Elizabeth Larkin

BACKGROUND: Acute ischemic stroke (AIS) survivors are at high risk of major adverse cardiovascular events (MACE), highlighting the need to identify modifiable secondary prevention targets. We assessed whether postacute discharge destination is associated with 1-year MACE risk among AIS survivors. METHODS: In this retrospective cohort study, adult AIS survivors were identified from the state inpatient and emergency department databases of 5 US states (2016–2019) and categorized by discharge destination: home, inpatient rehabilitation facility (IRF), or skilled nursing facility (SNF). Other destinations were excluded. The primary outcome was 1-year MACE, defined as recurrent stroke, acute myocardial infarction, systemic embolism, or vascular death. Multivariable Cox models, adjusted for demographic and clinical factors, were used to evaluate the association between discharge disposition and MACE risk. Fine-Gray models were used for nonfatal secondary outcomes, and restricted mean survival time analyses were used to estimate absolute risk. Effect modification by age (P _interaction =0.014). Restricted mean survival time analyses indicated that IRF discharge was associated with 3.47 and 3.87 additional MACE-free days versus home and SNF discharge, respectively (both P <0.001). Adjusted number-needed-to-be-exposed were 115 (95% CI, 80–207) for IRF versus home and 87 (95% CI, 64–136) for IRF versus SNF. CONCLUSIONS: Postacute IRF discharge is associated with a lower 1-year MACE risk after AIS, highlighting the postacute care setting as a potentially modifiable system-level target for secondary prevention of long-term vascular outcomes.

Background: Trends in functional recovery after ischemic stroke within inpatient rehabilitation settings are not well‐described. This study evaluated 18‐year trends in functional motor improvement among adults receiving inpatient rehabilitation for ischemic stroke. Methods: We conducted a retrospective cohort study of adults with ischemic stroke admitted to a large rehabilitation system from December 2001 to September 2019. The primary outcome was the attainment of a minimal clinically important difference (MCID) in the Functional Independence Measure Motor score, defined as a ≥20‐point increase in Functional Independence Measure Motor score. Multivariable logistic regression was used to evaluate temporal trends and their interaction with insurance. Sensitivity analyses evaluated changes in case‐mix index, Charlson Comorbidity Index, and length of stay. Results: Among 9809 ischemic stroke rehabilitation admissions representing 9126 unique patients, 4445 (45.3%) admissions attained MCID. The adjusted odds of MCID attainment increased annually (odds ratio, 1.085 [95% CI, 1.067–1.104]). Model‐based predicted probabilities for MCID attainment increased from 0.239 (95% CI, 0.192–0.286) in 2001 to 0.555 (95% CI, 0.509–0.601) in 2019 for Medicare Fee‐for‐Service and from 0.345 (95% CI, 0.307–0.383) to 0.564 (95% CI, 0.530–0.598) for non‐Medicare patients. The year‐by‐insurance interaction was significant, indicating smaller annual gains for non‐Medicare patients (odds ratio, 0.973 [95% CI, 0.953–0.993]; P =0.007). The case‐mix index showed no temporal change, while the Charlson Comorbidity Index increased and length of stay declined over time. However, neither the Charlson Comorbidity Index, case‐mix index, nor rehabilitation duration explains the temporal improvement in MCID attainment. Conclusions: Functional motor recovery improved substantially over 18 years, independent of patient complexity and comorbidity burden, establishing contemporary benchmarks for inpatient stroke rehabilitation outcomes.