Patients with non-medical drivers of health needs had a 12.4% 30-day readmission rate compared to 5.2% overall at the stroke center from 2021 to 2023.
Does the presence of non-medical drivers of health (NMDOH) needs or missed follow-up appointments increase readmission rates in stroke patients?
Unmet social needs and missed follow-up appointments are associated with higher 30-day readmission rates in stroke patients, highlighting the need for targeted interventions.
Introduction: Stroke is a leading cause of morbidity and mortality in the United States, with evidence demonstrating variations in care and outcomes across different sociodemographic groups, particularly those with unmet non-medical drivers of health (NMDOH) needs. Identifying and addressing these disparities is essential to advancing equitable care and improving patient outcomes. The Institute for Public Health (IPH) assisted a Comprehensive Stroke Center (CSC) at a large academic medical center in San Antonio, Texas in identifying disparities in outcomes for stroke patients, aiming to shape targeted interventions that address these inequities. Methods: The IPH studied patients who were admitted to the CSC for stroke between January 1, 2021 and December 31, 2023. The IPH used 30-day all-cause readmission, inpatient mortality and complications during hospitalization and compared the following demographics: race/ethnicity, age, language, sex, ZIP code, the Center for Disease Control’s social vulnerability index, whether the patient had a NMDOH need at the time of admission, and whether the patient completed a scheduled post-discharge follow-up visit. Results: The largest disparities were in all-cause 30-day readmission rates. Between 2021 and 2023 1,506 patients were admitted for stroke and 79 (5.2%) had a readmission. Patients with at least one NMDOH need had a readmission rate of 12.4%. Half (50%) of patients who were scheduled at the CSC’s outpatient stroke clinic for a follow-up visit missed or canceled their appointment. These patients had a readmission rate of 7.7%, while those that completed their appointment had a readmission rate of 4.5%. Conclusion: Readmission rates were higher for patients with social needs and for patients who did not attend the follow-up appointment. To address these disparities, the CSC is developing an action plan that assists patients in meeting these social needs and completing essential follow-up care. By addressing these issues, the CSC aims to reduce disparities and improve outcomes for all stroke patients.
Ridge et al. (2026) studied this question. Patients with non-medical drivers of health needs had a 12.4% 30-day readmission rate compared to 5.2% overall at the stroke center from 2021 to 2023.