25.9% of Medicare Fee for Service members discharged alive from an inpatient ischemic stroke admission are readmitted to a hospital within 90 days¹. Multiple comorbidities and demographic features significantly increase the odds of readmission– including race, differences in index hospital stay characteristic, and eligibility for Medicaid.
Most readmissions are due to causes other than recurrent stroke, as stroke survivors are uniquely vulnerable to impairment-related causes of readmissions including falls and infections due to their new impairments. Examining longitudinal Medicare Fee for Service claims data for patients discharged after ischemic and hemorrhagic stroke reveals that the leading cause for readmission transitions from recurrent stroke and TIA, to sepsis and infections within 30 days post-discharge¹.
This analytic data set is constructed using the Centers for Medicare and Medicaid Services Standard Analytic File Longitudinal Data Set 100% inpatient and outpatient claims for Medicare Fee for Service (FFS) patients who experienced ischemic stroke in CY 2018.
Stroke survivors have limited tools and resources upon discharge from the hospital after a stroke and subsequently face significant challenges in navigating their discharge plan and overall recovery. Cognitive issues, communication problems, psychosocial symptoms, and adjustment to functional changes all pose barriers to patient recovery if not adequately addressed. Stroke survivors often do not get the care appropriate for their health conditions when they experience difficulty navigating the complexities of the healthcare system or if they have Social Determinants of Health (SDOH) limiting their access to care.
Clinicians also encounter common challenges that make it difficult to provide optimal care at discharge for stroke patients' complex needs. Some of the challenges clinicians face include:
| 90-Day Readmit. Cohort (% or Avg.) | No 90-Day Readmit. Cohort (% or Avg.) | Difference Between Cohorts | p-value | ||
| N | 25.9% | 74.1% | <0.0001 | ||
| Patient Average Age | 76.3 | 77.5 |
(1.12) |
<0.0001 |
|
| Female % | 53.5% | 55.5% | -2.0% | <0.0001 | |
| White % | 79.4% | 83.1% | -3.7% | <0.0001 | |
| Disabled or ESRD % | 24.8% | 19.2% | 5.6% | <0.0001 | |
| Dually Eligible for Medicaid | 26.9% | 20.9% | 6.0% | <0.0001 | |
| Hospital Type %s | Teaching | 65.7% | 63.5% | 2.2% | <0.0001 |
| Not Teaching | 34.3% | 36.5% | <0.0001 | ||
| Hospital Location %s | Urban | 91.2% | 90.0% | 1.2% | <0.0001 |
| Rural | 8.8% | 10.0% | <0.0001 | ||
| Hospital Location | Acute Rehab | 24.2% | 20.5% | -3.7% | <0.0001 |
| Home | 36.0% | 41.7% | -5.7% | <0.0001 | |
| Hospice | 0.5% | 10.5% | -10.0% | <0.0001 | |
| Skilled Nursing Facility | 36.1% | 24.9% | 11.2% | <0.0001 | |
| Other | 3.3% | 2.5% |
0.8% |
<0.0001 |
| 90-Day Readmit. Cohort (% or Avg.) | No 90-Day Readmit. Cohort (% or Avg.) | Difference Between Cohorts | p-value | |
| Conditions on the Index Hospital Claims |
||||
| Intracerebral Hemorrhage (ICH) | 4.22% | 3.86% | 0.36% | 0.0003 |
| Hospital Index Treatment Variables |
||||
| Thrombectomy Treatment(s) Combined | 3.62% | 3.33% | -0.29% | 0.0019 |
| Use of IV-tPA | 6.75% | 7.79% | -1.04% | <0.0001 |
| Index Hospital and Claim Characteristics Variables |
||||
| Index Stay Includes Transfer | 11.82% | 11.40% | 0.42% | 0.0098 |
| Length of Stay of Index Hospital Stay | 7.05 | 5.19 | 1.86 | <0.0001 |
| Number of Beds for the Index Hospital | 478.01 | 459.93 | 18.08 | <0.0001 |
| Index Provider Is a Teaching Hospital | 65.74% | 63.54% | 2.20% | <0.0001 |
| 90-Day Readmit. Cohort | No 90-Day Readmit. Cohort | Difference Between Cohorts | p-value | |
| Condition Definition | 25.9% | 74.1% | ||
| Hypertension | 93.90% | 91.79% | 2.11% | <0.0001 |
| Hyperlipidemia | 75.41% | 72.88% | 2.53% | <0.0001 |
| Coronary Cardia Disease | 60.48% | 49.87% | 10.61% | <0.0001 |
| Diabetes | 48.31% | 39.90% | 8.41% | <0.0001 |
| History of Stroke and Sequelae Diagnosis | 47.74% | 37.61% | 4.13% | <0.0001 |
| Atrial Fibrillation | 40.45% | 35.35% | 5.10% | <0.0001 |
| Chronic Kidney Disease | 39.82% | 28.22% | 11.60% | <0.0001 |
| Heart Failure | 37.85% | 26.22% | 11.62% | <0.0001 |
| Peripheral Vascular Disease (PVD) | 29.02% | 21.85% | 7.17% | <0.0001 |
| Valvular disease, use to capture "mechanical valve replacement" | 25.04$ | 20.11% | 4.92% | <0.0001 |
| High (7 or more conditions) | 43.80% | 29.58% | 0.1426 | <0.0001 |
| Medium (4-6 conditions) | 40.80% | 45.60% | -0.0484 | |
| Low (1-3 conditions) | 15.00% | 24.23% | -0.0919 | |
| None | 0.40% | 0.59% | -0.0024 |
This data was first presented at the 2024 American Association of Neuroscience Nursing (AANN) Advances in Stroke Care Conference and is on file at Kandu Health.
The presence of multiple comorbidities and demographic features, including race, differences in index hospital stay characteristics, eligibility for Medicaid, and other comorbidities, significantly increase the odds of readmission. Efforts to reduce readmissions should be informed by both these comorbidities and the SDOH needs of each individual patient. Based on patient demographics and comorbidities that correlate with higher readmission rates, transitional care workflows may be able to mitigate the risk for readmissions by improving certain aspects of the patient transition from inpatient to home.
In 2024, the Centers for Medicare & Medicaid Services (CMS) introduced coding and coverage for Principal Illness Navigation (PIN) services. The CMS coverage of PIN services was developed based on decades of work in cancer navigation². This model of care, when applied to stroke care, has shown that navigation services can help reduce health disparities and improve patient outcomes². It has also established standards for the ethics, qualifications, knowledge, skills, activities, and supervision of navigators².
The research presented by Lauren Sheehan and Kiffon Keigher was conducted in collaboration with Kandu Health using data from the Centers for Medicare and Medicaid Services on patients who experienced a stroke in 2018. Additional support by Mary Jo Braid-Forbes, MPH, Braid-Forbes Health Research.
Kandu Health delivers remote navigator-led support to stroke survivors and care partners after hospital discharge. We provide education, counsel, and resource navigation, community support groups, through a clinical Navigator and easy to use app.