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  • Impact of transfer status on hospitalization cost and discharge disposition of patients treated for acute ischemic stroke in the nation wide inpatient sample database,2008–2010

    Final Number:

    Ashish Sonig MD MS MCh neurosurgery; Ning Lin MD; Chandan Krishna MD; Sabareesh Kumar Natarajan MD MBBS MS; Maxim Mokin MD PhD; L. Nelson Hopkins MD; Kenneth V. Snyder MD, PhD; Elad I. Levy MD, FACS, FAHA, FAANS; Adnan Hussain Siddiqui MD, PhD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2014 Annual Meeting

    Introduction: As the volume of stroke-interventions and case loads is increasing with time, knowledge of the proportion of patients who are transferred to a stroke-center from a primary-hospital and the differences in related costs and outcomes in transferred versus non-transferred patients are of paramount importance. In this study,we utilized the information provided in the NIS to study the impact of transferring a stroke patient from one facility to a center where they received some form of stroke intervention(intravenous tissue plasminogen activator[tPA],thrombectomy,either alone or in combination).

    Methods: We analyzed 2008–2010 NIS data. Figure1 gives the details of the variables used. Discharge-disposition, hospitalization-cost and mortality were the dependent variables that were studied. Univariate-analysis and multivariate-binary-logistic- regression analysis was done.

    Results: Data for 1,311,511 patients admitted for acute-stroke were reviewed from the 2008–2010 NIS database. The mean age of these patients was 71.11 years(standard deviation14.7,Figure2). We analyzed data for the cohort of patients(n=55,913) who received some form of active intervention(Figure3).When overall outcome was considered, patients with transfer-status had a significantly higher number of OTR(Other-then-routine) discharge-dispositions(p<0.0001)(Figure4).Multivariate-regression analysis that included pertinent patient(Figure5) and hospital-factors(factors6) showed that patients who were transferred had significant worse OTR (p<0.0001,OR2.575,CI 2.341–2.832)(Figure7) .The mean hospitalization-cost including an intervention was $70,325.11 at the direct-admission facility and $97,546.92 at the transfer-facility(figure8).Hospitalization-cost was analyzed, transfer from another facility (p<0.001,OR 1.677,CI 1.548–1.817) was associated with higher hospitalization cost (Figure9).

    Conclusions: Our study showed that the cost incurred by a hospital for acute-stroke intervention is significantly higher for a patient who is transferred from another facility than for a direct admission. Moreover, the frequency of OTR discharge was significantly higher among transferred patients compared with direct admissions. Future strategies should focus on the means and ways of transporting the patient appropriately and directly to a stroke center

    Patient Care: This current study shows the importance and overall cost effectiveness of the policy of transferring an acute stroke patient to a specialized center , directly.

    Learning Objectives: The reader would understand 1. The poor outcome and higher hospitalization cost of patients who are transferred from one facility to another for intervention vs a direct admission to a stroke intervention facility. 2. The regional disparity in the hospitalization of stroke patients

    References: References 1. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics--2012 update: a report from the American Heart Association. Circulation 2012;125:e2-e220 2. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics--2013 update: a report from the American Heart Association. Circulation 2013;127:e6-e245 3. Kimball MM, Neal D, Waters MF, et al. Race and income disparity in ischemic stroke Care: Nationwide Inpatient Sample database, 2002 to 2008. J Stroke Cerebrovasc Dis epub July 17 2012 4. Adamczyk P, Attenello F, Wen G, et al. Mechanical thrombectomy in acute stroke: utilization variances and impact of procedural volume on inpatient mortality. J Stroke Cerebrovasc Dis epub September 27 2012 5. Attenello FJ, Adamczyk P, Wen G, et al. Racial and socioeconomic disparities in access to mechanical revascularization procedures for acute ischemic stroke. J Stroke Cerebrovasc Dis (epub May 13 2013 6. Bateman BT, Schumacher HC, Boden-Albala B, et al. Factors associated with in-hospital mortality after administration of thrombolysis in acute ischemic stroke patients: an analysis of the nationwide inpatient sample 1999 to 2002. Stroke 2006;37:440-6 7. Brinjikji W, Rabinstein AA, Kallmes DF, et al. Patient outcomes with endovascular embolectomy therapy for acute ischemic stroke: a study of the national inpatient sample: 2006 to 2008. Stroke 2011;42:1648-52 8. Choi JH, Bateman BT, Mangla S, et al. Endovascular recanalization therapy in acute ischemic stroke. Stroke 2006;37:419-24 9. Hoh BL, Chi YY, Waters MF, et al. Effect of weekend compared with weekday stroke admission on thrombolytic use, in-hospital mortality, discharge disposition, hospital charges, and length of stay in the Nationwide Inpatient Sample Database, 2002 to 2007. Stroke 2010;41:2323-8 10. Sonig A, Khan IS, Wadhwa R, et al. The impact of comorbidities, regional trends, and hospital factors on discharge dispositions and hospital costs after acoustic neuroma microsurgery: a United States nationwide inpatient data sample study (2005-2009). Neurosurg Focus 2012;33:E3 11. Qureshi AI, Suri MF, Nasar A, et al. Changes in cost and outcome among US patients with stroke hospitalized in 1990 to 1991 and those hospitalized in 2000 to 2001. Stroke 2007;38:2180-4 12. Russo CA, Andrews RM. Hospital stays for stroke and other cerebrovascular diseases, 2005: Statistical brief #51. Available at Accessed September 30, 2013. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Health Care Policy and Research (US), 2008 13. U.S. Department of Health & Human Services. Agency for Healthcare Research and Quality. Household Component Summary Data Tables: Available at Accessed September 30, 2013 14. Bhattacharya P, Mada F, Salowich-Palm L, et al. Are racial disparities in stroke care still prevalent in certified stroke centers? J Stroke Cerebrovasc Dis 2013;22:383-8 15. Gupta R, Horev A, Nguyen T, et al. Higher volume endovascular stroke centers have faster times to treatment, higher reperfusion rates and higher rates of good clinical outcomes. J Neurointerv Surg 2013;5:294-7 16. McNeill L, English SW, Borg N, et al. Effects of institutional caseload of subarachnoid hemorrhage on mortality: a secondary analysis of administrative data. Stroke 2013;44:647-52 17. Silbergleit R, Scott PA, Lowell MJ. Cost-effectiveness of helicopter transport of stroke patients for thrombolysis. Acad Emerg Med 2003;10:966-72 18. Chalela JA, Kasner SE, Jauch EC, et al. Safety of air medical transportation after tissue plasminogen activator administration in acute ischemic stroke. Stroke 1999;30:2366-8 19. Wormer BA, Fleming GP, Christmas AB, et al. Improving overtriage of aeromedical transport in trauma: a regional process improvement initiative. J Trauma Acute Care Surg 2013;75:92-6

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