Hospital Readmissions and Mortality Among Fee‐for‐Service Medicare Patients With Minor Stroke or Transient Ischemic Attack: Findings From the COMPASS Cluster‐Randomized Pragmatic Trial

Abstract

Background Mortality and hospital readmission rates may reflect the quality of acute and postacute stroke care. Our aim was to investigate if, compared with usual care (UC), the COMPASS‐TC (Comprehensive Post‐Acute Stroke Services Transitional Care) intervention (INV) resulted in lower all‐cause and stroke‐specific readmissions and mortality among patients with minor stroke and transient ischemic attack discharged from 40 diverse North Carolina hospitals from 2016 to 2018. Methods and Results Using Medicare fee‐for‐service claims linked with COMPASS cluster‐randomized trial data, we performed intention‐to‐treat analyses for 30‐day, 90‐day, and 1‐year unplanned all‐cause and stroke‐specific readmissions and all‐cause mortality between INV and UC groups, with 90‐day unplanned all‐cause readmissions as the primary outcome. Effect estimates were determined via mixed logistic or Cox proportional hazards regression models adjusted for age, sex, race, stroke severity, stroke diagnosis, and documented history of stroke. The final analysis cohort included 1069 INV and 1193 UC patients (median age 74 years, 80% White, 52% women, 40% with transient ischemic attack) with median length of hospital stay of 2 days. The risk of unplanned all‐cause readmission was similar between INV versus UC at 30 (9.9% versus 8.7%) and 90 days (19.9% versus 18.9%), respectively. No significant differences between randomization groups were seen in 1‐year all‐cause readmissions, stroke‐specific readmissions, or mortality. Conclusions In this pragmatic trial of patients with complex minor stroke/transient ischemic attack, there was no difference in the risk of readmission or mortality with COMPASS‐TC relative to UC. Our study could not conclusively determine the reason for the lack of effectiveness of the INV. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02588664.

Factors and Behaviors Related to Successful Transition of Care After Hospitalization for Ischemic Stroke

“…16 More recently, a randomized trial focused on effective TOC showed that the intervention was inconsistently implemented, with no effect on functional outcome or readmission. 17,18 Some explanations proposed for this negative result include that hospitals had difficulty sustaining the intervention, there was significant loss to follow-up, and outcome measures may have been insensitive in a milder stroke population. 19…”

“…16 More recently, a randomized trial focused on effective TOC showed that the intervention was inconsistently implemented, with no effect on functional outcome or readmission. 17,18 Some explanations proposed for this negative result include that hospitals had difficulty sustaining the intervention, there was significant loss to follow-up, and outcome measures may have been insensitive in a milder stroke population. 19 Nonetheless, we posit that a detailed understanding of the associations and drivers behind poor adoption of important posthospitalization behaviors, as we have described in the current analysis, is important to inform interventions, identify high-risk patients, and direct limited healthcare resources to these individuals.…”

Post-acute Ambulatory Care Service Use Among Patients Discharged Home After Stroke or TIA

“…27 It is important to note, however, that the COMPASS intervention, as delivered, did not impact readmission rates or patients' functional status, despite the increased rate of ambulatory visits relative to usual care. 10,28 Additional research identifying effective models of cooperative and coordinated post-acute stroke care is therefore needed.…”

Impact of NP follow-up calls on reducing 30-day readmissions in patients with stroke

“…The average readmitted inpatient cost per person was $12,000 between 2008 and 2013 5. Some of the costs are avoidable because more than 50% of readmissions for patients with stroke and other cerebrovascular diseases are considered preventable 14,15…”

“…5 Some of the costs are avoidable because more than 50% of readmissions for patients with stroke and other cerebrovascular diseases are considered preventable. 14,15 Practical requirements for ongoing care are addressed and provided upon hospital discharge to patients with stroke in order to prevent complications, avoidable readmissions, and recurrent stroke. To reduce readmission rates, current literature supports a variety of successful pre-and postdischarge interventions including discharge planning, patient education, followup telephone calls, home visits, and transition coaching.…”