Postacute Discharge Destination and Major Adverse Cardiovascular Events Among Patients With Intracerebral Hemorrhage.

Abstract

Background: Studies evaluating health system factors associated with major adverse cardiovascular events (MACE) among intracerebral hemorrhage (ICH) survivors are lacking. We evaluate differences in MACE incidence across postacute ICH care settings-inpatient rehabilitation facilities (IRF), home, or skilled nursing facilities (SNF).

Methods: Using data from Florida, New York, Maryland, Washington, and Georgia, we identified adult ICH survivors discharged to home, IRF, or SNF (April 2016-December 2018). Multivariable logistic models, adjusted for sociodemographic factors, treatment intensity, comorbidities, and frailty, estimated adjusted odds ratios (aORs) and 95% CIs for the association between discharge disposition (IRF versus home; IRF versus SNF) and MACE (a composite of acute stroke, acute myocardial infarction, systemic embolism, and vascular death), recurrent ICH, acute ischemic stroke, acute myocardial infarction, vascular death, and all-cause mortality within 1 year. Cardiovascular outcomes were ascertained using International Classification of Diseases, Tenth Revision codes. We assessed age-discharge disposition interaction, performing stratified analyses for patients <65 and ≥65 years when the interaction was significant.

Results: Among 58 591 patients with ICH (mean age [SD], 68.1 [16.0] years; 47.1% female), 17 647 ICH survivors discharged home (46.4%), to IRF (25.5%), or to SNF (28.1%) were included. Within 1 year, 1302 (7.4%) patients experienced MACE, with rates for recurrent ICH, acute ischemic stroke, acute myocardial infarction, vascular death, and mortality at 2.5%, 3.2%, 0.6%, 1.3%, and 3.5%, respectively. In fully adjusted models, patients discharged to IRF had significantly lower odds of MACE (versus home: aOR, 0.84 [CI, 0.71-0.98]; versus SNF: aOR, 0.79 [CI, 0.67-0.93]), with a significant discharge disposition-age interaction (P=0.047). In stratified analysis, IRF discharge (versus home) was only significantly associated with MACE in patients aged <65 years (aOR, 0.70 [CI, 0.54-0.92]), not in those aged ≥65 years (aOR, 0.94 [CI, 0.77-1.15]). Patients discharged to IRF had significantly lower odds of recurrent ICH (versus SNF: aOR, 0.60 [CI, 0.45-0.80]), vascular death (versus SNF: aOR, 0.70 [CI, 0.49-0.99]), and all-cause mortality (versus SNF: aOR, 0.63 [CI, 0.50-0.79]).

Conclusions: IRF care (versus SNF and home) was associated with lower odds of MACE. Further research is needed to determine specific components of IRF care contributing to better outcomes.