Hospital Variation in Home-Time After Acute Ischemic Stroke: Insights From the PROSPER Study (Patient-Centered Research Into Outcomes Stroke Patients Prefer and Effectiveness Research).
Stroke survivors identify home-time as a high-priority outcome; there are limited data on factors influencing home-time and home-time variability among discharging hospitals.



We ascertained home-time (ie, time alive out of a hospital, inpatient rehabilitation facility, or skilled nursing facility) at 90 days and 1-year post discharge by linking data from Get With The Guidelines-Stroke Registry patients (≥65 years) to Medicare claims. Using generalized linear mixed models, we estimated adjusted mean home-time for each hospital. Using linear regression, we examined associations between hospital characteristics and risk-adjusted home-time.



We linked 156 887 patients with ischemic stroke at 989 hospitals to Medicare claims (2007-2011). Hospital mean home-time varied with an overall unadjusted median of 59.5 days over the first 90 days and 270.2 days over the first year. Hospital factors associated with more home-time over 90 days included higher annual stroke admission volume (number of ischemic stroke admissions per year); South, West, or Midwest geographic regions (versus Northeast); and rural location; 1-year patterns were similar. Lowest home-time quartile patients (versus highest) were more likely to be older, black, women, and have more comorbidities and severe strokes. Home-time variation decreased after risk adjustment (interquartile range, 57.4-61.4 days over 90 days; 266.3-274.2 days over 1 year). In adjusted analyses, increasing annual stroke volume and rural location were associated with significantly more home-time.



In older ischemic stroke survivors, home-time post discharge varies by hospital annual stroke volume, severity of case-mix, and region. In adjusted analyses, annual ischemic stroke admission volume and rural location were associated with more home-time post stroke.
From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); and University of Texas Southwestern, Dallas (D.O.). emily.obrien@duke.edu.
Emily C
EC
O'Brien
From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); and University of Texas Southwestern, Dallas (D.O.).
Ying
Y
Xian
From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); and University of Texas Southwestern, Dallas (D.O.).
Haolin
H
Xu
From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); and University of Texas Southwestern, Dallas (D.O.).
Jingjing
J
Wu
From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); and University of Texas Southwestern, Dallas (D.O.).
Jeffrey L
JL
Saver
From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); and University of Texas Southwestern, Dallas (D.O.).
Eric E
EE
Smith
From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); and University of Texas Southwestern, Dallas (D.O.).
Lee H
LH
Schwamm
From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); and University of Texas Southwestern, Dallas (D.O.).
Eric D
ED
Peterson
From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); and University of Texas Southwestern, Dallas (D.O.).
Mathew J
MJ
Reeves
From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); and University of Texas Southwestern, Dallas (D.O.).
Deepak L
DL
Bhatt
From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); and University of Texas Southwestern, Dallas (D.O.).
Lesley
L
Maisch
From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); and University of Texas Southwestern, Dallas (D.O.).
Deidre
D
Hannah
From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); and University of Texas Southwestern, Dallas (D.O.).
Brianna
B
Lindholm
From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); and University of Texas Southwestern, Dallas (D.O.).
DaiWai
D
Olson
From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); and University of Texas Southwestern, Dallas (D.O.).
Janet
J
Prvu Bettger
From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); and University of Texas Southwestern, Dallas (D.O.).
Michael
M
Pencina
From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); and University of Texas Southwestern, Dallas (D.O.).
Adrian F
AF
Hernandez
From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (E.C.O., Y.X., H.X., J.W., E.D.P., J.P.B., M.P., A.F.H.); University of California at Los Angeles (J.L.S., G.C.F.); Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.); Harvard-Massachusetts General Hospital, Cambridge (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); and University of Texas Southwestern, Dallas (D.O.).
Gregg C
GC
Fonarow
D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000628:therapy*; D005260:Female; D006761:Hospitals; D006801:Humans; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge; D063868:Patient Outcome Assessment; D057240:Patient Preference; D011787:Quality of Health Care; D012042:Registries; D020521:Stroke / Q000628:therapy*
health services research; healthcare quality assessment; patient centered outcomes research; risk adjustment; stroke, acute