Validation of stroke diagnosis in the National Hospital Discharge Register and the Register of Causes of Death in Finland

The validity of stroke diagnosis in the National Hospital Discharge Register and the Register of Causes of Death was examined among 546 middle-aged men in Finland. The subjects were cases of cerebrovascular diseases of the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study and identified by record linkage to the registers. In all, 375 events with cerebrovascular disease as hospital discharge diagnosis and 218 events with cerebrovascular disease as the underlying cause of death were reviewed using specific criteria modified from the classifications of the National Survey of Stroke and the WHO MONICA Study. For hospital stroke diagnoses, there was agreement on diagnosis for all strokes in 90%, for subarachnoid hemorrhage in 79%, intracerebral hemorrhage in 82%, and cerebral infarction in 90%. The respective agreement rates for stroke as the underlying cause of death were 97%, 95%, 91%, and 92%. The data were insufficient for review in 1% and 3% of the stroke events, respectively. Age, observation year and trial supplementation with alpha-tocopherol or beta-carotene had no effect on validity. In conclusion, the validity of stroke diagnosis was good in registers of hospital diagnoses and causes of death justifying their use for endpoint assessment in epidemiological studies.     

Comparison of self-report, hospital discharge codes, and adjudication of cardiovascular events in the Women's Health Initiative

Limited information is available from large clinical investigations about the agreement among sources of diagnoses for endpoints. The authors used data from the Women's Health Initiative clinical trials and observational study from January 1994 to November 2000 to evaluate the agreement among self-report, hospital discharge codes, and two different levels of physician review of medical records for cardiovascular endpoints. For myocardial infarction, stroke, pulmonary embolism, and venous thrombosis, the agreement of hospital discharge codes or self-report with review by study physicians at clinical centers was substantial (kappa = 0.64-0.84). For coronary revascularization, agreement among these sources of information was substantial to almost perfect (kappa = 0.79-0.92), but for angina, congestive heart failure, and peripheral vascular disease, concordance was only fair to moderate (kappa = 0.37-0.56), indicating that these endpoints remain difficult to classify reliably. Agreement between physician adjudicators at clinical centers and central physician adjudicators was substantial to almost perfect (kappa = 0.67-0.94). The findings also suggest that, for the endpoint of myocardial infarction, physician review of events with hospital discharge codes for angina and congestive heart failure is an important source of validated events, and for stroke, review of all events with cerebrovascular codes is important.     

The validity of hospital discharge register data on coronary heart disease in Finland

We studied the validity of the Finnish hospital discharge register data on coronary heart disease (CHD) for the purposes of epidemiologic studies and health services research. The Finnish nationwide hospital discharge register (HDR) was linked with the FINMONICA acute myocardial infarction (AMI) register for the years 1983–1990. The frequency of errors in the HDR was assessed separately. Between 8% and 13% of hospitalized AMI events registered in the AMI Register were not found in the HDR with an ICD code for CHD. Problems with the register linkage and the use of some ICD code other than one of the codes for CHD explained these missing events. The frequency of errors in the personal identification number was about 5% in the early 1980s. After 1986 errors were found only occasionally. The diagnosis recorded in the HDR was the same as that in the discharge sheet in about 95% of hospitalizations. The positive predictive value of the ICD code 410 (AMI), compared with the FINMONICA definite+possible AMI category, was very high and stable, about 90% in all areas and all hospitals, but it sensitivity varied from 50% at local hospitals to 80% at central hospitals. In summary, data on CHD obtained from the Finnish hospital discharge register give, on average, a correct picture on changes in the occurrence of AMI in Finland and can, with necessary caution, be used in epidemiological studies and health services research. However, the classification of individual cases is not standardized in the HDR, but varies over time, between geographical areas and the levels of care. Therefore, these data should not be used without confirmation in studies where correct classification of individual outcomes is of crucial importance, such as follow-up studies and case-control studies.     

Predicting place of discharge from hospital for patients with a stroke or hip fracture on admission

OBJECTIVES: To determine the predictive power of patient and service characteristics on place of discharge following hospital admission for an acute stroke and for hip fracture. METHODS: Prospective cohort of 440 acute stroke and 572 hip fracture patients aged 65 years or over admitted from home to six district general hospitals and associated community hospitals, three in the North and three in the South of England. RESULTS: Age, marital status, living arrangements, mental health status at admission, pre-admission self-rated disability, pre-admission use of home-care services, post-admission staff assessments of functional dependency as measured by Barthel Index and of confusion as measured by the modified Crichton Royal Behavioural Rating Scale and nursing staffs' expectation of place of discharge are all significantly related to place of discharge for stroke and hip fracture participants. Logistic regression correctly predicted discharge destination for 87% of stroke patients from data available at time of admission and 83% of hip fracture patients. Of the 30% of stroke patients discharged to an institution, the model correctly predicted 73%. However, of the 19% of hip fracture patients discharged to an institution, only 28% were correctly predicted. CONCLUSIONS: Data about older patients admitted to hospital with an acute condition should be routinely collected by hospital staff to inform clinical management and to permit risk-adjusted audit.     

The costs of caring for stroke patients in a GP-led community hospital: an application of programme budgeting and marginal analysis

There has been little evaluation of the role of community hospitals in the provision of integrated health care services in a primary care-led health system. The aim of this study was to model the probable changes in the use of NHS resources from the introduction of integrated stroke care in a general pracititioner-led community hospital. A programme budgeting and marginal analysis (PBMA) exercise was conducted combining practice data for the 'before' period and data from the literature to model the 'after' period. Data were collected from all patients discharged with a primary diagnosis of stroke 1994-96 in Nairn and Ardersier Total Fundholding pilot site, Highland Health Board, Scotland. Under several assumptions, a policy of early discharge of patients to the community hospital, and/or avoiding admission at the acute trust and admitting patients to the community hospital directly (except emergencies), is likely to result in a reduction of the total annual costs of treating stroke patients, from 183,000 pounds per annum to, at most, 74,000 pounds. The analysis of routine discharge data since integrated stroke care was set up has shown that progress has been made in shifting the treatment of patients from the acute trust to the community hospital. The care of stroke patients in a GP-led community hospital is likely to reduce the use of scarce health service resources. Current evidence suggests that health outcomes are unchanged due to early discharge, but further research is required to ensure that patients' health status and quality of life are maintained before such a policy is widely adopted.     

Effects of policosanol on patients with ischemic stroke: a pilot open study

Stroke is a major health problem worldwide. Its pharmacological management includes thrombolytic therapy for the acute phase and antiplatelet drugs for stroke recovery and prevention. Statins can help in the acute phase and in preventing stroke in secondary prevention patients. Policosanol is a cholesterol-lowering drug with concomitant antiplatelet effects, with protective effects in stroke models. This observational study investigated the effects of policosanol (20 mg/day) administered during the acute phase and for 5 years later on the neurological recovery of patients with ischemic stroke treated with antiplatelets and vitamins. After hospital discharge, patients were followed up every 3 (first year) and 6 (thereafter) months. Neurological improvement was assessed with the modified Canadian Neurological Scale. Adverse events were recorded. Fifty patients were included; all completed the study. Neurological score improved throughout the study. No patient died, and most [40 (80.0%)] did not experience new vascular events; only one (2.0%) suffered a new stroke, and two (4.0%) suffered more than one transient ischemic attack. The time to the first recurrent event was 46.2 months. Policosanol persistently lowered serum total cholesterol, with such reduction correlating with the neurological improvement (R = 0.995253301). Triglycerides were unchanged. Treatment was well tolerated. Policosanol administered to patients suffering ischemic stroke treated with aspirin and vitamins showed good results on neurological outcomes and recurrent events. This study, however, has limitations, since it was open and uncontrolled, and patients also consumed aspirin and vitamins. New randomized, controlled studies are needed to assess the usefulness of policosanol in stroke management.     

Issues of recruitment and maintaining high response rates in a longitudinal study of older hospital patients in England--pathways through care study.

STUDY OBJECTIVES: To describe and discuss the methods used to recruit and maintain an unbiased sample of older discharged hospital patients in a study of the process and outcomes of hospital care. DESIGN: Prospective longitudinal interview study of consecutive patients admitted to hospital over a 12 month period and followed up for six months. Interviews took place in hospital five days after admission, at home 10 days after discharge, and six months after admission. SETTING: Six hospital locations: three in the north of England and three in the south. PARTICIPANTS: People aged 65 and over admitted to hospital with a new stroke or fractured neck of femur, their significant other, and nursing staff caring for them. MAIN RESULTS: Of 3105 patients referred to the study, 2111 were eligible and 1671 (79%) were recruited. Recruited stroke patients were younger than those not recruited and rates differed between locations for both stroke and fractured neck of femur. By six months after admission 25% had died. Outcome data were obtained for 85% of the surviving patients. Patients who died were older and frailer before admission. Among survivors, outcome data for stroke patients were less likely to be obtained for men, those more able initially, and those who were married. Response rates to each interview differed according to respondent types. Interviews were more likely to be obtained with significant others than patients. Patients who were not able to be interviewed were older and frailer; significant others were less likely to be interviewed if the patients were younger and more able. CONCLUSIONS: High response rates can be achieved with very frail older people if strategies are adopted to maintain their interest and if self reported data are supplemented by interviewing significant others.     

Perceived Quality of Care Transitions between Hospital and the Home in People with Stroke

ObjectivesTo explore the perceived quality of care transitions from hospital to the home with referral to subsequent rehabilitation in the home, and factors associated with low perceived quality, in people with stroke.DesignObservational study.Setting and ParticipantsEligible were patients with a suspected acute stroke admitted to 1 of 4 inpatient hospital units in the Stockholm region and discharged home with referral to a neurorehabilitation team in primary care.MethodsData on perceived quality of care transition was collected with the Care Transition Measure (CTM-15) 1 week after discharge. Additional data were mainly retrieved from medical records. To analyze difference in mean total score of the CTM-15 between participants' characteristics, length of hospital stay, disease-related data, and functioning, the Mann-Whitney U test and independent sample t test were used for dichotomized variables and 1-way analysis of variance and the Tukey post hoc test for variables with more than 2 groups. To analyze differences between participants with low and high perceived quality per item, univariable regression analyses were performed. Thereafter, multivariable regression models were created to explore associations between low perceived quality and the independent variables.ResultsMean age of the 189 participants was 75 years and 91% had a mild or very mild stroke. The majority perceived most areas of the care transition to be of high quality. Nevertheless, several areas for improvement were identified. People with a more severe stroke perceived the quality of the care transition to be lower in comparison with those with a mild stroke. The association was weak between patient or clinical characteristics and the perceived quality.Conclusion and ImplicationsOur findings suggest that preparation for discharge and information and support for self-management postdischarge should be enhanced in the referral-based care transition after stroke. Special attention should be given to people with severe stroke.     

Bouncing-back: rehospitalization in patients with complicated transitions in the first thirty days after hospital discharge for acute stroke

BACKGROUND: "Bounce-backs" (movements from a less intensive to a more intensive care setting) soon after hospital discharge are common, but reasons for bouncing-back remain unknown. OBJECTIVE: To examine how the primary diagnosis for first rehospitalization relates to thirty-day bounce-back number and initial discharge destination in acute stroke. POPULATION: Administrative data from 5,250 Medicare beneficiaries > or = 65 years discharged with acute ischemic stroke in 1998-2000 to a rehabilitation center, skilled nursing facility or home with home health care and with at least one thirty day rehospitalization. ANALYSIS: Probability of thirty-day bounce-back was calculated using multivariate models. Results: Infections and aspiration pneumonitis were the most common reasons for rehospitalization, regardless of initial discharge site. CONCLUSIONS: Efforts addressing aspirations and infections, the preventable complications of immobility, will be critical in decreasing acute stroke bounce-backs.     

The reliability of racial classifications in hospital discharge abstract data.

Many studies demonstrating an association between race and the use of medical services have used hospital discharge abstract data. The quality of the measures of race in such data sources has heretofore been unexplored. Hospital discharge abstract data from New York State were used to identify 767 cardiac patients who had been admitted to a hospital twice. Racial classifications during the two admissions were concordant 93.7% of the time. Kappa was .89 for Blacks, .72 for Whites, and .43 for all other racial groups. Evidence suggests that the misclassification of race in hospital discharge abstract data is nondifferential; racial discrepancies in access to medical services are thus probably even greater than those previously reported.     

Estimating the out-of-hospital mortality rate using patient discharge data

This paper explores the hospital quality measures based on routine administrative data such as patient discharge records. Most of the measures used in the literature are based on in-hospital mortality risks rather than post-discharge events. The in-hospital outcomes are sensitive to the hospital's discharge policy, thus could bias the quality estimates. This study aims at identifying out-of-hospital mortality risks and disentangling discharge and re-hospitalization rates from mortality rates using patient discharge data. It is shown that these objectives can be achieved without post-discharge death records. This is an example of the use of public use administrative data for estimating empirical relations when key dependent variables are not available. Using data on the lengths of hospitalizations and out-of-hospital spells, the mortality rates before and after discharge are estimated for a sample of heart-attack patients hospitalized in California between 1992 and 1998. The results suggest that the quality assessments that ignore the variation of discharge rates among hospitals could be misleading.     

Comparison of active and passive surveillance for cerebrovascular disease: The Brain Attack Surveillance in Corpus Christi (BASIC) Project

To provide a scientific rationale for choosing an optimal stroke surveillance method, the authors compared active surveillance with passive surveillance. The methods involved ascertaining cerebrovascular events that occurred in Nueces County, Texas, during calendar year 2000. Active methods utilized screening of hospital and emergency department logs and routine visiting of hospital wards and out-of-hospital sources. Passive means relied on International Classification of Diseases, Ninth Revision (ICD-9), discharge codes for case ascertainment. Cases were validated by fellowship-trained stroke neurologists on the basis of published criteria. The results showed that, of the 6,236 events identified through both active and passive surveillance, 802 were validated to be cerebrovascular events. When passive surveillance alone was used, 209 (26.1%) cases were missed, including 73 (9.1%) cases involving hospital admission and 136 (17.0%) out-of-hospital strokes. Through active surveillance alone, 57 (7.1%) cases were missed. The positive predictive value of active surveillance was 12.2%. Among the 2,099 patients admitted to a hospital, passive surveillance using ICD-9 codes missed 73 cases of cerebrovascular disease and mistakenly included 222 noncases. There were 57 admitted hospital cases missed by active surveillance, including 13 not recognized because of human error. This study provided a quantitative means of assessing the utility of active and passive surveillance for cerebrovascular disease. More uniform surveillance methods would allow comparisons across studies and communities.     

Childhood intelligence in relation to adult coronary heart disease and stroke risk: evidence from a Danish birth cohort study

While recent studies have reported an inverse relation between childhood intelligence test scores and all-cause mortality in later life, the link with disease-specific outcomes has been rarely examined. Furthermore, the potential confounding effect of birthweight and childhood social circumstances is unknown. We investigated the relation of childhood intelligence with coronary heart disease (CHD) and stroke risk in a cohort of 6910 men born in 1953 in the Copenhagen area of Denmark. Events were ascertained from 1978 to 2000 using a cause-of-death register and hospital discharge records. There were 150 CHD (19 fatal; 131 non-fatal) and 93 stroke (4 fatal; 89 non-fatal) events during follow-up into mid-life. Childhood intelligence was inversely related to CHD with the highest rate apparent in adults with low childhood test scores (HR(lowest vs. highest quartile), 2.70; 95% confidence interval: 1.60, 4.57; P(trend) = 0.0001). After adjustment for paternal social class and birthweight, this association was attenuated only marginally. There was little evidence of a IQ-stroke relationship. The cognitive characteristics captured by IQ testing in the present study, such as communication and problem solving ability, appear to be associated with risk of CHD. Health promotion specialists and clinical practitioners may wish to consider these skills in their interactions with the general public. Replication of these results using studies which hold data on intelligence and socio-economic position across the life course is required.     

Resource Utilization and Costs of Stroke Unit Care in Germany

OBJECTIVES: Stroke imposes a considerable economic burden on the individual and society. Recently, the concept of an integrated stroke unit has been established in several countries to improve the outcome of patients. This study evaluates the costs of acute care of the different cerebrovascular insults in a stroke unit. METHODS: The study population included 340 patients who were consecutively admitted to the Department of Neurology, Philipps University Marburg, with the diagnosis of stroke or transient ischemic attack (TIA) between January 1 and June 30, 2000. Clinical status and course were evaluated by using the Barthel index and the modified Rankin scale. Employing a "bottom-up" approach, we calculated the costs from the perspective of the hospital and the third-party payer using data from provider departments and other published sources. RESULTS: Inpatient costs were 3020 euros (3290 US dollars) for TIA, 3480 euros (3790 US dollars) for ischemic stroke (IS), and 5080 euros (5540 US dollars) for intracerebral hemorrhage (ICH) and differed significantly among these subgroups (P < .05). Patient subgroups ranked in the same order for average length of stay at 9.4 days for TIA, 10.2 days for IS, and 11.9 days for ICH (P > .05). Approximately 30% of the hospital costs are due to physician charges and care. Imaging amounted to 10% and lab investigations to 14% of total costs, independent of the diagnosis. Postacute treatment, including inpatient rehabilitation, cost 9880 euros per patient. Across all diagnostic groups, a mean clinical improvement was observed at time of discharge. CONCLUSIONS: Care of patients with cerebrovascular events in a stroke unit causes a high demand of resources and has a considerable impact on health-care expenditure. Therefore, investigations comparing the stroke unit concept with other strategies in stroke care are necessary to evaluate the stroke unit concept for a rational use of available resources in patients with cerebrovascular events.     

A survey of survivors of acute stroke discharged from hospital to private nursing homes in Nottingham

Increasing numbers of disabled elderly stroke survivors are being discharged from hospital to Private Nursing Homes. However, there is little data available on which specific guidelines for the care of stroke patients in these homes can be based. A survey was undertaken therefore, to review patients on their discharge from hospital to Private Nursing Homes, and to assess the severity of their disability and handicap before and after entering the home. Nearly all patients were severely disabled on discharge from hospital, and the Barthel Activities of Daily Living scores of the survivors showed no significant change after four months. High levels of emotional distress and loneliness were identified by the Nottingham Health Profile, with little change after four months of nursing home care. The National Health Service has a continuing responsibility for the welfare of such vulnerable elderly people. The findings of this survey indicate that the emphasis of their care should be on the management of severe physical disability, exploitation of opportunities for further rehabilitation, alleviation of emotional distress and loneliness and, where appropriate, the provision of humane terminal care.     

Acute myocardial infarction incidence and hospital mortality: routinely collected national data versus linkage of national registers

Background and Objective To compare levels of and trends in incidence and hospital mortality of first acute myocardial infarction (AMI) based on routinely collected hospital morbidity data and on linked registers. Cases taken from routine hospital data are a mix of patients with recurrent and first events, and double counting occurs when cases are admitted for an event several times during 1 year. By linkage of registers, recurrent events and double counts can be excluded. Study Design and Setting In 1995 and 2000, 28,733 and 25,864 admissions for AMI were registered in the Dutch national hospital discharge register. Linkage with the population register yielded 21,565 patients with a first AMI in 1995 and 20,414 in 2000. Results In 1995 and 2000, the incidence based on the hospital register was higher than based on the linked registers in men (22% and 23% higher) and women (18% and 20% higher). In both years, hospital mortality based on the hospital register and on linked registers was similar. The decline in incidence between 1995 and 2000 was comparable whether based on standard hospital register data or linked data (18% and 20% in men, 15% and 17% in women). Similarly, the decline in hospital mortality was comparable using either approach (11% and 9% in both men and women). Conclusion Although the incidence based on routine hospital data overestimates the actual incidence of first AMI based on linked registers, hospital mortality and trends in incidence and hospital mortality are not changed by excluding recurrent events and double counts. Since trends in incidence and hospital mortality of AMI are often based on national routinely collected data, it is reassuring that our results indicate that findings from such studies are indeed valid and not biased because of recurrent events and double counts. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Ischemic stroke hospital stay and discharge destination

PURPOSE: Stroke hospitalizations are among the most expensive, with a mean length of stay (LOS) higher than other hospitalizations. This retrospective study assesses factors influencing ischemic stroke LOS taking into consideration the discharge destination of patients. METHODS: Linked hospital separation records between July 1995 and December 1999 were extracted to determine the first admission for ischemic stroke in Western Australia. Multiple hospitalization records for the same patient were screened to obtain the total duration of hospitalization. Demographic characteristics, hospital type, and medical history of patients were also retrieved. In the presence of censoring and without prior assumption on the time-to-discharge distribution, the Cox's proportional hazards model was used to assess the factors affecting LOS. RESULTS: During the study period, 6469 patients with a first-ever admission for ischemic stroke were identified, with average LOS being 28 days (95% CI, 26-30 days). Hospital stays were significantly longer for females and patients directly admitted to hospitals maintaining a specialist stroke unit, whereas patients residing in rural areas had shorter stays. CONCLUSIONS: The impact of stroke severity and placement in nursing homes after discharge need to be understood to manage LOS and the cost of acute care. Accurate diagnosis upon initial presentation would benefit both the efficiency of hospitals and the outcomes of rural ischemic stroke patients.     

Monitoring the quality of maternity care: how well are labour and delivery events reported in population health data?

Administrative or population health data sets (PHDS), such as birth and hospital discharge data, are used increasingly to evaluate maternity care. Use of PHDS requires reliable identification of diagnoses and procedures. The aim of this study was to determine the accuracy and reliability of the reporting of diagnoses and procedures related to childbirth in both individual and linked, birth and ICD10-coded hospital discharge data. Data from a population-based validation study of 1200 women provided the 'gold standard' for labour and delivery events and were compared with the hospital discharge and birth databases. Reporting characteristics (sensitivity, specificity, positive and negative predictive values) were determined for: induction, augmentation and obstruction of labour, modes of delivery (including failed instrumental delivery), episiotomy, perineal tears and repairs, and manual removal of the placenta. Differences in reporting by mode of delivery were also examined.
Of the 1184 records available for review, 25% had labour induced, 25% had labour augmented and, of those who laboured, 17% had obstructed labour reported. Fourteen per cent had an elective/planned caesarean section (CS) including 2% that went into labour prior to the planned date, and 11% had an emergency, unplanned CS including 2% who had no labour. With the exception of augmentation and obstruction of labour, failed instrumental delivery and manual removal, there were high levels of accuracy for reporting of diagnoses and procedures during labour and delivery. There were no significant differences in reporting by mode of delivery. The findings suggest that PHDS-reported induction of labour, mode of delivery, and 3rd and 4th degree tears and repairs can be reliably used to evaluate maternity care. Consistency in reporting in birth and hospital discharge data from different countries and over time suggests the findings are likely to be generalisable to high-income countries.     

Measurement of adverse events using "incidence flagged" diagnosis codes

OBJECTIVE: To compare two methods for identifying adverse events using routinely recorded hospital abstract data in all public and private hospitals in Victoria, Australia. METHODS: Secondary analysis of data on all admissions in the period 1 July 2000-30 June 2001 (n = 1,645,992) to estimate the rates of adverse events using International Classification of Diseases 10th Revision Australian Modification codes alone and in combination with an "incidence" data flag indicating complicating diagnoses which arise after hospitalization; rates of incidence and pre-existing adverse events, and rates for same-day and multi-day admissions. RESULTS: In total, 8% of all admissions were recorded with an adverse event. Use of ICD codes alone identified only 59% of the events identified using the combined method, giving a prevalence rate of only 5%. Incident cases, that is, those occurring in the index admission, represented 68% of identified adverse events.The adverse events incidence rate for multi-day admissions was significantly higher at 12%, compared with the same day rate of 0.4%. CONCLUSION: An "incidence flag" is essential to identify those adverse events for which a hospital has unambiguous responsibility. Using such a flag, secondary analysis of administrative data can provide hospital quality assurance programmes with a comprehensive view of all adverse events (not just "sentinel" events) at a reasonable cost and with more timely results than more intensive methods can achieve. Although the method is likely to underestimate the true rate of adverse events (in particular, by not capturing adverse events which only manifest after discharge), in this study of Australian hospitals, rates of adverse events were found to be similar to those derived from studies using manual review of patient records.