Discharge To Skilled Nursing Facility May Explain The Association Between Neighborhood Disadvantage And Mortality After Stroke: The Cardiovascular Health Study

Background: Older adults who reside in disadvantaged communities have higher mortality after stroke. We examined whether hospital discharge disposition contributed to neighborhood differences in post-stroke mortality. Methods: We used data from the Cardiovascular Health Study, a population-based, longitudinal study of adults ≥65 years. The outcome was death after stroke. Neighborhood socioeconomic status (NSES) was a composite of 6 census variables. Post stroke discharge status, assessed using linked Center for Medicare and Medicaid Services (CMS) data, was classified into no hospitalization, discharge home, or discharge to a skilled nursing facility (SNF)/other subacute care. Multilevel Cox proportional hazard models adjusted for age, sex, race, and stroke type were constructed to examine the association of post-stroke discharge status to mortality at 1 year. Results: Among the 592 participants (93% matched to CMS data) with a stroke during the mean 11.5 year follow up, mortality at 1-year post stroke was higher among those discharged to SNF/other care than those discharged home (HR=3.85, 95% CI 2.49-5.93). Participants with no hospitalization did not differ in mortality from those discharged home (HR = 1.08, 0.59-1.99). There was higher mortality in the most disadvantaged neighborhoods among those discharged to SNF/other care, but no differences for those who were discharged home or never hospitalized (Figure). Conclusions: The association between lower neighborhood socioeconomic disadvantage and higher post-stroke mortality may be due to characteristics of the SNFs/other facilities where residents of lower SES communities receive care after stroke.