Age-Related Disparities in the Quality of Stroke Care and Outcomes in Rehabilitation Hospitals: The Australian National Audit

https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.105707Get rights and content

Highlights

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    Focused on describing rehabilitation not acute care of younger patients with stroke.

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    Younger patients more likely to receive psychological and community reintegration support.

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    Younger patients have a longer length of stay, and higher FIM efficiency.

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    Care gaps exist in rehabilitation, regardless of age.

Abstract

Introduction

Stroke affects all ages. Despite increased incidence in those <65 years, little is known about age-based differences in inpatient rehabilitation management and outcomes.

Objectives

To investigate management and outcomes, comparing younger (<65 years) and older (≥65 years) patients with stroke, who received inpatient rehabilitation.

Methods

Multicentre, cross-sectional study using data from Australian hospitals who participated in the Stroke Foundation national stroke rehabilitation audit (2016-2018). Chi-square tests compared characteristics and care by age. Multivariable regression models were used to compare outcomes by age (e.g. length of stay). Models were adjusted for sex, stroke type and severity factors.

Results

7,165 audited cases from 127 hospitals; 23% <65 years (66% male; 72% ischaemic stroke). When compared to older patients, younger patients were more likely male (66% vs 52%); identify as Aboriginal or Torres Strait Islander (6% vs 1%); be less disabled on admission; receive psychology (46% vs 34%) input, and community reintegration support, including return to work (OR 1.47, 95% CI 1.03, 2.11), sexuality (OR 1.60, 95% CI 1.39, 1.84) and self-management (OR 1.39, 95% CI 1.23, 1.57) advice. Following adjustment, younger patients had longer lengths of stay (coeff 3.54, 95% CI 2.27, 4.81); were more likely to be independent on discharge (aOR 1.96, 95% CI 1.68, 2.28); be discharged to previous residences (aOR 1.64, 95% CI 1.41, 1.91) and receive community rehabilitation (aOR: 2.27, 95% CI 1.91, 2.70).

Conclusions

Age-related differences exist in characteristics, management and outcomes for inpatients with stroke accessing rehabilitation in Australia.

Introduction

Stroke is a life-changing event affecting survivors, their families, communities and workplaces. About 75% of strokes occur in people 65 years or older,1 but the incidence is increasing in those aged 20-64,2,3 during the most productive years of people's live. This contributes substantially to the social and economic burden of stroke to society.2,4 Specialist inpatient rehabilitation is cost effective in working age adults, even with complex neurological conditions such as stroke.5 The characteristics and rehabilitative needs often differ between younger and older survivors of stroke. For example, in younger survivors, more consideration may need to be given to vocation and return to work6, driving a motor vehicle,7 relationships, and caring for children and/or elderly parents. Rehabilitation for older survivors may not always address the needs of younger survivors. Therefore, although younger survivors generally have better functional outcomes,8 evidence indicates they still have significant unmet needs six months to one year post stroke,9,10 and poor, long-term outcomes.11

Despite age-related differences in rehabilitation needs, and in the nature and aetiology of stroke,2 there are no age-related guidelines or models of care.2 Although researchers have suggested age-related quality of care differences exist in the acute setting,1,12 limited research has focused on age-related differences in inpatient rehabilitation. We aimed to investigate patient characteristics, clinical management and discharge outcomes, comparing younger (<65 years) and older (≥65 years) patients with stroke who received inpatient rehabilitation in hospitals across Australia.

Section snippets

Methods

This multicentre, cross-sectional, retrospective observational cohort study used nationally representative data collected from hospitals participating in national stroke audits of inpatient rehabilitation services. Within Australia, the audit program, coordinated by the Stroke Foundation every two years, is voluntary for hospitals providing inpatient rehabilitation.13 Information on resources and features of the inpatient rehabilitation service, including bed and admission numbers, were

Data analysis

Aggregated data from 127 hospitals that participated in the 2016 or 2018 audits were analysed. For the purposes of this study, rehabilitation was defined as inpatient care only, and younger patients defined as aged between 18 and 64 years1. Valid yes/no responses were included for medical history and impairment data. Not documented and unknown responses were assumed to be negative and included in the denominator for processes of care data collected.

Demographics, patient characteristics and

Results

In total, 7,165 cases (2016: 3,514 and 2018: 3,651) were included from 127 hospitals (n=90 contributing to both audits). Of these, 23% were younger (18-64 years); 66% were male, and 72% experienced ischaemic stroke in this cohort. Organisational features of participating hospitals in the audit are provided in Supplemental Table I.

Outcomes

After adjusting for factors known to affect outcomes, when compared to older patients, younger patients had a median 3.5 days longer LOS (coeff 3.54, 95% CI 2.27, 4.81), were nearly twice as likely to be independent on discharge (aOR 1.96, 95% CI 1.68, 2.28), were more often discharged directly to their previous places of residence (aOR 1.64, 95% CI 1.41, 1.91) (Table 2), and 2.3 times more likely to receive further outpatient/community-based rehabilitation on discharge (95% CI 1.91, 2.70).

Discussion

To date, there has been limited research examining the care that younger patients with stroke receive in inpatient rehabilitation. In Australian patients, we found age-related differences in patients’ characteristics, management and outcomes. When compared to older patients (≥ 65years), younger patients had longer admissions and were more independent on discharge. During their admissions, they were more likely to have access to psychologists, and to receive information supporting community

Conclusion

Age-related differences exist in the characteristics, clinical management received and outcomes for patients with stroke accessing inpatient rehabilitation services in Australia. When compared to older patients, younger patients were more likely to receive care focussed on their emotional and psychological support, and community reintegration.

Acknowledgement

We acknowledge the hospitals participating in the National Stroke Audit and the clinicians who contributed to data collection using the Australian Stroke Data Tool (AuSDaT).

Statement of ethics

Ethics approval was obtained from Monash University Human Ethics Committee (Project ID 8842). All data were de-identified, retrospectively collected and aggregated; therefore, consent from individual patients was not required.

Disclosure statement

The authors have no conflicts of interest to declare.

Funding Sources

DAC acknowledges a research fellowship from the National Health and Medical Research Council (NMHRC) (1063761 co-funded by Heart Foundation; 1154273). MFK acknowledges support from an Early Career Fellowship from the NHMRC (1109426), and NAL is supported by a National Heart Foundation of Australia Future Leader Fellowship (102055).

Author contributions

All authors collaborated on the research proposal, aims and methods, provided their expertise in stroke and reviewed all drafts of the manuscript. Hubbard and Purvis jointly led the writing of the manuscript; Purvis analysed the data, and in consultation with Kilkenny, provided statistical expertise; Cadilhac, Hill, Watkins, Lannin and Faux provided relevant expertise in relation to the audit, the clinical guidelines and clinical relevance; and Kilkenny overall, led the study.

From the

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