Predictive value of discharge destination for 90-day outcomes among ischemic stroke patients eligible for endovascular treatment: Post-hoc analysis of DEFUSE 3

doi:10.1016/j.jstrokecerebrovasdis.2020.104902

Journal of Stroke and Cerebrovascular Diseases

Volume 29, Issue 8, August 2020, 104902

https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104902 Get rights and content

Abstract

Background

The endovascular treatment (ET) for acute ischemic stroke (AIS) is increasing among eligible patients. To help address care quality, administrative data sets are utilized but do not usually include formal outcome scales. We explore the predictive ability of discharge destination from acute hospitalizations for long-term disability among AIS patients eligible for ET within a clinical trial.

Methods

We analyzed publicly available data from the DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) trial. We evaluated patients who survived beyond the time of discharge from their acute hospitalizations. We calculated positive and negative predictive values and accompanying likelihood ratios for patients discharged to home, inpatient rehabilitation facility (IRF), or subacute nursing facility (SNF) for unfavorable outcome as defined by modified Rankin Scale (mRS) scores ≥3 at 90-days.

Results

Our final analysis included 127 patients (median age 67 [23–89] years, 51.2% men). There were 23.6% patients discharged home, 53.5% to IRF, and 22.8% to SNF. Approximately 61% of patients had 90-day post-stroke mRS scores ≥3. Patients discharged to SNF had the highest positive predictive value (93.1%) and positive likelihood ratio (8.77 [CI 95% 2.18–35.25]) for unfavorable outcome. Discharge to home had the highest negative likelihood ratio (2.09 [CI 95% 1.54–2.83]) for unfavorable outcome.

Conclusions

Among AIS patients eligible for ET within the DEFUSE 3 trial, discharge destination can provide high predictive value of 90-day functional outcomes. A discharge to SNF is highly predictive of long-term unfavorable outcomes.

Section snippets

Background

The endovascular treatment (ET) of ischemic stroke is now standard of care among eligible patients.¹ This evolution in acute ischemic stroke (AIS) care was driven primarily by positive findings from the ESCAPE (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT Recanalization Times), EXTEND-IA (Extending the Time for Thrombolysis in Emergent Neurological Deficits-Intra-Arterial), MR CLEAN (Multicenter Randomized Clinical Trial of

Methods

We analyzed publicly available data from the DEFUSE 3. The DEFUSE 3 trial (principal investigator Gregory W. Albers, NCT02586415) data and analyses presented in this manuscript are based on fully deidentified research files downloaded from the Archived Clinical Research website of the National Institute of Neurologic Disorders and Stroke (https://www.ninds.nih.gov/Current-Research/Research-Funded-NINDS/Clinical-Research/Archived-Clinical-Research-Datasets). The DEFUSE 3 trial was an open-label,

Results

Of the 182 patients randomized into DEFUSE 3, 127 were included in our analysis (median age 67 [23–89] years, 51.2% men). Among the 55 patients excluded from analysis, 34 died prior to discharge, three were lost to follow up and had no recorded 90-day mRS, 12 were discharged to an acute care facility, and six had no recorded discharge destination. Our final analysis included 23.6% patients discharged home, 53.5% to IRF, and 22.8% to SNF (Table 1). The median age for patients discharged to SNF

Discussion

Our analysis of survivors in the DEFUSE 3 trial reveals that discharge destination can be predictive of unfavorable outcomes at 90-days post-stroke. Although other AIS stroke trials have considered additional thresholds for unfavorable outcome within mRS,¹⁶^,¹⁷ we chose to focus on mRS scores ≥3 to be consistent with endovascular stroke trials for large vessel occlusions that consistently designate mRS scores ≤2 as favorable outcomes. The highest positive predictive value and positive likelihood

Author contributions

Each author listed should receive authorship credit based on substantial contribution to this article, revision of this article, and final approval of this article for submission to this journal.

Declaration of Competing Interest

None.

Funding

This research received no specific grant from any funding agency in the public, commercial, or non-for-profit sectors.

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Predictive value of discharge destination for 90-day outcomes among ischemic stroke patients eligible for endovascular treatment: Post-hoc analysis of DEFUSE 3

Abstract

Background

Methods

Results

Conclusions

Section snippets

Background

Methods

Results

Discussion

Author contributions

Declaration of Competing Interest

Funding

Lancet

Lancet

Clin Neurol Neurosurg

Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

Stroke

Randomized assessment of rapid endovascular treatment of ischemic stroke

N Engl J Med

Endovascular therapy for ischemic stroke with perfusion-imaging selection

N Engl J Med

A randomized trial of intraarterial treatment for acute ischemic stroke

N Engl J Med

Thrombectomy within 8 hours after symptom onset in ischemic stroke

N Engl J Med

Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke

N Engl J Med

Stroke

Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct

N Engl J Med