Over two-thirds of survivors of stroke experience enduring physical, cognitive, or emotional disability after discharge from acute care [1]. With the majority of survivors being discharged from acute care to the community [2], patients and caregivers face many challenges throughout post-stroke recovery and rehabilitation. These include inadequate provision of information, unmet needs for equipment and support services, and poor mental health [2, 3, 4]. Consequently, overcoming barriers in the transition from hospital, and planning for ongoing management in the community is important to mitigate these challenges and the risk of adverse events post-discharge.

The provision of a comprehensive discharge care plan, that has been co-developed with the patient, after acute stroke or transient ischaemic attack (TIA) is recommended in the Australian clinical guidelines and standards [5]. However, nearly one third of patients in Australia do not receive a care plan at discharge [6, 7], compared to 96% of patients in the United Kingdom [8]. The poor adherence to discharge care planning guidelines in Australia is of particular concern, given that many Australian survivors of stroke report having unmet needs long-term after discharge [9, 10]. Moreover, many survivors are readmitted to the hospital within the first 12 months following stroke [11, 12], potentially as a result of inadequate management of risk factors [13] or suboptimal management of stroke related impairments and poor adherence to prevention medications post-discharge [14]. Implementation of a comprehensive discharge care plan has the potential to reduce these unmet needs and mitigate any adverse events in survivors of stroke [15].

An understanding of the factors influencing the receipt of discharge care plans in the acute stroke care setting is necessary to guide improvements to this aspect of recommended care. Prior research on factors associated with discharge care planning after acute stroke has been limited to the investigation of single or few factors [16, 17, 18, 19, 20, 21]. We aimed to comprehensively evaluate patient, clinical and system factors associated with receiving a discharge care plan after acute stroke/TIA in Australia.

Differences between patients who did and did not receive a discharge care plan were compared using $\chi$${}^2$ tests for categorical variables and Mann-Whitney U tests for nonparametric, continuous variables (normality of data determined using Shapiro-Wilk test).

Multilevel (hospital, patient) multivariable logistic regression models, built using a parsimonious approach, were used to determine the factors associated with receiving a discharge care plan. Variables that reached a significance level of $\le$0.1 in univariable analyses were included in the regression model. The only exceptions were year of stroke/TIA, age, sex, type of stroke, ability to walk on admission and CCI, which were included priori. Standard techniques were used to check for multicollinearity between independent variables, and a condition index of 25 was considered acceptable. A standard two-tailed alpha value of 0.05 was used and results were reported as odds ratios (ORs) with corresponding 95% confidence intervals (CIs). Data were analysed using Stata SE 16.0 (StataCorp, College Station, Texas, USA).

Due to ethical and legal restrictions, linked administrative data from this study cannot be shared. However, aggregated data outputs and coding that support the findings of this study are available from the corresponding author on reasonable request, following approval from the relevant data custodians. Final linked data were available for analysis in 2018, five years after initial applications for data linkage.

Of 15,482 AuSCR registrants admitted between 2009–2013 (median age 76 years, 46% female, 64% ischaemic stroke), 7812 (50.4%) were eligible for this study (median age 73 years, 45% female, 57% ischaemic stroke; Fig. 1). Forty-seven percent (N = 3675) of eligible patients received a discharge care plan.

Fig. 1.

Final cohort selection process. Boxes shaded in grey indicate excluded registrants. TIA, Transient ischaemic attack.

In univariable analyses, compared to patients who did not receive a care plan, those who did were more often younger, male, living in areas having socioeconomic advantage, or had a diagnosis of ischaemic stroke (Table 1). Similarly, patients who received a care plan at discharge were more often prescribed antihypertensive medications at hospital discharge, but were significantly less often transferred from another hospital, discharged on a weekend, or discharged to a residential aged care. Patients who did not receive a care plan were more often treated in a regional or large hospital than patients who did not receive a care plan. Length of hospital stay was greater among patients who received discharge planning (median 4 days), compared to those who did not (median 3 days), although this difference was not statistically significant. With the exception of dyslipidaemia, diabetes, and dementia, there was no significant difference in the prevalence of comorbidities between those who received discharge care plans and those who did not (Table 2).

In multivariable models, factors associated with a greater odds of receiving a discharge care plan included living in areas of greater socioeconomic position (OR 1.18, 95% CI 1.02–1.38), having a clinical diagnosis of ischaemic stroke (OR 1.18, 95% CI 1.05–1.33), being unable to walk on admission (i.e., more severe stroke, OR 1.15, 95% CI 1.01–1.31), and being discharged on antihypertensive medication (OR 3.07, 95% CI 2.69–3.50; Table 3). Similarly, the odds of receiving a discharge care plan increased over time (OR 1.39 per year, 95% CI 1.37–1.48). In contrast, factors associated with a reduced odds of receiving a care plan included being aged $\ge$85 years (vs85 years; OR 0.79, 95% CI 0.64–0.96), being treated in a large hospital (OR 0.30, 95% CI 0.10–0.92), and being discharged on a weekend (OR 0.56, 95% CI 0.46–0.67) or to residential aged care (OR 0.48, 95% CI 0.39–0.60). Of all the comorbidities investigated, only a history of angina was associated with the odds of receiving a discharge care plan (OR 0.75, 95% CI 0.64–0.88). Having a greater CCI was not associated with receiving a discharge care plan.

In this study we identified patient-, process- and system-level factors associated with the provision of discharge care plan after stroke. In particular, our main finding that the day of discharge (weekend), discharge destination (residential aged care facility), and size of hospital (large, metropolitan) reduced the likelihood of receiving recommended discharge care plans was of concern. We also found that less than half of patients received a discharge care plan following stroke, indicating variations in the standard of management of stroke. Given the association of such variations with adverse long-term outcomes, such as death, poor quality of life, and more unmet needs [3, 29, 30], addressing the identified factors warrants urgent attention.

Reasons for preferential provision of care plans to patients with ischaemic stroke are currently unclear, and may be due to physician concern about bleeding resulting from these patients being discharged on single or dual antiplatelet therapy [31, 32]. Those who were prescribed antihypertensive medications at discharge in our cohort also had greater odds of receiving a discharge care plan. This indicates that hospitals which engage in routine discharge care planning for their patients are also more likely to adhere to other evidence-based practices for stroke, such as the provision of preventive medicines at discharge.

Patients aged $\ge$85 years are less likely to receive a care plan after acute stroke. Although all patients with stroke should receive guideline-recommended care irrespective of their age, there is evidence from an earlier study to suggest that being older is associated with sub-optimal provision of evidence-based care after stroke [33]. Cognitive decline in very elderly patients may underpin the clinician reasoning for not providing appropriate prevention management in older patients with stroke [34]. It is also possible that older patients are more likely to be receiving ongoing care from their regular healthcare practitioners, and may not require a discharge care plan. Nonetheless, discharge care planning should be tailored to the individual needs and goals of each patient and is considered to have significant benefit, and minimal harm for all patients, irrespective of age [5].

Patients who are discharged on a weekend less often receive a care plan at the time of hospital discharge than those discharged during the week, as do those discharged to an aged care facility [19]. Discharge processes for patients with stroke may be particularly sensitive to resourcing deficits on weekends, as care planning requires interactions between a diverse range of healthcare professionals from the multidisciplinary team. For those transitioning to residential aged care, there are particular challenges for patients and their families [35]. Barriers include, difficulties in coordinating a suitable time to meet with the patient, their family, and care staff, as previously reported [18]. Consequently, a reduced availability of the patient’s family while organising the transition to aged care may be a possible explanation as to why discharge care planning was not received. However, as we did not collect data on pre-stroke living arrangements, we could not explore whether there were any differences in the receipt of care plans between patients being discharged to an aged care facility for the first time and those returning to residential care after their stroke. We are unable to explain why large hospitals are less likely to provide a care plan at discharge. Further research is required to understand differences in the provision of discharge care planning based on hospital size.

A strength of this study was the use of a comprehensive linked dataset that allowed the investigation of many variables which would not have been possible for a study involving a single data source. Despite this, not all relevant factors were captured in the dataset, such as in-hospital complications, more sensitive measures of stroke severity (e.g., National Institutes of Health Stroke Scale), measures of pre- and post-stroke disability, and other pre-stroke variables such as living arrangements. Even though hospitals submit information to the AuSCR based on defined criteria, there is still an overall lack of standardisation for what is considered a “discharge care plan” (i.e., some hospitals may require different levels of documentation before this variable is considered to be a “yes”). Therefore, our results should be interpreted with caution in the context of these discrepancies. We acknowledge the limitations of using historical administrative data from 2009 to 2013, as they may not reflect the most contemporaneous practices for discharge care planning for acute stroke. However, adherence to discharge care planning is still sub-optimal based on more recent AuSCR and audit data [6, 7]. Our study is also limited by lack of data on other important factors, such as marital status, thrombolysis, discharge on antiplatelet or anticoagulant agents, and the presence of aphasia or dysarthria. Also, our measure of stroke severity, i.e., inability to walk on admission, may not reflect severity symptoms after treatment.

Several opportunities for future research exist in this area. Understanding clinical interpretations and application of current recommendations for discharge care planning will help to determine the underlying causes of inequitable discharge care (e.g., misinterpretation of the guidelines, need for clinician education, resource deficits), so that these areas can be targeted in future quality improvement projects. Whilst barriers and enablers of effective discharge care have been examined in the past, only staff from “high performing” hospitals with outstanding adherence to indicators of discharge care were interviewed [18]. In order to gain a more complete understanding of how the current discharge care planning recommendations are utilised, a variety of acute care staff from hospitals with varied adherence to indicators of discharge care should be recruited for future qualitative studies.

We have identified important factors that should be considered to improve discharge care planning processes after acute hospital care for stroke. Further research is needed to identify the best practices for delivering discharge care planning for all patients with stroke in the acute care environment. The most important aspect for future directions in this area will be to gather input from relevant stakeholders, such as patients and carers, clinicians, policy makers, and researchers. In this way, we can obtain different perspectives in order to optimise discharge care planning and ensure all patients with stroke are afforded this important process of care.

AuSCR, Australian Stroke Clinical Registry; ARIA+, Accessibility and Remoteness Index of Australia; CCI, Charlson Comorbidity Index; CI, Confidence Interval; IRSAD, Index of Relative Socioeconomic Advantage and Disadvantage; ICD-10-AM, International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification; NHMRC, National Health and Medical Research Council; OR; Odds ratio; TIA, Transient ischaemic attack.

EP undertook data analysis and prepared the first draft of the manuscript. MTO and MFK were responsible for the conceptualization and supervision of data analysis. DAC, NEA and MFK were responsible for data acquisition. LLD assisted with data analysis. DAC, LLD, TP, NEA, VS, AGT and NAL reviewed and edited the manuscript for intellectual content. All authors reviewed and approved the final version of the manuscript.

Data are deidentified after linkage, and no individual patient consent has been obtained since the project is using the data for secondary purpose. Ethics approvals for the Stroke123 project were obtained from ethics committees at Monash University (CF13/1303 – 2013000641), the New South Wales Ministry of Health (HREC/14/CIPHS/66), the Western Australian Department of Health (#2015/33), and Metro South Health (HREC/13/QPAH/31). Approvals were also obtained from each data custodian to permit the access and linkage of health information in this project [36]. Specific approvals for the current research study were sought from the New South Wales Ministry of Health (2021UMB0606) and the Western Australian Department of Health.

We thank members of the Australian Stroke Clinical Registry (AuSCR) Steering Committee and staff from the George Institute for Global Health and the Florey Institute of Neuroscience and Mental Health who manage the AuSCR (Supplementary Material). We also thank the hospital clinicians (Supplementary Material) and patients who contribute data to the AuSCR. We acknowledge the staff of Departments of Health in Queensland, New South Wales, Victoria and Western Australia who undertook the data linkage for this project and each state data collection agency that provided access to these data.

The study was funded as part of the National Health and Medical Research Council (NHMRC) Stroke123 Partnership Grant (1034415), with partnership funding from Monash University, Queensland Health and the Stroke Foundation (Australia). The AuSCR, during the period of data used in this research, received funding from the Florey Institute of Neuroscience and Mental Health, the Stroke Foundation (Australia), consumer and industry donations. The following authors receive Research Fellowship support from the NHMRC: MFK (1109426), NEA (1072053), AGT (1042600), DAC (1063761 co-funded Heart Foundation, 1154273), and NAL (1112158). LLD is supported by a Research Training Program scholarship from the Australian Government.

DAC reports educational grants from Boehringer Ingelhiem, Ipsen, Amgen, and Medtronic paid to her institution; and is the Data Custodian for AuSCR. AGT is a board member of the Stroke Foundation and prior member of the AuSCR Steering Committee. DAC and NAL are members of the AuSCR Steering Committee. MFK is a member of the AuSCR Management Committee. NEA is a member of the AuSCR Research Task Group. All other authors report no potential conflicts of interest with respect to the research, authorship and/or publication of this article.