Department of Neurology Wake Forest Baptist Health Winston-Salem NC.
Department of Epidemiology College of Public Health University of Kentucky Lexington KY.
J Am Heart Assoc. 2021 Dec 7;10(23):e023394. doi: 10.1161/JAHA.121.023394. Epub 2021 Nov 3.
Background Mortality and hospital readmission rates may reflect the quality of acute and postacute stroke care. Our aim was to investigate if, compared with usual care (UC), the COMPASS-TC (Comprehensive Post-Acute Stroke Services Transitional Care) intervention (INV) resulted in lower all-cause and stroke-specific readmissions and mortality among patients with minor stroke and transient ischemic attack discharged from 40 diverse North Carolina hospitals from 2016 to 2018. Methods and Results Using Medicare fee-for-service claims linked with COMPASS cluster-randomized trial data, we performed intention-to-treat analyses for 30-day, 90-day, and 1-year unplanned all-cause and stroke-specific readmissions and all-cause mortality between INV and UC groups, with 90-day unplanned all-cause readmissions as the primary outcome. Effect estimates were determined via mixed logistic or Cox proportional hazards regression models adjusted for age, sex, race, stroke severity, stroke diagnosis, and documented history of stroke. The final analysis cohort included 1069 INV and 1193 UC patients (median age 74 years, 80% White, 52% women, 40% with transient ischemic attack) with median length of hospital stay of 2 days. The risk of unplanned all-cause readmission was similar between INV versus UC at 30 (9.9% versus 8.7%) and 90 days (19.9% versus 18.9%), respectively. No significant differences between randomization groups were seen in 1-year all-cause readmissions, stroke-specific readmissions, or mortality. Conclusions In this pragmatic trial of patients with complex minor stroke/transient ischemic attack, there was no difference in the risk of readmission or mortality with COMPASS-TC relative to UC. Our study could not conclusively determine the reason for the lack of effectiveness of the INV. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02588664.
背景 死亡率和住院再入院率可能反映了急性和亚急性脑卒中护理的质量。我们旨在调查与常规护理（UC）相比，COMPASS-TC（综合急性后脑卒中服务过渡护理）干预（INV）是否会降低 2016 年至 2018 年期间从北卡罗来纳州 40 家不同医院出院的轻度卒中和短暂性脑缺血发作患者的全因和卒中特定再入院率和死亡率。
方法和结果 我们使用医疗保险按服务收费索赔与 COMPASS 集群随机试验数据进行意向治疗分析，用于 INV 和 UC 组之间的 30 天、90 天和 1 年非计划性全因和卒中特定再入院率以及全因死亡率，90 天非计划性全因再入院率为主要结局。通过混合逻辑或 Cox 比例风险回归模型确定效应估计值，模型调整了年龄、性别、种族、卒中严重程度、卒中诊断和记录的卒中史。最终分析队列包括 1069 名 INV 和 1193 名 UC 患者（中位年龄 74 岁，80%为白人，52%为女性，40%为短暂性脑缺血发作），中位住院时间为 2 天。INV 与 UC 相比，30 天（9.9%与 8.7%）和 90 天（19.9%与 18.9%）的非计划性全因再入院风险相似。随机分组组间 1 年全因再入院率、卒中特定再入院率或死亡率无显著差异。
结论 在这项针对复杂轻度卒中和短暂性脑缺血发作患者的实用试验中，与 UC 相比，COMPASS-TC 并未降低再入院或死亡率的风险。我们的研究无法确定 INV 无效的原因。
