Background
The Centers for Medicare and Medicaid Services (CMS) penalizes hospitals for higher than expected 30-day mortality rates using methods without accounting for condition severity risk ...adjustment. For patients with stroke, CMS claims did not quantify stroke severity until recently, when the National Institutes of Health Stroke Scale (NIHSS) reporting began.
Objective
Examine the predictive ability of claim-based NIHSS to predict 30-day mortality and 30-day hospital readmission in patients with ischemic stroke.
Design
Retrospective cohort study of Medicare claims data.
Patients
Medicare beneficiaries with ischemic stroke (
N
=43,241) acute hospitalization between October 2016 and November 2017.
Measurements
All-cause 30-day mortality and 30-day hospital readmission. NIHSS score was derived from ICD-10 codes and stratified into the following: minor to moderate, moderate, moderate to severe, and severe categories.
Results
Among 43,241 patients with ischemic stroke with NIHSS from 2,659 US hospitals, 64.6% had minor to moderate stroke, 14.3% had moderate, 12.7% had moderate to severe, and 8.5% had a severe stroke,10.1% died within 30 days, 12.1% were readmitted within 30 days. The NIHSS exhibited stronger discriminant property (
C
-statistic 0.83, 95% CI: 0.82–0.84) for 30-day mortality compared to Elixhauser (0.74, 95% CI: 0.73–0.75). A monotonic increase in the adjusted 30-day mortality risk occurred relative to minor to moderate stroke category: hazard ratio HR=2.92 (95% CI=2.59–3.29) for moderate stroke, HR=5.49 (95% CI=4.90–6.15) for moderate to severe stroke, and HR=7.82 (95% CI=6.95–8.80) for severe stroke. After accounting for competing risk of mortality, there was a significantly higher readmission risk in the moderate stroke (HR=1.11, 95% CI=1.03–1.20), but significantly lower readmission risk in the severe stroke (HR=0.84, 95% CI=0.74–0.95) categories.
Limitation
Timing of NIHSS reporting during hospitalization is unknown.
Conclusions
Medicare claim–based NIHSS is significantly associated with 30-day mortality in Medicare patients with ischemic stroke and significantly improves discriminant property relative to the Elixhauser comorbidity index.
Motor learning is fundamental to motor rehabilitation outcomes. There is growing evidence from non-neurological populations supporting the role of visuospatial memory function in motor learning, but ...current predictive models of motor recovery of individuals with stroke generally exclude cognitive measures, thereby overlooking the potential link between motor learning and visuospatial memory. Recent work has demonstrated that a clinical test of visuospatial memory (Rey-Osterrieth Complex Figure Delayed Recall) may predict 1-month skill learning in older adults; however, whether this relationship persists in individuals with chronic stroke remains unknown. The purpose of this short report was to validate previous findings using Rey-Osterrieth Complex Figure Delayed Recall test scores to predict motor learning and determine if this relationship generalized to a set of individuals post-stroke. Two regression models (one including Delayed Recall scores and one without) were trained using data from non-stroke older adults. To determine the extent to which Delayed Recall test scores impacted prediction accuracy of 1-month skill learning in older adults, we used leave-one-out cross-validation to evaluate the prediction error between models. To test if this predictive relationship generalized to individuals with chronic ischemic stroke, we then tested each trained model on an independent stroke dataset. Results indicated that in both stroke and older adult datasets, inclusion of Delayed Recall scores explained significantly more variance of 1-month skill performance than models that included age, education, and baseline motor performance alone. This proof-of-concept suggests that the relationship between delayed visuospatial memory and 1-month motor skill performance generalizes to individuals with chronic stroke, and supports the idea that visuospatial testing may provide prognostic insight into clinical motor rehabilitation outcomes.
•Diverse/rural dyads experience barriers to engagement and retention in interventions.•These barriers can be overcome by providers using specific communication strategies.•Effective communication ...builds trust and may lead to better outcomes.
Abstract Ankle dorsiflexion weakness that impedes walking affects some 30% of people after a stroke, which increases the risk of falls and mortality. Recent advances in functional electrical ...stimulation or electrical stimulation orthotic substitute walking devices facilitate the use of surface electrode stimulation during therapeutic gait training and as an orthotic substitute. However, many therapists who could promote the use of these electrical stimulation orthotic substitute devices are not doing so, possibly because of a lack of knowledge about the devices and uncertainty about which patients could benefit from the devices but also because of a lack of reimbursement by some insurance providers. In addition, there is limited evidence about the efficacy of electrical stimulation orthotic substitute devices for therapeutic use or as a substitute for a traditional ankle-foot orthosis (AFO). This article provides clinicians with information to guide them in the use of electrical stimulation orthotic substitute devices, discusses current research about the use of electrical stimulation orthotic substitute devices for therapeutic and orthotic purposes, and compares the use of electrical stimulation orthotic substitute devices and AFOs. There is insufficient evidence thus far to conclude that walking with an electrical stimulation orthotic substitute device is superior to walking with an AFO, but electrical stimulation orthotic substitute devices may be the optimal choice for some patients.
To assess the feasibility of measuring ventilatory threshold (VT) in adults with walking impairments due to stroke. Secondary objectives are to assess reliability of VT over trials; assess whether ...participants could sustain treadmill walking at VT; and compare mean heart rate during sustained treadmill walking to estimated heart rate reserve (HRR).
Cross-sectional, single-group design.
University research laboratory.
Volunteer sample of adults (N=8) with impaired walking resulting from chronic stroke.
Three submaximal treadmill walking tests on 3 separate days; a 30-minute treadmill walking session on a fourth day.
Gas exchange variables were measured, and 2 independent observers identified VT. Mean heart rate response to treadmill walking at VT was measured and compared with estimated 40% of HRR.
VT was measured successfully in 88% of all trials. There was no difference in VT among trials (P=.17). After multiple imputations to account for 3 missing data points, the intraclass correlation coefficient was .87 (95% confidence interval, .80-.95). All participants were able to walk for 20 minutes at VT. Mean ± SD heart rate during the session was 66.0%±8.0% of estimated maximal heart rate. There was no significant difference between mean heart rate and estimated HRR values (P=.70).
In adults with impaired walking resulting from stroke, VT can be safely measured during submaximal treadmill walking. Participants were able to sustain walking at VT, and this value may provide an appropriate stimulus for aerobic exercise prescription in this population.
Black and Hispanic US residents are disproportionately affected by stroke incidence, and patients with dual eligibility for Medicare and Medicaid may be predisposed to more severe strokes. Little is ...known about differences in stroke severity for individuals with dual eligibility, Black individuals, and Hispanic individuals, but understanding hospital admission stroke severity is the first important step for focusing strategies to reduce disparities in stroke care and outcomes.
To examine whether dual eligibility and race and ethnicity are associated with stroke severity in Medicare beneficiaries admitted to acute hospitals with ischemic stroke.
This retrospective cross-sectional study was conducted using Medicare claims data for patients with ischemic stroke admitted to acute hospitals in the United States from October 1, 2016, to November 30, 2017. Data were analyzed from July 2021 and January 2022.
Dual enrollment for Medicare and Medicaid; race and ethnicity categorized as White, Black, Hispanic, and other.
Claim-based National Institutes of Health Stroke Scale (NIHSS) categorized into minor (0-7), moderate (8-13), moderate to severe (14-21), and severe (22-42) stroke.
Our sample included 45 459 Medicare fee-for-service patients aged 66 and older (mean SD age, 80.2 8.4; 25 303 55.7% female; 7738 17.0% dual eligible; 4107 9.0% Black; 1719 3.8% Hispanic; 37 715 83.0% White). In the fully adjusted models, compared with White patients, Black patients (odds ratio OR, 1.21; 95% CI, 1.06-1.39) and Hispanic patients (OR, 1.54; 95% CI, 1.29-1.85) were more likely to have a severe stroke. Using White patients without dual eligibility as a reference group, White patients with dual eligibility were more likely to have a severe stroke (OR, 1.75; 95% CI, 1.56-1.95). Similarly, Black patients with dual eligibility (OR, 2.15; 95% CI, 1.78-2.60) and Hispanic patients with dual eligibility (OR, 2.50; 95% CI, 1.98-3.16) were more likely to have a severe stroke.
In this cross-sectional study, Medicare fee-for-service patients with ischemic stroke admitted to acute hospitals who were Black or Hispanic had a higher likelihood of worse stroke severity. Additionally, dual eligibility status had a compounding association with stroke severity regardless of race and ethnicity. An urgent effort is needed to decrease disparities in access to preventive and poststroke care for dual eligible and minority patients.
To examine the association between committed caregivers and caregiver training with community discharge from inpatient rehabilitation after a stroke.
Secondary analysis of data extracted from ...electronic health records linked with the Uniform Data System for Medical Rehabilitation.
Three hospital-based inpatient rehabilitation facilities (IRF) in a major metropolitan area.
1397 adult patients (mean ± SD age: 69.4 13.5; 724 men) transferred from an acute care setting to inpatient rehabilitation after an ischemic or hemorrhagic stroke (N=1397).
None.
Community discharge from IRF.
82.4% of patients had caregivers, 63.4% of patient caregivers received training at the IRF, and 79.5% had community discharge. After adjusting for age, stroke severity, functional status, and other social risk factors, having a committed caregiver and caregiver training were significantly associated with community discharge (odds ratio OR=7.80, 95% confidence interval CI: 5.03-12.10 and OR=4.89, 95% CI: 3.16-7.57, respectively).
Caregivers increase a patient's likelihood of discharge from IRF; the added benefit of caregiver training needs to be further assessed, with essential elements prioritized prior to patients’ IRF discharge.
This study tested the hypotheses that aging is associated with greater hypothalamic–pituitary–adrenal (HPA) axis reactivity to psychological stress, and whether aerobic fitness is associated with a ...lower HPA axis response to psychological stress. Three groups, consisting of young-unfit women (27.9±2.5
yr,
n=10), older-unfit women (66.3±1.4
yr,
n=14), and older-fit women (66.6±2.0
yr,
n=12), underwent the Matt Stress Reactivity Protocol (MSRP). The MSRP is a stress test battery that combines mental challenges, a physical challenge, and a psychosocial stressor. Definition of fitness was based on maximal oxygen consumption (VO
2
max
) where unfit was defined as having VO
2
max
≤average for the respective age group and fit was defined as VO
2
max
>average for the respective age group. The MSRP elicited increases in heart rate, blood pressure, ACTH, and cortisol (
P<0.001). The older-unfit women had significantly greater cortisol responses to the challenge than both the young-unfit and the older-fit women (
P<0.05), who did not differ from each other. ACTH levels were significantly higher in the older-unfit women at baseline and throughout the trial, compared to both young-unfit and the older-fit (
P<0.01). The ACTH response was not different between any of the groups. The young-unfit women had greater heart rate responses than the older-unfit (
P<0.01), while the latter had greater systolic blood pressure responses (
P<0.01). There were no significant differences between the older-unfit and older-fit in terms of heart rate or blood pressure responses.
Our result shows that among unfit women, aging is associated with greater HPA axis reactivity to psychological stress, and that higher aerobic fitness among older women can attenuate these age-related changes as indicated by a blunted cortisol response to psychological stress. These findings suggest that exercise training may be an effective way of modifying some of the neuroendocrine changes associated with aging.
Stress, both psychological and physiological, has been implicated as having a role in the onset and exacerbations of rheumatoid arthritis (RA).
This study investigated whether neuroendocrine and ...physical function in women with RA can be altered through a yoga intervention.
Exercise intervention.
University research conducted at a medical clinic.
Sixteen independently living, postmenopausal women with an RA classification of I, II, or III according to the American College of Rheumatology functional classification system served as either participants or controls.
The study group participated in three 75-minute yoga classes a week over a 10-week period.
At baseline and on completion of the 10-week intervention, diurnal cortisol patterns and resting heart rate were measured. Balance was measured using the Berg Balance Test. Participants completed the Health Assessment Questionnaire (HIQ), a visual analog pain scale, and the Beck Depression Inventory.
Yoga resulted in a significantly decreased HAQ disability index, decreased perception of pain and depression, and improved balance. Yoga did not result in a significant change in awakening or diurnal cortisol patterns (P = .12).
Early physical functional changes after gastric bypass surgery (GBS) are unclear, and the relationship between these changes and health-related quality of life (HR-QOL) has not been reported. We ...measured distances from a 6-minute walk test (6MWT) and scores on the 36-Item Short-Form Health Survey (SF-36) before and after GBS.
Twenty-five people undergoing GBS completed the SF-36 and 6MWT presurgically and at the 3-month and 6-month follow-up visits. Ratings of perceived exertion (RPE) were measured during 6MWTs.
Presurgical walking distance (X+/-SD; 414.1+/-103.7 m) was 55%+/-14% of normative values. Distances increased significantly at 3 months (505.2+/-98.0 m) and at 6 months (551.5+/-101.2 m). Final RPEs decreased significantly, and HR-QOL improved significantly. Both physical and mental health components of the SF-36 improved significantly. Distance was inversely correlated with body mass throughout the study and positively correlated with the SF-36 Physical Component Summary change from 3 to 6 months.
Improved functional capacity was associated with enhanced HR-QOL. At 6 months, walking distances remained 75% of those for age-matched peers who had normal weight.
Celotno besedilo
Dostopno za:
DOBA, FSPLJ, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
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