Adherence to recommendations and clinical outcomes of patients hospitalized for stroke: the role of the admission ward-a real-life investigation from Italy.
OBJECTIVE
To determine whether out-of-hospital healthcare and adverse outcomes are better in stroke patients admitted to a neurology ward compared with those admitted to general wards.


METHODS
Beneficiaries of the National Health Service from the Italian Lombardy Region who were discharged alive after hospital admission during the year 2009 for ischemic stroke (9776 patients) or intracerebral or subarachnoid hemorrhage (1102 patients) entered into the cohort and were followed until 2012. Exposure of interest was the ward type where inpatients were admitted (neuro vs. general wards). Outcomes were out-of-hospital healthcare (i.e., drug prescriptions, diagnostic procedures, and laboratory clinical evaluations) and adverse clinical outcomes (i.e., all-cause death and hospital readmission). Exposure-outcome associations were investigated. High-dimensional propensity score methodology was used for taking into account confounders. Mediation analysis was used to verify whether the association between ward type and clinical outcomes is mediated by out-of-hospital adherence to healthcare.


RESULTS
Better adherence to out-of-hospital healthcare received from patients discharged from neuro, rather than general, wards was observed being the proportions of adherent patients 42.4% and 39.5%, respectively. Compared with general wards, discharge from neuro was associated with reduced 3-year emergency admissions (from 50.1 to 47.5% among ischemic stroke patients) and reduced 3-year mortality (from 37.5 to 27.0% among hemorrhagic stroke patients). From 10 to 15% of outcome risk, reductions were mediated by better adherence to out-of-hospital healthcare.


CONCLUSIONS
For patients with acute ischemic and hemorrhagic stroke, admission to neuro vs. general wards is associated with better out-of-hospital healthcare and long-term adverse outcomes.
['Rea|Federico|F|http://orcid.org/0000-0001-7988-5101', 'Micieli|Giuseppe|G|', 'Musicco|Massimo|M|', 'Cavallini|Anna|A|', 'Santucci|Claudia|C|', 'Merlino|Luca|L|', 'Ieva|Francesca|F|', 'Ferrarese|Carlo|C|', 'Corrao|Giovanni|G|']
D000293:Adolescent D000328:Adult D000368:Aged D000369:Aged, 80 and over D002545:Brain Ischemia D002543:Cerebral Hemorrhage D015331:Cohort Studies D005260:Female D006801:Humans D007558:Italy D008297:Male D008875:Middle Aged D009462:Neurology D010343:Patient Admission D010349:Patient Compliance D017410:Practice Guidelines as Topic D057216:Propensity Score D013038:Specialization D020521:Stroke D016896:Treatment Outcome D055815:Young Adult
Neurology wards Ischemic stroke Intracerebral or subarachnoid hemorrhage Mortality Healthcare utilization database Population-based cohort study