Postacute care and ischemic stroke mortality: findings from an integrated health care system in northern California.

OBJECTIVE

To study the association of postacute care (PAC) settings and mortality outcome of patients who sustained an ischemic stroke.

DESIGN

A retrospective cohort study.

SETTING

An integrated health care system in northern California.

PARTICIPANTS

Patients who sustained an acute ischemic stroke between 1996 and 2004, survived the initial acute care hospital stay, and received PAC services within 14 days of discharge (n = 16,538) and 61 days of discharge (n = 16,468).

INTERVENTIONS: PAC rehabilitation ranked by resource level, that is, inpatient rehabilitation hospital (IRH), skilled nursing facility (SNF), home health (HH), and outpatient (OP) rehabilitation.

MAIN OUTCOME MEASUREMENTS: One-year mortality after acute care hospital discharge.

RESULTS

The highest level of PAC services received within 14 days of acute care discharge was IRH for 5.6% of patients, SNF for 48.3% of patients, HH for 18.9% of patients, and OP for 27.3% of patients. The highest level of PAC services received within 61 days of acute care discharge was IRH for 10.9% of patients, SNF for 40.4% of patients, HH for 19.1% of patients, and OP for 29.6% of patients. Cox proportional hazard models showed that patients whose highest level of PAC service was provided by an IRH, through HH, or OP had a significantly better 1-year survival than did those admitted to an SNF. The following factors were associated with a higher risk of 1-year mortality: older age, male gender, African American ethnicity, history of previous stroke, higher Deyo-Charlson comorbidity scores, a longer acute care hospital stay, and hospitalization in one remotely located health service area.

CONCLUSIONS

In the year after a stroke occurred, the rate of patient survival varied based on PAC rehabilitation services. Age, gender, race or ethnicity, history of a previous stroke, comorbid conditions, and service area also were significantly associated with 1-year mortality after acute care discharge. Further investigation of the differences in mortality among PAC settings is indicated.