Functional recovery trajectories in post-acute stroke care: rethinking the length of stay.

Abstract

Background: Post-acute care (PAC) restores function after stroke, but the optimal length of stay (LOS) is undefined, particularly in high-intensity rehabilitation settings, causing practice variation and resource-allocation challenges.

Objective: To examine the association between PAC LOS and functional outcomes after stroke using propensity score-based adjustment for baseline functional severity and to characterise recovery trajectories across rehabilitation durations.

Methods: In a retrospective cohort of patients enrolled in Taiwan's PAC stroke programme (January 2018-December 2023), functional outcomes were assessed using the modified Rankin scale (mRS) and Barthel Index (BI). Associations between prolonged LOS (>6 weeks) and outcomes were examined using multivariable logistic regression and an inverse probability of treatment weighting model incorporating baseline functional status into the propensity score. Exploratory analyses evaluated weekly LOS cut-offs and stroke subtypes.

Results: Among 610 patients, prolonged PAC LOS was associated with higher odds of mRS improvement (OR 1.75, 95% CI 1.20 to 2.57), lower odds of mRS non-improvement (0.57, 0.39 to 0.84) and lower odds of discharge BI≤60 (0.37, 0.25 to 0.55). Lower odds of BI non-improvement were also observed but rested on very few events (penalised-likelihood (Firth) estimation) and warrant caution. The decline in mRS non-improvement continued with longer LOS and differed by subtype, persisting beyond 6 weeks in ischaemic stroke.

Conclusions: After adjustment for baseline functional status, prolonged PAC LOS remained associated with more favourable outcomes, but this should not be interpreted as evidence that longer rehabilitation independently causes better recovery. LOS appears to reflect individual recovery trajectories, whose timing differed by stroke subtype. These findings argue against a single uniform duration threshold and support individualised, subtype-aware reassessment.