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