Background and Purpose Stroke mortality has been declining since the early twentieth century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with this decline. This review considers the evidence of various contributors to the decline in stroke risk and mortality and can be used in the design of future interventions regarding this major public health burden. Methods Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council’s Scientific Statement Oversight Committee and the AHA’s Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and indicate gaps in current knowledge. All members of the writing group had the opportunity to comment and approved the final version of this document. The document underwent extensive AHA internal peer review, Stroke Council Leadership review and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. Results The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both genders, and all race and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among individuals less than 65 years of age represents a reduction on years of potential life lost. The decline in mortality results from reduced stroke incidence and lower case fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. While it is difficult to calculate specific attributable risk estimates, the hypertension control efforts initiated in the 1970s appears to have had the most substantial influence on the accelerated stroke mortality decline. Although implemented later in the time period, diabetes and dyslipidemia control and smoking cessation programs, particularly in combination with hypertension treatment, also appear to have contributed to the stroke mortality decline. Telemedicine and stroke systems of care, while showing strong potential effects, have not been in place long enough to show their influence on the decline. Other factors had probable effects, but additional studies are needed to determine their contributions. Conclusion The decline in stroke mortality is real and represents a major public health and clinical medicine success story. The repositioning of str...

Importance The Centers for Medicare and Medicaid Services (CMS) recently identified 30-day readmission after discharge from inpatient rehabilitation facilities as a national quality indicator. Research is needed to determine the rates and factors related to readmission in this patient population. Objective Determine 30-day readmission rates and factors related to readmission for patients receiving post-acute inpatient rehabilitation. Design Retrospective cohort study. Setting 1,365 post-acute inpatient rehabilitation facilities providing services to Medicare fee-for service beneficiaries. Participants Records for 736,536 post-acute patients discharged from inpatient rehabilitation facilities to the community in 2006 through 2011. Mean age 78.0 (SD = 7.3) years. Sixty-three percent of patients were female and 85.1% were non-Hispanic white. Main Outcome and Measures 30-day readmission rates for the six largest diagnostic impairment categories receiving inpatient rehabilitation. These included stroke, lower extremity fracture, lower extremity joint replacement, debility, neurological disorders and brain dysfunction. Results Mean rehabilitation length of stay was 12.4 (SD = 5.3) days. The overall 30-day readmission rate was 11.8% (95%CI, 11.7%, 11.8%). Rates ranged from 5.8% (95%CI, 5.8%, 5.9%) for patients with lower extremity joint replacement to 18.8% (95%CI, 18.8%, 18.9%). for patients with debility. Rates were highest in men (13.0%; 95%CI, 12.8%, 13.1%), non-Hispanic blacks, (13.8%; 95%CI, 13.5%, 14.1%), dual eligible beneficiaries (15.1%; 95%CI, 14.9%, 15.4%), and in patients with tier 1 comorbidities (25.6%; 95%CI, 24.9%, 26.3%). Higher motor and cognitive functional status were associated with lower hospital readmission rates across the six impairment categories. Variability in adjusted readmission rates by state ranged from 9.2% to 13.6%. Approximately 50% of patients who were rehospitalized within the 30-day period were readmitted within 11 days of discharge. MS-DRG codes for heart failure, urinary tract infection, pneumonia, septicemia, nutritional and metabolic disorders, esophagitis, gastroenteritis and digestive disorders were common reasons for readmission. Conclusion and Relevance Among post-acute rehabilitation facilities providing services to Medicare fee-for-service beneficiaries, 30-day readmission rates ranged from 5.8% to 18.8% for selected impairment groups. Further research is needed to understand the reasons for readmission.

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