In-hospital outcomes and 30-day readmission rates among ischemic and hemorrhagic stroke patients with delirium

ObjectiveDelirium is associated with poor outcomes among critically ill patients. However, it is not well characterized among patients with ischemic or hemorrhagic stroke (IS and HS). We provide the population-level frequency of in-hospital delirium and assess its association with in-hospital outcomes and with 30-day readmission among IS and HS patients.MethodsWe analyzed Nationwide in-hospital and readmission data for years 2010–2015 and identified stroke patients using ICD-9 codes. Delirium was identified using validated algorithms. Outcomes were in-hospital mortality, length of stay, unfavorable discharge disposition, and 30-day readmission. We used survey design logistic regression methods to provide national estimates of proportions and 95% confidence intervals (CI) for delirium, and odds ratios (OR) for association between delirium and poor outcomes.ResultsWe identified 3,107,437 stroke discharges of whom 7.45% were coded to have delirium. This proportion significantly increased between 2010 (6.3%) and 2015 (8.7%) (aOR, 95% CI: 1.04, 1.03–1.05). Delirium proportion was higher among HS patients (ICH: 10.0%, SAH: 9.8%) as compared to IS patients (7.0%). Delirious stroke patients had higher in-hospital mortality (12.3% vs. 7.8%), longer in-hospital stay (11.6 days vs. 7.3 days) and a significantly greater adjusted risk of 30-day-readmission (16.7%) as compared to those without delirium (12.2%) (aRR, 95% CI: 1.13, 1.11–1.15). Upon readmission, patients with delirium at initial admission continued to have a longer length of stay (7.7 days vs. 6.6 days) and a higher in-hospital mortality (9.3% vs. 6.4%).ConclusionDelirium identified through claims data in stroke patients is independently associated with poor in-hospital outcomes both at index admission and readmission. Identification and management of delirium among stroke patients provides an opportunity to improve outcomes.谵妄（Delirium）与重症患者的不良预后密切相关，但在缺血性卒中（ischemic stroke, IS）与出血性卒中（hemorrhagic stroke, HS）患者中，其临床特征尚未得到充分阐明。本研究旨在明确缺血性与出血性卒中患者院内谵妄的人群水平发生率，并评估其与院内预后以及30天再入院的相关性。 方法：本研究分析了2010至2015年全国住院与再入院数据库数据，通过ICD-9编码（ICD-9）识别卒中患者，采用经验证的诊断算法识别谵妄病例。研究结局包括院内死亡率、住院时长、不良出院转归以及30天再入院率。本研究采用调查设计logistic回归方法，计算谵妄发生率的全国估计值及其95%置信区间（CI），并分析谵妄与不良预后之间关联的优势比（OR）。 结果：本研究共纳入3,107,437例卒中出院病例，其中7.45%被诊断为谵妄。该比例在2010年（6.3%）至2015年（8.7%）间显著上升（校正优势比，95% CI：1.04，1.03–1.05）。出血性卒中患者的谵妄发生率高于缺血性卒中患者：其中脑出血（ICH）患者为10.0%，蛛网膜下腔出血（SAH）患者为9.8%，缺血性卒中患者为7.0%。与无谵妄的卒中患者相比，合并谵妄的卒中患者院内死亡率更高（12.3% vs. 7.8%），住院时长更长（11.6天 vs. 7.3天），且30天再入院的校正后风险显著升高（16.7% vs. 12.2%；校正相对风险，95% CI：1.13，1.11–1.15）。再入院患者中，首次入院时合并谵妄者的住院时长仍更长（7.7天 vs. 6.6天），院内死亡率也更高（9.3% vs. 6.4%）。 结论：本研究通过医保申报数据识别的卒中患者谵妄，与首次入院及再入院阶段的不良院内预后独立相关。对卒中患者的谵妄进行识别与管理，有望改善其临床预后。