Research indicates that more than 750,000 patients per year are hospitalized for stroke in the US, with 50% experiencing lasting effects. Among stroke survivors, 5% to 14% experience another stroke in the following year, and the hospital readmission rate for all causes has been estimated at 20% to 50%. “The annual cost of unplanned hospital readmissions has been estimated to be more than $17 billion dollars for Medicare patients alone,” explains Michelle H. Leppert, MD, MBA. “Stroke readmissions are especially common, occurring at an estimated 17% at 30 days and 42% at 1 year.”
Dr. Leppert and colleagues sought to determine whether early follow-up with a primary care physician or neurologist was associated with a lower rate of both 30- and 90-day readmissions and published their results in Neurology. The study team conducted a retrospective analysis of a large commercial database representing 90 million members and 80 health plans. Participants were aged 18 to 89, diagnosed with acute ischemic stroke (AIS), and enrolled in insurance for at least 6 months prior to their stroke and 3 months after. The study team only included patients who were discharged home, as patients discharged to facilities did not consistently have follow-up data.
Readmission rates were 7.3% at 30 days and 13.7% at 90 days. Among patients readmitted within 30 days the median number of days to readmission was 11 days, while the median number of days to readmission was 28 days for those readmitted within 90 days. Nearly 60% of patients visited their primary care physician within 30 days of discharge (median, 7 days), and about 70% did so within 90 days (median, 9 days). Far fewer patients visited neurologists with about 24% doing so within 30 days (median, 15 days) and approximately 42% within 90 days (median, 26 days). Among patients who visited a primary care physician or neurologist, 81.6% were first seen by their primary care physician.
Early follow-up with a primary care physician was associated with a 16% reduction in 30-day readmission. “This benefit was even more pronounced in the patients younger than 65, among whom there was a 27% reduction in 30-day readmission associated with primary care physician follow-up,” highlights Dr. Leppert. Conversely, reductions in readmission were not indicated at 90 days with primary care physician follow-up, nor were they observed at 30 or 90 days with neurologist follow-up (Table). A sensitivity analysis—conducted because a large portion of patients lacked a discharge disposition—produced similar results to the primary analysis.
Dr. Leppert notes that most readmissions observed in the study were for either a new stroke or transient ischemic attack. “Risk of a recurrent stroke is 10 times higher within the first month than in the rest of the first year after a stroke,” she adds. “Early follow-up with primary care is likely reinforcing risk factor modifications, such as blood pressure control, thereby preventing another stroke.”
Reflecting on the Data
“As a neurologist, I would like to think that we are just as clinically adequate as primary care providers,” says Dr. Leppert in regard to the finding that readmissions were reduced with primary care follow-up but not neurology follow-up. “However, it is possible that primary care physicians are better at addressing outstanding medical problems, whereas a neurology follow-up may be more focused, addressing only pertinent neurologic issues. Another possible explanation is the timing of follow-ups. Neurology follow-ups trended to happen later than primary care follow-ups. In fact, most of the neurology follow-ups happened after the majority of readmissions had already occurred. It might be that timing, and not who does the follow-up, which has the strongest association with readmissions.”
“Our team studied a group of insured patients who should readily have access to primary care,” notes Dr. Leppert. “Based on our data, we think that having a primary care follow-up within 1 week of discharge after stroke is likely beneficial in reducing the risk of readmissions.”
Relationship between early follow-up and readmission within 30 and 90 days after ischemic stroke