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Stroke Severity is Predominant Predictor of Discharge Destination for Patients

CHICAGO Increasing stroke severity, as measured by the National Institutes of Health Stroke Scale, increases the likelihood that stroke patients who are treated with a clot-dissolving drug will be discharged to rehabilitation or nursing homes, rather than to their own homes, according to an article in the July issue of The Archives of Neurology, one of the JAMA/Archives journals.

A stroke is the sudden death of some brain cells due to a lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. According to information in the article, early determination of discharge destination after acute stroke may promote earlier rehabilitation and reduce costs by shortening the duration of hospitalization. The National Institutes of Health Stroke Scale (NIHSS) is a widely used quantitative measure of stroke-related neurological deficit that includes items to assess level of consciousness, gaze, visual fields, facial palsy, motor strength, ataxia (wobbliness), sensation, language, dysarthria (slurred speech), and extinction or inattention.

Daniel J. Schlegel, M.D., of the University of Pennsylvania Medical Center, Philadelphia, and colleagues conducted a study to determine whether the NIHSS score predicts disposition in stroke patients treated with thrombolysis (administration of medication to dissolve a clot). The study included 546 patients from three countries with acute ischemic stroke, who were treated with recombinant tissue plasminogen activator (rt-PA), a powerful "clot-buster" that is infused through the vein. Medical records were reviewed for demographic information, vascular risk factors, location of stroke, initial NIHSS score, acute hospital disposition, and complications of symptomatic or asymptomatic intracerebral hemorrhage (ICH; bleeding within the brain tissue).

Of the 546 patients included in the study, 44 percent were discharged to home, 42 percent to rehabilitation, and 14 percent to a nursing facility.

This study demonstrates that stroke severity, as measured by the NIHSS, is the predominant predictor of discharge destination after initial hospitalization for patients with acute ischemic stroke treated with intravenous rt-PA, the authors report.

Analysis showed that increasing NIHSS score was a robust and independent predictor of discharge to rehabilitation or nursing facilities, roughly doubling for each five-point increment.

The authors also found that symptomatic ICH was a devastating complication. Patients who developed symptomatic ICH were never discharged to home, they write. But asymptomatic ICH had no significant independent effect on disposition.

This multinational community and academic center-based study reinforces the usefulness of the NIHSS score as a predictor of disposition after stroke, the authors write. The NIHSS score can predict discharge disposition when thrombolysis is used, although possibly with less precision than in patients not given this treatment.

The authors suggest that future studies should search for other variables rapidly available at admission like the NIHSS score, that could improve prediction of disposition after acute care.

In addition, simulations or decision analyses could be performed to assess whether cost savings may be realized by using the NIHSS score to initiate early planning for disposition immediately on admission, they conclude.

(Arch Neurol. 2004;61:1061-1064. Available post-embargo at www.archneurol.com)

Editors Note: This study was supported by grants from the National Institutes of Health, Bethesda, Md.; the Canadian Institutes of Health Research, Ottawa, Ontario; and the Alberta Heritage Foundation for Medical Research, Edmonton.

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