Regional variation in health care utilization and outcomes in ischemic stroke

Little information is available about regional variation in health care utilization and the effect of utilization on outcomes after ischemic stroke. The goal of this study was to investigate the effect of regional variation in outpatient health care use on mortality after ischemic stroke. We performed a retrospective cohort study of 55,094 veterans hospitalized for ischemic stroke at any US Veterans Affairs Medical Center between October 1, 1990, and September 30, 1997. We extracted administrative data on patient demographics, coexisting medical conditions, site of hospitalization, inpatient and outpatient health care utilization, and all-cause mortality during hospitalization and after stroke discharge. Predictors of long-term mortality in patients surviving at least 60 days post-stroke were modeled using Cox regression. Patients in the Northeast part of the country had higher comorbidity scores, a longer median length of stay, and higher in-hospital mortality than patients in other regions. However, Northeast and West patients had lower all-cause mortality after stroke than those in the Midwest or South. Patients in the Northeast (28%) and West (32%) were also more likely than those in the South (21%) or Midwest (22%) to have a neurology and/or general medicine visit within 60 days of discharge (P < .001). Adjusted mortality (HR, 95% CI) was lower in the Northeast (0.84, 0.80-0.88) and West (0.93, 95% CI 0.89, 0.97), and in patients with neurology (0.72, 0.67-0.77) or general medicine (0.85, 0.81-0.89) follow-up within 60 days of stroke discharge. We concluded that regional variation exists in patient outcomes and patterns of care following stroke. Mortality is lower in regions where more patients have early outpatient care after stroke. Prospective studies evaluating the cause and impact of these variations are needed to identify optimal stroke care practices.