2 tables omitted
Stroke is the third leading cause of death in the United States and
a major cause of serious, long-term disability among adults; the projected
cost of stroke during 2003 is $51 billion, including $12 billion in nursing
home costs.1 During 1988-1997, the rate
of hospital admissions for stroke increased 18.6%, from approximately 560
per 100,000 population in 1988 to 664 in 1997.2 To
assess the burden of stroke hospitalizations and discharge status after hospitalization
among U.S. residents aged ≥65 years, CDC analyzed Medicare hospital claims
for persons with stroke during 2000 for the 50 states and the District of
Columbia (DC). This report summarizes the results of that analysis, which
indicate that geographic variation exists in both rates of hospitalization
for stroke and patient discharge status. Reducing the burden of stroke in
the United States will require primary prevention and control of risk factors,
public education, early evaluation and treatment of persons with acute stroke,
and effective secondary prevention among persons living with stroke.
Medicare hospital claims and enrollment record data for 2000 were obtained
from the Centers for Medicare and Medicaid Services. A hospitalization for
stroke was defined as one for which the principal diagnosis on the hospital
claims record during 2000 was classified according to the International Classification of Diseases, Ninth Revision (ICD-9) codes
430-434 or 436-438. The number of persons at risk (i.e., U.S. residents in
the 50 states and DC aged ≥65 years who were entitled to Medicare Part
A benefits on July 1, 2000, excluding members of health maintenance organizations)
was obtained from Medicare enrollment records. Age-adjusted hospitalization
rates per 1,000 Medicare enrollees were calculated by using the 2000 U.S.
standard population. Outcomes included discharge to home, a skilled nursing
facility, or another care facility (i.e., intermediate care, short-term care,
or other type of facility); death during the hospital stay; or other outcome
(i.e., left against medical advice or experienced an unknown discharge outcome).
During 2000, a total of 445,452 hospitalizations among Medicare enrollees
were attributed to stroke, resulting in an age-adjusted rate of 16.3 per 1,000
enrollees. Stroke hospitalization rates increased with age and were higher
among men than women and among blacks than whites.
The majority of hospitalizations for stroke resulted in discharge to
home (50.3%), followed by discharge to a skilled nursing facility (21.0%),
discharge to another facility (19.6%), and death (8.7%). A total of 0.5% either
left against medical advice or experienced an unknown discharge outcome. Discharge
status varied by age. Approximately half (54.7%) of persons aged ≥85 years
were discharged to either a skilled nursing facility or other facility, compared
with 30.3% of persons aged 65-74 years. Higher proportions of women and blacks
were discharged to either a skilled nursing facility or other facility than
men or whites, respectively.
Age-adjusted stroke hospitalization rates per 1,000 Medicare enrollees
varied by state (range: 11.8 [New Mexico]–21.9 [Mississippi]). Discharge
status also varied by state; the proportion of persons hospitalized for stroke
who were discharged to home ranged from 41.0% (Massachusetts) to 58.0% (West
Virginia), and the proportion discharged to a skilled nursing facility ranged
from 10.8% (Louisiana) to 34.4% (Connecticut).
HF Davis, PhD, JB Croft, PhD, AM Malarcher, PhD, C Ayala, PhD, TL Antoine,
MPH, A Hyduk, MPH, GA Mensah, MD, Div of Adult and Community Health, National
Center for Chronic Disease Prevention and Health Promotion, CDC.
As the U.S. population continues to age, stroke hospitalization rates
and the proportion of persons discharged to skilled nursing facilities might
increase.3 Older stroke patients, those
with specific neurologic deficits (i.e., language deficits, facial weakness,
and leg weakness), and those hospitalized longer are more likely to be discharged
to a skilled nursing facility.3- 5 Approximately
20% of stroke patients die within 1 year after discharge,6 and
the types of post-acute care change over time, with an increasing proportion
of patients using a combination of services.4
Use of Medicare services and Medicare spending rates vary across the
United States.4 State-specific variations
in discharge location probably reflect differences in patient demographics,
medical practice styles, local regulatory practices, and availability and
accessibility of post-acute care facilities.4 Payment
for post-acute care is one of the fastest growing categories in Medicare spending,
and stroke has been identified as one of the diagnostic-related groups with
the highest number of beneficiaries using post-acute care.4 After
adjustment for stroke severity, home health care for Medicare stroke patients
results in better functional outcomes and is more cost-effective than skilled
nursing home care, rehabilitation care, and recuperation at home with no formal
care at both 6 weeks and 6 months after discharge.3
The findings in this report are subject to at least four limitations.
First, the data cannot be generalized to other age and racial/ethnic groups
because the population included only Medicare enrollees, and small numbers
precluded the use of other racial/ethnic groups in this analysis. Second,
the accuracy of physician and administrative reporting of ICD codes and the
severity and timing of stroke could not be determined by using Medicare hospital
claims. Third, these records could not be used to determine whether a person
was discharged for a new or a recurrent stroke. Finally, because Medicare
hospital claims data do not provide follow-up information, only discharge
status was examined.
Stroke hospitalization rates can be reduced by educating the public
about the control and treatment of the major risk factors for stroke (i.e.,
high blood pressure, high cholesterol, smoking, and diabetes). Prompt treatment
after a stroke decreases long-term disability, which reduces the need for
admission to a skilled nursing facility; for example, thrombolytic therapy
is time-dependent and beneficial to ischemic stroke patients only if administered
within 3 hours of symptom onset.7 Educating
health-care providers and officials who determine Medicare payment policies
about optimal post-acute stroke care might help decrease the need to use skilled
nursing facilities.4 Reducing the burden
of stroke in the United States will require (1) primary prevention and control
of risk factors; (2) public education about signs and symptoms of stroke,
the need for emergency response (i.e., calling 911), and the importance of
immediate transport to a primary stroke center (i.e., a specialized emergency
facility for treatment of stroke); (3) early appropriate evaluation and treatment
of persons with acute stroke; and (4) effective secondary prevention among
persons living with stroke.8
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The Rational Clinical Examination
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Original Article: Will This Patient Fall?
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