Janina Wilmskoetter

Hospital Readmissions of Stroke Patients with Percutaneous Endoscopic Gastrostomy Feeding Tubes.

OBJECTIVES A critical mission of acute care hospitals is to reduce hospital readmissions to improve patient care and avoid monetary penalties. We speculated that stroke patients with enteral tube feeding are high-risk patients and sought to evaluate their hospital readmissions. METHODS We analyzed archival hospital billing data from stroke patients discharged from acute care hospitals in Florida in 2012 for 30- and 60-day readmission rates, 30-day readmission rates by discharge destination, most frequent primary readmission diagnoses, and predictors of 30-day readmissions. We conducted univariate and multivariable logistic regression analyses. RESULTS We analyzed 26,774 discharge records. Within 30 days after discharge, 21.06% (N = 299) of stroke patients with percutaneous endoscopic gastrostomy (PEG) tube placement were rehospitalized. Of those readmissions, 11.71% (N = 35) were preventable. Among stroke patients with a PEG tube placement, 53.80% were discharged to skilled nursing facilities and 27.88% were rehospitalized within 30 days. Septicemia was the most frequent primary readmission diagnosis. Comorbidities, stroke type, length of hospital stay, and discharge destinations were predictive for 30-day readmissions (area under the receiver operating characteristic curve was .81). CONCLUSIONS Stroke patients with a PEG tube placement during their index hospital stay are twice as likely to be readmitted within 30 days compared to stroke patients without PEG tube placements. The primary readmission diagnosis for some patients was directly linked to PEG tube complications. We have identified risk factors that can be used to focus resources for readmission prevention.

Practice Patterns of Percutaneous Endoscopic Gastrostomy Tube Placement in Acute Stroke: Are the Guidelines Achievable?

OBJECTIVES Our objectives were to evaluate trends in percutaneous endoscopic gastrostomy (PEG) tube placement rate and timing in acute stroke patients. We hypothesized that noncompliance with clinical practice guidelines for timing of tube placement and an increase in placement occurred because of a decrease in length of hospital stay. METHODS We conducted a retrospective observational study of archival hospital billing data from the Florida state inpatient healthcare cost and utilization project database from 2001 to 2012 for patients with a primary diagnosis of stroke. Outcome measures were timing of PEG tube placements by year (2006-2012), rate of placements by year (2001-2012), and length of hospital stay. Univariate analyses and simple and multivariable logistic regression analyses were conducted. RESULTS The timing of gastrostomy tube placement remained stable with a median of 7 days post admission from 2006 through 2012. The proportion of tubes that were placed at or after 14 days and thereby met the guideline recommendations varied from 14.09% in 2006 to 13.41% in 2012. The rate of tube placement in stroke patients during the acute hospital stay decreased significantly by 25% from 6.94% in 2001 to 5.22% in 2012 (P < .0001). The length of hospital stay for all stroke patients decreased over the study period (P < .0001). CONCLUSIONS The vast majority of PEG tube placements happen earlier than clinical practice guidelines recommend. Over the study period, the rate of tubes placed in stroke patients decreased during the acute hospital stay despite an overall reduced length of stay.

Factors Associated With Gastrostomy Tube Removal in Patients With Dysphagia After Stroke: A Review of the Literature.

Gastrostomy feeding tubes are commonly placed in patients with dysphagia after stroke. The subsequent removal of the tube is a primary goal during rehabilitation. The purpose of our review was to identify predictors and factors associated with gastrostomy tube removal in patients with dysphagia after stroke. We conducted a literature review following the PRISMA statement and included the search databases PubMed, Scopus, Web of Science, and CINAHL. Articles were included in the final analysis per predefined inclusion and exclusion criteria. Our search retrieved a total of 853 results consisting of 416 articles (after eliminating duplicates). Six articles met our final eligibility criteria. The following factors were identified in at least 1 article as being significantly associated with gastrostomy tube removal: reduced age, decreased number of comorbidities, prolonged inpatient rehabilitation stay, absence of bilateral stroke, nonhemorrhagic stroke, reduced dysphagia severity, absence of aspiration, absence of premature bolus loss, and timely initiation of pharyngeal swallow. Aspiration was the only factor that was investigated by 2 studies-both using multiple regression and both showing stable results, with absence of aspiration increasing the chances for tube removal. In conclusion, little is known about factors associated with gastrostomy tube removal in patients with dysphagia after stroke. Most of the identified factors are associated with stroke or disease severity; however, the role of the individual factors remains unclear. The strongest predictor appears to be absence of aspiration on modified barium swallow studies emphasizing the importance of instrumental swallow studies in this patient population.Gastrostomy feeding tubes are commonly placed in patients with dysphagia after stroke. The subsequent removal of the tube is a primary goal during rehabilitation. The purpose of our review was to identify predictors and factors associated with gastrostomy tube removal in patients with dysphagia after stroke. We conducted a literature review following the PRISMA statement and included the search databases PubMed, Scopus, Web of Science, and CINAHL. Articles were included in the final analysis per predefined inclusion and exclusion criteria. Our search retrieved a total of 853 results consisting of 416 articles (after eliminating duplicates). Six articles met our final eligibility criteria. The following factors were identified in at least 1 article as being significantly associated with gastrostomy tube removal: reduced age, decreased number of comorbidities, prolonged inpatient rehabilitation stay, absence of bilateral stroke, nonhemorrhagic stroke, reduced dysphagia severity, absence of aspiration, absence of premature bolus loss, and timely initiation of pharyngeal swallow. Aspiration was the only factor that was investigated by 2 studies—both using multiple regression and both showing stable results, with absence of aspiration increasing the chances for tube removal. In conclusion, little is known about factors associated with gastrostomy tube removal in patients with dysphagia after stroke. Most of the identified factors are associated with stroke or disease severity; however, the role of the individual factors remains unclear. The strongest predictor appears to be absence of aspiration on modified barium swallow studies emphasizing the importance of instrumental swallow studies in this patient population.

Changes in Swallowing After Anterior Cervical Discectomy and Fusion With Instrumentation: A Presurgical Versus Postsurgical Videofluoroscopic Comparison

Purpose The purpose of this study was to explore the impact of anterior cervical discectomy and fusion (ACDF) with anterior instrumentation on swallowing function and physiology as measured on videofluoroscopic swallowing studies. Method We retrospectively analyzed both functional measures (penetration-aspiration, residue) and physiological/anatomical measures (hyoid excursion, posterior pharyngeal wall thickness) in a series of 17 patients (8 men, 9 women, mean age 54 years). These measures were extracted from calibrated 5-ml boluses of thin radio-opaque liquids on both pre-ACDF and post-ACDF videofluoroscopies, thus controlling for individual variation and protocol variation. Results After ACDF surgery, we found significant within-subject worsening of Penetration-Aspiration Scale (Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996) scores, vallecular (but not piriform sinus) residue, superior (but not anterior) hyoid excursion, and posterior pharyngeal wall thickness. Results are discussed in the context of previous literature. Conclusions ACDF surgery can affect both physiological/anatomical and functional measures of swallowing. Future research should expand to other biomechanical and temporal variables, as well as greater bolus volumes and a wider array of viscosities and textures.

Effective dose per unit Kerma-Area Product conversion factors in adults undergoing Modified Barium Swallow Studies

This study presents an investigation of adult effective dose (E) per unit Kerma-Area Product (KAP) in Modified Barium Swallow Study (MBSS) examinations. PC program for X-ray Monte Carlo (version 2.0.1) was used to calculate patient organ doses during MBSS examinations, which used combined to generate effective dose. Normalized patient doses were obtained by dividing the effective dose (mSv) by the incident KAP (Gy·cm2). Five standard projections were studied and the importance of X-ray beam size and in patient size (body mass index) were investigated. Lateral projections had an average E/KAP conversion factor of 0.19 ± 0.04 mSv/Gy·cm2. The average E/KAP was highest for upper gastrointestinal (GI) anterior-posterior projections (0.27 ± 0.04 mSv/Gy·cm2) and lowest for upper GI posterior-anterior projections (0.09 ± 0.03 mSv/Gy·cm2). E/KAP always increased with increasing filtration and/or X-ray tube voltage. Reducing the X-ray beam cross-sectional area increased the E/KAP conversion factors. Small patients have the E/KAP conversion factors that are twice those of a standard adult. Conversion factors for effective dose of adult patients undergoing MBSS examinations must account for X-ray beam projection, beam quality (kV and filtration), image size and patient size.

Construct validity of the Eating Assessment Tool (EAT-10)

Abstract Purpose: We aimed to evaluate the construct validity of the Eating Assessment Tool (EAT-10) by determining its dimensionality, rating scale integrity, item-person match, precision and relationship with the degree of airway invasion and functional oral intake. Methods: We conducted a retrospective analysis of patients’ EAT-10 scores. We used the Rasch rating scale model. We investigated correlations between the EAT-10 and scores on the Penetration-Aspiration Scale (PAS) and Functional Oral Intake Scale (FOIS). Results: The median score of the EAT-10 from 127 patients was 16 of 40 (range 0–40). Confirmatory factor analysis supported unidimensionality. The 5-point rating scale categories met published criteria. Two items misfit the Rasch model and two other items displayed differential item functioning. Rasch person reliability was 0.79. Our patient cohort was divided into three person-strata. Correlations between the EAT-10 and the PAS and FOIS were weak to moderate in strength (respectively: r = 0.26, p = 0.0036; r = −0.27, p = 0.0027). Conclusions: Our analyses identified deficits in the construct validity of the EAT-10 suggestive of a need to improve the EAT-10 to support its frequent use in clinical practice and research. Implications for Rehabilitation Swallowing disorders are associated with severe complications, such as pneumonia and malnutrition, and impose both social and psychological burdens on patients. The Eating Assessment Tool is a self-report instrument developed to estimate initial dysphagia severity and monitor change in patient-reported dysphagia symptoms as a response to treatment. This study shows that the Eating Assessment Tool has deficits in its construct validity and a need to improve the instrument to support its frequent use in clinical practice and research.

Differences in swallow physiology in patients with left and right hemispheric strokes

BACKGROUND We sought to determine the impact of lesion lateralization and lesion volume on swallow impairment on group-level by comparing patients with left and right hemisphere strokes and on patient-level by analyzing patients individually. METHODS We performed a retrospective, observational, cross-sectional study of 46 patients with unilateral (22 left, 24 right), acute, first-ever, ischemic strokes who received a diffusion weighted MRI (DW-MRI) and modified barium swallow study (MBSS) during their acute hospital stay. We determined lesion side on the DW-MRI and measured swallow physiology using the Modified Barium Swallow Impairment Profile (MBSImP™©), Penetration-Aspiration Scale (PAS), swallow timing, distance, area, and speed measures. We performed Pearsons Chi-Square and Wilcoxon Rank-Sum tests to compare patients with left and right hemisphere strokes, and Pearson or Spearman correlation, simple logistic regression, linear, and logistic multivariable regression modeling to assess the relationship between variables. RESULTS At the group-level, there were no differences in MBSImP oral swallow impairment scores between patients with left and right hemisphere stroke. In adjusted analyses, patients with right hemisphere strokes showed significantly worse MBSImP pharyngeal total scores (p = 0.02), worse MBSImP component specific scores for laryngeal vestibular closure (Bonferroni adjusted alpha p ≤ 0.0029), and worse PAS scores (p = 0.03). Patients with right hemisphere strokes showed worse timing, distance, area, and speed measures. Lesion volume was significantly associated with MBSImP pharyngeal residue (p = 0.03) and pharyngeal total scores (p = 0.04). At the patient-level, 24% of patients (4 left, 7 right) showed opposite patterns of MBSImP oral and pharyngeal swallow impairment than seen at group-level. CONCLUSION Our study showed differences in swallow physiology between patients with right and left unilateral strokes with patients with right hemisphere strokes showing worse pharyngeal impairment. Lesion lateralization seems to be a valuable marker for the severity of swallowing impairment at the group-level but less informative at the patient-level.

Fibroblast growth factor23 is associated with axonal integrity and neural network architecture in the human frontal lobes

Elevated levels of FGF23 in individuals with chronic kidney disease (CKD) are associated with adverse health outcomes, such as increased mortality, large vessel disease, and reduced white matter volume, cardiovascular and cerebrovascular events. Apart from the well-known link between cardiovascular (CV) risk factors, especially diabetes and hypertension, and cerebrovascular damage, elevated FGF23 is also postulated to be associated with cerebrovascular damage independently of CKD. Elevated FGF23 predisposes to vascular calcification and is associated with vascular stiffness and endothelial dysfunction in the general population with normal renal function. These factors may lead to microangiopathic changes in the brain, cumulative ischemia, and eventually to the loss of white matter fibers. The relationship between FGF23 and brain integrity in individuals without CKD has hitherto not been investigated. In this study, we aimed to determine the association between FGF23, and white matter integrity in a cohort of 50 participants with varying degrees of CV risk burden, using high resolution structural human brain connectomes constructed from MRI diffusion images. We observed that increased FGF23 was associated with axonal loss in the frontal lobe, leading to a fragmentation of white matter network organization. This study provides the first description of the relationship between elevated levels of FGF23, white matter integrity, and brain health. We suggest a synergistic interaction of CV risk factors and FGF23 as a potentially novel determinant of brain health.

Impact of Gastrostomy Feeding Tube Placement on the 1-Year Trajectory of Care in Patients After Stroke

BACKGROUND Percutaneous endoscopic gastrostomy (PEG) feeding tubes are commonly placed in acute stroke patients with a need for enteral nutrition. However, PEG tubes are associated with medical complications and a decrease in quality of life. We compared the 1-year care trajectory of stroke patients with and without PEG tube placement to enhance knowledge about the long-term impact of PEG tube placement. METHODS We conducted a retrospective analysis of commercially insured stroke patients included in the Truven Health MarketScan Research Databases of 2011. We analyzed their index hospital stay and conducted 1-month, 3-months, 6-months, and 1-year follow-ups. We compared admissions to inpatient rehabilitation facilities, acute hospitals, skilled nursing facilities, outpatient hospital visits, and home visits for stroke patients with and without PEG tube placement using unadjusted and adjusted modelling. RESULTS Of the 8911 included stroke patients, 148 patients (1.7%) had a PEG tube placed during their index hospital stay. After controlling for age, gender, stroke severity, comorbidities, and stroke type, PEG tube placement was an independent predictor for admissions to inpatient rehabilitation facilities and skilled nursing facilities. Furthermore, PEG tube placement was an independent predictor for all-cause, unplanned hospital readmissions in a multivariable logistic model (area under the receiver operating characteristic curve was .84). CONCLUSION Stroke patients who receive a PEG tube can expect a significantly different care trajectory after being discharged from the acute hospital. Our findings can aide in predicting recovery and planning resources and identifying gaps and points for improvement in stroke care for patients with PEG tube placement.

Stroke Administrative Severity Index: using administrative data for 30-day poststroke outcomes prediction

Aim: Current stroke severity scales cannot be used for archival data. We develop and validate a measure of stroke severity at hospital discharge (Stroke Administrative Severity Index [SASI]) for use in billing data. Methods: We used the NIH Stroke Scale (NIHSS) as the theoretical framework and identified 285 relevant International Classification of Diseases, 9th Revision diagnosis and procedure codes, grouping them into 23 indicator variables using cluster analysis. A 60% sample of stroke patients in Medicare data were used for modeling risk of 30-day postdischarge mortality or discharge to hospice, with validation performed on the remaining 40% and on data with NIHSS scores. Results: Model fit was good (p > 0.05) and concordance was strong (C-statistic = 0.76–0.83). The SASI predicted NIHSS at discharge (C = 0.83). Conclusion: The SASI model and score provide important tools to control for stroke severity at time of hospital discharge. It can be used as a risk-adjustment variable in administrative data analyses to measure postdischarge outcomes.