title: Utilization of long-term care after decompressive hemicraniectomy for severe stroke among older patients.
abstract: BACKGROUND
  While clinical trial data support decompressive hemicraniectomy (DHC) as improving survival among patients with severe ischemic stroke, quality of life outcomes among older persons remain controversial.
  
  
  OBJECTIVE
  To aid decision-making and understand practice variation, we measured long-term outcomes and patterns of regional variation for a nationwide cohort of ischemic stroke patients after DHC.
  
  
  METHODS
  Medicare fee-for-service ischemic stroke cases over age 65 during the year 2008 were used to create a cohort followed for 2 years (2009-2010) after stroke and DHC procedure. Rates of mortality, acute hospital readmission, and long-term care (LTC) utilization were calculated. Multiple logistic regression was used to identify individual predictors of institutional LTC. Regional variation in DHC was calculated through aggregation and merging with the state-level data.
  
  
  RESULTS
  Among 397,503 acute ischemic stroke patients, 130 (0.03 %) underwent DHC. Mean age was 72 years, and 75 % were between the ages of 65 and 74. Mortality was highest (38 %) within the first 30 days. At 2 years, 59 % of the original cohort had died. The 30-day rate of acute hospital readmission was 25 %. Among survivors, 75 % returned home 1 year after index stroke admission. States with higher per capita health expenditures were associated with wider variation in utilization of DHC.
  
  
  CONCLUSIONS
  There is a high rate of mortality among older stroke patients undergoing DHC. Although most survivors of DHC are not permanently institutionalized, there is wide variation in utilization of DHC across the USA.
authors: Division of Neurocritical Care, Brown University Alpert Medical School, Rhode Island Hospital, 593 Eddy St, APC-712.6, Providence, RI, 02903, USA. corey_fehnel@brown.edu.|Department of Health Services, Policy and Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI, USA. corey_fehnel@brown.edu.
authors: Corey R
authors: http://orcid.org/0000-0003-1726-5809
authors: CR
authors: Fehnel
authors: Department of Health Services, Policy and Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI, USA.
authors: Yoojin
authors: Y
authors: Lee
authors: Division of Neurocritical Care, Brown University Alpert Medical School, Rhode Island Hospital, 593 Eddy St, APC-712.6, Providence, RI, 02903, USA.
authors: Linda C
authors: LC
authors: Wendell
authors: Division of Neurocritical Care, Brown University Alpert Medical School, Rhode Island Hospital, 593 Eddy St, APC-712.6, Providence, RI, 02903, USA.
authors: Bradford B
authors: BB
authors: Thompson
authors: Division of Neurocritical Care, Brown University Alpert Medical School, Rhode Island Hospital, 593 Eddy St, APC-712.6, Providence, RI, 02903, USA.
authors: N
authors: N
authors: Stevenson Potter
authors: Department of Health Services, Policy and Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI, USA.
authors: Vincent
authors: V
authors: Mor
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D056424:Decompressive Craniectomy / Q000401:mortality*; D005260:Female; D006801:Humans; D016015:Logistic Models; D008134:Long-Term Care / Q000706:statistics & numerical data*; D008297:Male; D010359:Patient Readmission / Q000706:statistics & numerical data; D011788:Quality of Life; D020521:Stroke / Q000401:mortality / Q000601:surgery*; D016896:Treatment Outcome
keywords: Health services research; Healthcare policy; Hemicraniectomy; Ischemic stroke; Outcome