A demographic analysis has revealed that an association exists between discharge disposition and National Institutes of Health Stroke Scores (NIHSS) at 90-day follow-up. Patients discharged to an inpatient rehabilitation facility were found to have more favourable outcomes compared with those sent home or to a skilled nursing facility. According to the authors, this study is the first to examine the role of discharge disposition in an acute stroke treatment trial in the modern era.
Rishi Gupta (Wellstar Neurosurgery, Marietta, USA) and others evaluated the demographic data from the SENTIS (The safety and efficacy of NeuroFlo technology in ischemic stroke) trial to determine the impact of stroke severity and discharge disposition on 90-day outcomes in US patients—the results were published in the Journal of NeuroInterventional Surgery.
The SENTIS trial, originally published in the American Journal of Neuroradiology in 2013, was a multicentre, prospective, randomised controlled trial that evaluated the safety and effectiveness of the NeuroFlo catheter (CoAxia) in stroke patients compared to standard medical therapy. In the trial, it was found that there were consistent reductions in all-cause and stroke-related mortality in the NeuroFlo-treated patients. Although the results showed that treatment with NeuroFlo was safe, it was also demonstrated that there was not a benefit of doing so when compared to standard medical therapy. Therefore, Gupta and colleagues analysed NIHSS from days one and four, discharge disposition and 90-day modified Rankin Score to investigate whether discharge disposition to home or acute rehabilitation is associated with a clinical favourable outcome from the SENTIS data.
Of the 292 patients, 153 (52.1%) were discharged to an inpatient rehabilitation facility, 11 (38%) to home and 28 (9.6%) to a skilled nursing facility.
Two out of the 28 patients discharged to a skilled nursing facility achieved a 90-day modified Rankin Score of ≤2 compared with the 60/153 patients in the inpatients rehabilitation facility (OR 8.39, 95% CI 1.92 to 36.64, p=0.0047).
According to Gupta et al, these results show that an association between outcomes and discharge disposition remains after adjustments for age and admission NIHSS.
They add that three of the 50 patients with NIHSS of ≥14 at four days achieved modified Rankin Scored of 0–2 at 90 days.
“This analysis shows that discharge to an inpatient rehabilitation facility is associated with better neurological outcomes than discharge to a skilled nursing facility. Additionally, patients with NHISS of ≥14 at day four are unlikely to achieve independent function.”
Co-author Samir R Belagaje, assistant professor, Neurology and Rehabilitation Medicine, Emory University School of Medicine, USA, spoke to NeuroNews and shed light on the implications of the findings of the study for the future.
How could these findings be applied to patient care after stroke in the future?
Our results reinforce the concept that care of patients with stroke must be optimised in all phases of their care and not just the acute phase. In the real world, neurologists and other healthcare practitioners should try to get their patients to their acute rehabilitation (inpatient rehabilitation) whenever possible and when their patients are unable to go home immediately. In the research world, our research helps with the design of future clinical trials of acute stroke intervention by pointing out the importance of the discharge disposition and possibly standardised. Our data may also point to further examination of the decision process in determining which patients go to inpatient rehabilitation facility vs. skilled nursing facility and help get more patients to an inpatient rehabilitation facility to improve their overall outcome.
Would discharging all patients to an inpatient rehabilitation facility be cost-effective?
We do not have any data at this point to clearly say one way or another. It is probably not cost-effective as there are some patients who, because of their stroke severity, simply do not make the improvements to justify the resources in terms of therapists and the intensity of therapy. They would do the same with less intensity as provided in a skilled nursing facility.
Furthermore, there are some patients because of their age, stroke severity, or other medical comorbidities are unable to tolerate the intensity of the inpatient facility rehabilitation and could actually do worse. This would result in more acute hospitalisations, longer stays in facilities, and worsened outcomes all of which would add further costs making this strategy less cost-effective.