Functional Impairment and Postacute Care Discharge Setting May Be Useful for Stroke Survival Prognostication

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Abstract
Background: The aim of this study was to discussions about post‐stroke outcomes related to post‐stroke function and post‐acute care discharge setting.inform patient‐provider. Methods and Results: We conducted a retrospective cohort study of Medicare beneficiaries with acute ischemic stroke or intracerebral hemorrhage in 2013. Our primary outcome was mortality within at least 1‐year post discharge. We performed multivariate logistic regression to estimate 90‐day odds ratios (ORs) and Cox proportional hazards regression to estimate post 90‐day hazard ratios on mortality, adjusting for demographics, procedures, comorbidities, discharge setting (inpatient rehabilitation facility, skilled nursing facility, or home health care agency), post‐stroke function (measured by the Functional/Pseudo‐Functional Independence Measure) and setting‐function interactions. There were 167 000 patients with a mean follow‐up of 441 days. Mortality within 90 days was associated with post‐stroke function (OR, 0.23; 95% CI, 0.19–0.27 comparing highest to lowest quintile of post‐stroke function) and discharge setting (OR, 4.05; 95% CI, 3.78–4.33 for skilled nursing facility versus inpatient rehabilitation facility). Among the highest functioning patients, those discharged to inpatient rehabilitation facility had a 1‐year mortality of 9% and those discharged with home health had 11% mortality at 1 year. The lowest functioning survivors of stroke discharged to a skilled nursing facility had 64% mortality at 1 year and those discharged to an inpatient rehabilitation facility had 29.6% mortality at 1 year. Conclusions: Nearly two thirds of the lowest functioning survivors of stroke discharged to a skilled nursing facility die within a year. This finding should inform discussions between providers and patients/caregivers in aligning goals of care with the care survivors of stroke receive.

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