Acute Intravenous Tissue Plasminogen Activator Therapy does not Impact Community Discharge after Inpatient Rehabilitation

Abstract

IntroductionCerebrovascular disease is the leading cause of disability in the United States, costing an estimated $36.5 billion annually [1]. To curb cost and decrease disability rates, iterations of outcomes research are of critical importance, particularly related to post-acute rehabilitation care. In 1995, the NINDS [National Institute of Neurologic Disorders and Stroke] and Stroke t-PA (tissue plasminogen activator) trial showed improved functional outcomes at three months in patients treated with t-PA compared to placebo [2]. However, the impact of t-PA on the rehabilitation process and acute care re-hospitalization during those three months has not been elucidated.Early efforts to quantify the impact of intravenous thrombolysis on the need for inpatient rehabilitation in the acute stroke setting have been promising. In a 2011 study, acute stroke patients who received t-PA were found to have significant improvement in their NIHSS [National Institutes of Health Stroke Scale] values and increased likelihood of community discharge without an inpatient rehabilitation stay [3]. Unfortunately for the acute stroke patient who requires inpatient rehabilitation, the impact of intravenous thrombolysis on NIHSS score and eventual community discharge is unknown. AbstractBackground and purpose: Discharge status and acute re-hospitalization are used as indicators of stroke severity and recovery. Intravenous t-PA (tissue plasminogen activator) is one of two treatments shown to have a positive impact. Stroke rehabilitation patients are an important population who will end up integrated back into the community, institutionalized or hospitalized due to late stroke complications. We sought to determine factors contributing to post rehabilitation discharge and acute re-hospitalization, in particular, the impact of t-PA therapy.Methods: Retrospective analysis of census data from ischemic stroke patients on the UTHealth Stroke/ Neurorehabilitation Services at Memorial Hermann Hospital -Texas Medical Center between Jan 2011 and Nov 2013, discharged to the Community, SNF (Skilled Nursing Facility) or AC (Acute Care). Demographics and NIHSS (National Institutes of Health Stroke Scale) were collected. Discharge FIM (Functional Independence Measure) was the reference standard. Genitourinary infections were a negative mediator in the multivariate regression.Results: Of 346 patients, 274 returned to the community, 47 to SNF, and 25 to AC.NIHSS and t-PA therapy: Median NIHSS values were 8 in the community group, 11 in SNF and 9.5 in AC.31.8% of patients received IV t-PA in the community group, 23.4% in SNF and 24% in AC. There were no statistically differences in community discharge rates.Community vs. AC: One day increase in rehabilitation hospitalization correlated with 19% decreased odds of AC readmission (OR 0.81; P=0.001).One unit discharge FIM increase correlated with 13% decreased odds of AC readmission (OR 0.87; P=0.003).Community vs. SNF: One year age increase correlated with 4% increased odds of SNF admission (OR 1.04; P=0.02)...