NeuroVoices: Shumei Man, MD, on How Collaboration Between Hospitals Reduces Readmission for Stroke

Shumei Man, MD, PhD

Previous research has suggested that patients discharged to post-acute facilities after acute ischemic stroke carry a high risk of readmission. At the 2023 International Stroke Conference (ISC), February 8-10, in Dallas, Texas, a group of clinicians presented a study that aimed to see whether close collaborations among the acute stroke care team and rehabilitation facility care can improve patient outcomes following ischemic stroke. Led by Shumei Man, MD, PhD, the analysis specifically focused in on all-cause mortality and readmission within 30 days after acute hospital discharge.

The study featured 624 poststroke patients who discharged from an acute hospital to acute rehabilitation hospitals. In the study, clinicians from the rehabilitation hospital first monitored and reviewed each readmission case. Following that, providers and leadership from rehabilitation hospitals and acute stroke care teams held monthly multidisciplinary meetings that included an in-depth review of each readmission, knowledge sharing, and decision-making to establish best practice protocols.

In total, 360 (58%) patients were transferred before and 264 (48%) after the introduction of the monthly multidisciplinary case review meetings in January 2020. At the conclusion of the trial, investigators observed significant changes in all-cause mortality and readmission, as well as 30-day readmission (adjusted odds ratio [OR], 0.56; 95% CI, 0.34-0.92; P <.001).

Man, medical director of stroke at Fairview Hospital, a thrombectomy capable stroke center at Cleveland Clinic, sat down as part of a new iteration of NeuroVoices, to discuss the trial. She provided insight on motivation behind the study, the need for improved cross-collaboration between centers, and the reasons behind readmission. Additionally, she discussed the clinical applicability of this intervention, and whether it can be widely used in centers across the country.

NeurologyLive®: Can you just provide a little bit of an overview a brief overview as to what you were trying to accomplish with this specific study?

Shumei Man, MD: Readmission can be a setback for patient recovery. Studies have shown that patients who are readmitted have a higher risk of dying in the hospital, and patients who are discharged to post-acute care facilities after acute ischemic stroke are at higher risk of readmission. Compared with patients who are discharged to home, those discharged to rehab are 2 times more likely to be readmitted within 30 days of stroke discharge. We have been working on these issues for years.

In January 2020, we launched a quality improvement initiative through the joint effort between the Cerebrovascular Center and Cleveland Clinic. At the cerebrovascular center, the efforts were led by Zeshaun Khawaja, MD, and the stroke managers at the main hospital. I joined this last year. At the rehabilitation hospitals, efforts were led by the chief executive officer Erica Druin, and physical medicine/rehab specialist John Lee, MD, and was participated by all their care providers taking care of patients.

The first step out this intervention is for select rehab providers to monitor and review each readmission case every month. Every month, we hold a multidisciplinary meeting among the leadership and the providers from the rehab hospitals and acute stroke care team. The meeting agenda included an in depth review of each readmission case to identify the cause of readmission, and opportunities to improve. We shared our knowledge and aimed to establish best practice protocols and promote communications with follow up. Two years after this intervention, we analyzed the readmission and the mortality rate among patients who were discharged to select the rehab facilities before and after the intervention.

Because the intervention was launched in January 2020, we'll used data from 2018 and 2019 as preintervention and data from 2020 and 2021 as post intervention or during intervention. We were happy to see that the 30 day all-cause readmission rate decreased from 22% before the intervention to 11% during the intervention or post intervention period. The composite all-cause readmission and mortality rate decreased by 44%. It is worth noting that the 30-day mortality was low at the selected rehab center, at around 1%. We do not observe significant difference in that measure alone. We all think this research is a major success that's worth celebration. It provides an experience from a large healthcare organization, showing that we can tackle this readmission rate and improve patient safety through our collaborations.

Can the intervention process be easily adopted by hospitals across the country?

Yes, of course. This intervention is highly feasible. It does involve some work from the rehab side, but they need to do it anyway to keep track of each readmission case. The thing that’s added is that we meet with the rehabilitation providers. Between the rehabilitate providers and the acute care team, we have this meeting once a month. The meeting lasts for only an hour, but sometimes it takes less time to present the case and point out potential problems because the rehabilitation hospitals have already reviewed the case. For ourselves, we have experienced providers from the acute care team in meeting who are familiar with the patients because they are cared in our facility.

We can analyze, point out the opportunities and cause for readmission fairly quickly. Then, we can identify the opportunities and problems if it forms a pattern. For example, if a patient was readmitted for a blood clot in the leg or in the lung, we will discuss how to improve this, whether there is an existing protocol on the rehab side or it’s because the communication broke down during when the patient was discharged from acute care hospital to the rehab. This might have caused the patient to not being on a deep vein thrombosis (DVT) prophylaxis medication, Heparin or Coumadin, or Lovenox. Things like this. If it forms a pattern—hesitancy on either side to start the medications—because the concern was bleeding, then we share our knowledge that the DVT prophylaxis actually doesn't increase the risk of bleeding. We're working on how to establish the protocol for our patients who cannot move to get this pharmacological prophylaxis, and essentially prevent future events like this.

What are some of the lingering factors that lead to increased rates of readmission?

I’ve been studying the cause of readmission for years. There are many reasons that a patient might be readmitted. One, the stroke returns. Stroke isn’t the number one cause of readmission, the most common cause of admission is changing mental status, then infection, DVT blood clot in the lung or legs, cardiovascular diseases like heart attack, and then stroke. These are the most common causes for readmission.

When handling each patient, it depends on the cause of readmission. Apparently, change in mental status sometimes is caused by infection, the most common cause being urinary tract infection. Pneumonia can also be a cause. The way to prevent this is to reduce the full catheter associated in infection, reduce the length of the catheter placement, things like this. For DVT prophylaxis, we touched upon the idea that we should have low thresholds to start heparin and Lovenox for DVT prophylaxis. We shared our knowledge that after a patient is discharged to a rehabilitation hospital or skilled nursing facility, there are very few reasons that patient should not be starting this medication. Even for patients who had this intracerebral hemorrhage, after two days in acute hospital when the bleeding has stopped, and the hematoma is stable, we can start the heparin or Lovenox for DVT prophylaxis, things like this. I’d rather not discuss about the individual cause, but our experience has shown that to half of the readmissions can actually be prevented.

Was there any specific change in patient characteristics that stood out after the intervention?

Overall, we didn't see significant change in the comorbidity profiles before and after intervention. One thing we noticed is that during the post-intervention period, the patients NIH Stroke score was higher. That means the patients who were discharged to rehab during the post intervention period have more severe stroke than those discharged before the intervention. The decrease in the readmission rate is caused by the patient population change. Especially now that we’re discharging to the milder stroke patients, patients we see are more severe.

Transcript edited for clarity. Click here for more iterations of NeuroVoices.

REFERENCE
1. Blaginykh E, Uchino K, Khawaja Z, et al. Collaboration between acute care hospitals and rehabilitation hospitals reduces 30-day readmission and mortality after ischemic stroke hospital discharge. Presented at: 2023 International Stroke Conference; February 8-10; Dallas, TX.