Introduction: Reducing hospital readmission is an important target for reducing morbidity and cost in acute ischemic stroke. However, strategies to reduce readmissions are lacking. We examined the association between time to first outpatient contact and readmission to inform interventions to optimize the inpatient-outpatient transition.
Methods: We performed a retrospective cohort study of all Medicare fee-for-service patients discharged home after an acute ischemic stroke in 2012. Stroke hospitalizations were identified with ICD-9-CM codes 433.x1, 434.x1 and 436. Our primary explanatory variable was whether patients had a primary care or neurology visit within 30 days of discharge. Our primary outcome variable was all-cause 30-day hospital readmission. This relationship was evaluated using mixed-effects logistic regressions adjusted for patient demographics and comorbidities, hospital quality of care (using Hospital Compare data), stroke volume, regional socioeconomic (SES) variables and a random hospital-level intercept. Secondary analyses explored timing of follow-up, provider continuity, combined provider effects, follow-up-SES interactions and time-to-event analyses.
Results: The cohort included 69,981 Medicare beneficiaries with acute ischemic stroke. A primary care physician (OR 0.82, 95% CI 0.77-0.86) or neurologist (OR 0.84, 95% CI 0.78-0.91) visit within 30 days of discharge were associated with decreased odds of readmission. On secondary analyses, return visits within 15 days were associated with further reductions in the odds of readmission for primary care (OR 0.79, 95% 0.75-0.84), but not for neurology follow-up (OR 0.94, 95% 0.85-1.05). The primary findings differed minimally when adjusting for provider effects simultaneously, accounting for provider-SES interactions or in time-to-event analyses.
Conclusion: Early outpatient follow-up was associated with a lower odds of hospital readmission among elderly stroke patients who are discharged from the hospital to home. Our data suggest that outpatient care may be crucial in reducing preventable hospital readmissions and identifies a potentially important target for future interventions aimed at reducing the cost and burden of stroke.