher quality of care during the early phase of stroke was associated with substantially lower mortality rates.