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Stroke in Older Adults Living in Care Homes: Results From a National Data Linkage Study in Wales

  • Stephanie L. Harrison
    Correspondence
    Address correspondence to Stephanie Harrison, PhD, Liverpool Center for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, William Henry Duncan Building, Liverpool, L7 8TX, UK.
    Affiliations
    Liverpool Center for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom

    Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
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  • Gregory Y.H. Lip
    Affiliations
    Liverpool Center for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom

    Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom

    Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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  • Ashley Akbari
    Affiliations
    Population Data Science, Health Data Research UK, Swansea University Medical School, Swansea University, Swansea, Wales

    Population Data Science, Administrative Data Research Wales, Swansea University Medical School, Swansea University, Swansea, Wales
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  • Fatemeh Torabi
    Affiliations
    Population Data Science, Health Data Research UK, Swansea University Medical School, Swansea University, Swansea, Wales
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  • Leona A. Ritchie
    Affiliations
    Liverpool Center for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom

    Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
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  • Asangaedem Akpan
    Affiliations
    Musculoskeletal and Aging Science, Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom

    Liverpool University Hospitals NHS FT, Liverpool, United Kingdom
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  • Julian Halcox
    Affiliations
    Population Data Science, Health Data Research UK, Swansea University Medical School, Swansea University, Swansea, Wales
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  • Sarah Rodgers
    Affiliations
    Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, United Kingdom
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  • Joe Hollinghurst
    Affiliations
    Population Data Science, Health Data Research UK, Swansea University Medical School, Swansea University, Swansea, Wales
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  • Daniel Harris
    Affiliations
    Population Data Science, Health Data Research UK, Swansea University Medical School, Swansea University, Swansea, Wales

    Swansea Bay University Health Board, Swansea, Wales
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  • Deirdre A. Lane
    Affiliations
    Liverpool Center for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom

    Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom

    Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Open AccessPublished:June 03, 2022DOI:https://doi.org/10.1016/j.jamda.2022.05.003

      Abstract

      Objectives

      To determine the proportion of older people moving to care homes with a recent stroke, incidence of stroke after moving to a care home, mortality following stroke, and secondary stroke prevention management in older care home residents.

      Design

      Retrospective cohort study using population-scale individual-level linked data sources between 2003 and 2018 in the Secure Anonymized Information Linkage (SAIL) Databank.

      Setting and Participants

      People aged ≥65 years residing in long-term care homes in Wales.

      Methods

      Competing risk models and logistic regression models were used to examine the association between prior stroke, incident stroke, and mortality following stroke.

      Results

      Of 86,602 individuals, 7.0% (n = 6055) experienced a stroke in the 12 months prior to care home entry. The incidence of stroke within 12 months after entry to a care home was 26.2 per 1000 person-years [95% confidence interval (CI) 25.0, 27.5]. Previous stroke was associated with higher risk of incident stroke after moving to a care home (subdistribution hazard ratio 1.83, 95% CI 1.57, 2.13) and 30-day mortality following stroke (odds ratio 2.18, 95% CI 1.59, 2.98). Severe frailty was not significantly associated with risk of stroke or 30-day mortality following stroke. Secondary stroke prevention included statins (51.0%), antiplatelets (61.2%), anticoagulants (52.4% of those with atrial fibrillation), and antihypertensives (92.1% of those with hypertension).

      Conclusions and Implications

      At the time of care home entry, individuals with history of stroke in the previous 12 months are at a higher risk of incident stroke and mortality following an incident stroke. These individuals are frequently not prescribed medications for secondary stroke prevention. Further evidence is needed to determine the optimal care pathways for older people living in long-term care homes with history of stroke.

      Keywords

      In the United Kingdom there are an estimated 421,000 older people (≥65 years of age) living in care homes.
      Laing and Buisson
      Care of older people UK market report.
      Older people living in care homes often have multiple long-term health conditions, polypharmacy, high levels of disability, and unmet needs, and may have less access to health care services compared with people living in their own homes.
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      Challenges of conducting research in long-term care facilities: A systematic review.
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      • et al.
      Health status of UK care home residents: A cohort study.
      • Jokanovic N.
      • Tan E.C.
      • Dooley M.J.
      • et al.
      Prevalence and factors associated with polypharmacy in long-term care facilities: A systematic review.
      The global age-standardized incidence of stroke declined by 8.1% between 1990 and 2016, and the age-standardized mortality with stroke declined by 36.2%.
      • Johnson C.O.
      • Nguyen M.
      • Roth G.A.
      • et al.
      Global, regional, and national burden of stroke, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016.
      Nevertheless, it is unclear if this trend has also been observed in older adults living in care homes, as these individuals are under-represented in epidemiologic studies and clinical trials.
      A report from the Sentinel Stroke National Audit Program (SSNAP) suggested approximately 7% of over 85,000 patients were discharged directly from hospital to care homes for the first-time following stroke in England, Wales, and Northern Ireland in 2017, but this figure had declined from 12% to 15% in previous years.
      Sentinel Stroke National Audit Program (SSNAP)
      Clinical audit April 2013—March 2018 Annual Public Report National results.
      Although the SSNAP can provide a national estimate of the proportion of people being discharged directly to a care home following a stroke, the proportion of people with a recent stroke upon care home entry, and incidence of stroke after moving to a care home remains unclear.
      People with history of stroke should receive optimal treatment for secondary stroke prevention, and guidelines state that persistence with these treatments for individuals with previous stroke is critical to long-term risk reduction. However, treatment decisions in older adults living in care homes are complex due to a high prevalence of comorbidities and polypharmacy.
      Provision of optimal care for people living in care homes is a recognized health policy challenge worldwide.
      • Prince M.J.
      • Wu F.
      • Guo Y.
      • et al.
      The burden of disease in older people and implications for health policy and practice.
      The use of linked routinely collected data are valuable to answer important research questions for this population.
      • Hanratty B.
      • Burton J.K.
      • Goodman C.
      • et al.
      Covid-19 and lack of linked datasets for care homes.
      The objective of this study was to use population-scale individual-level linked routinely collected data sources to determine the proportion of older people moving to care homes with a recent stroke, incidence of stroke after moving to a care home, and mortality following stroke in older care home residents. A secondary objective was to examine secondary stroke prevention management in older care home residents.

      Methods

      Data Sources

      The Secure Anonymized Information Linkage (SAIL) Databank is a privacy-protecting trusted research environment that holds population-scale individual-level linkable anonymized data sources regarding the health and service utilization for the population of Wales.
      • Lyons R.A.
      • Jones K.H.
      • John G.
      • et al.
      The SAIL databank: Linking multiple health and social care datasets.
      The SAIL Databank includes secondary care data for the entire population of Wales and primary care data for approximately ∼80% of the population.
      Care home identifiers in the SAIL Databank have been previously determined using records held by the Care Inspectorate Wales.
      • Hollinghurst J.
      • Akbari A.
      • Fry R.
      • et al.
      Study protocol for investigating the impact of community home modification services on hospital utilisation for fall injuries: A controlled longitudinal study using data linkage.
      Each care home was assigned a Residential Anonymous Linking Field,
      • Rodgers S.E.
      • Lyons R.A.
      • Dsilva R.
      • et al.
      Residential Anonymous Linking Fields (RALFs): A novel information infrastructure to study the interaction between the environment and individuals' health.
      which were linked to the anonymized address data for participants. Care homes with a classification of either care homes for older adults or care homes for older adults with nursing were included. The inclusion criteria for this study were (1) identified as moving to a care home between January 1, 2003 and December 31, 2018, (2) age ≥65 years at the date of care home entry, and (3) had a minimum of 12-months coverage at a participating general practitioner prior to the date of entry to a care home.

      Stroke Definition

      Stroke (including ischemic stroke, hemorrhagic stroke, or unspecified stroke) in the 12-month period prior to entering a care home was determined from hospital admissions recorded in Patient Episode Database for Wales (PEDW) and general practitioner data sourced from the Welsh Longitudinal General Practice (WLGP). PEDW uses International Classification of Diseases, 10th Revision (ICD-10) codes and WLGP uses Read codes (version 2). Read codes have been used in the National Health Service (NHS) in the UK since 1985, and this extensive list of codes was based on ICD-10 codes and provides a standard vocabulary for healthcare professionals to record patient diagnoses and procedures. All ICD-10 and Read codes used in this study are provided in Supplementary Tables 1 and 2.

      Covariates

      Age, sex, Welsh Index of Multiple Deprivation (grouped in to quintiles, with the lowest quintile representing the most deprived postcodes and the highest quintile representing the least deprived postcodes), smoking history, and health conditions including hypertension, diabetes mellitus, renal disease, pulmonary embolism, atrial fibrillation, peripheral vascular disease, myocardial infarction, and heart failure were included in statistical models as covariates. Frailty was determined using the electronic frailty index.
      • Hollinghurst J.
      • Akbari A.
      • Fry R.
      • et al.
      Study protocol for investigating the impact of community home modification services on hospital utilisation for fall injuries: A controlled longitudinal study using data linkage.
      The electronic frailty index is based on the internationally established cumulative deficit model, and assigns a frailty score to an individual calculated using 36 variables from primary care data including symptoms, signs, diseases, disabilities, and abnormal laboratory values, referred to as deficits.
      • Hollinghurst J.
      • Akbari A.
      • Fry R.
      • et al.
      Study protocol for investigating the impact of community home modification services on hospital utilisation for fall injuries: A controlled longitudinal study using data linkage.
      ,
      • Mitnitski A.B.
      • Mogilner A.J.
      • Rockwood K.
      Accumulation of deficits as a proxy measure of aging.
      ,
      • Clegg A.
      • Bates C.
      • Young J.
      • et al.
      Development and validation of an electronic frailty index using routine primary care electronic health record data.
      Further details are provided in the Supplementary Methods.

      Outcomes

      Incident stroke after entry to a care home was determined from PEDW or WLGP records, or if stroke was recorded as a cause of death. Date and cause of death were determined from the Annual District Death Extract (ADDE) data sourced from the Office for National Statistics (ONS) mortality register.

      Statistical Analyses

      The age and sex-standardized proportions of people entering care homes with stroke by year of entry to a care home (2003‒2018) were calculated using direct standardization based on a recording of ischemic, hemorrhagic, or unspecified stroke within the 12-month period before moving to a care home. Incidence of stroke in the 12-month period after moving to a care home adjusted for age and sex were calculated by year of entry to care home (2003‒2017 only to allow for 12-month follow-up). Poisson regression models adjusted for age and sex were used to determine the annual and absolute change in incidence of stroke over time.
      Fine-Gray competing risk models were used to estimate subdistribution hazard ratios (sHRs) for the association between stroke in the previous 12 months before care home entry and incident stroke in the 12 months following entry to a care home, with mortality as a competing risk. The only variable with missing data was the Welsh Index of Multiple Deprivation. Individuals with missing data for this variable were excluded from multivariate analyses as the number was <1% of the total number of participants.
      For individuals with history of stroke in the 12 months prior to care home entry, the following medicines, which can be prescribed for secondary stroke prevention management, were examined: antiplatelets, statins, oral anticoagulants, and antihypertensives. Antihypertensives included beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, thiazide and thiazide-like diuretics, alpha blockers, centrally acting antihypertensives, neprilysin inhibitors, and vasodilators. The proportion of individuals who received each type of medicine in the 6 months before care home entry was reported for any stroke and by type of most recent stroke before care home entry. The odds of receiving each type of medicine was examined by type of most recent stroke recorded (ischemic, hemorrhagic, or unspecified), and ischemic stroke was the reference group. Prescriptions of medicines were captured using Read codes from the WLGP. All analyses were completed using Stata v 15 (StataCorp).

      Ethical Approval

      Approval for the use of anonymized data in this study, provisioned within the SAIL Databank was granted by an independent Information Governance Review Panel under project 0912.

      Results

      Cohort Characteristics at the Time of Moving to a Care Home

      Between 2003 and 2018, 86,602 people aged ≥65 years became new residents in care homes in Wales and had at least 12 months of primary care data captured within the SAIL Databank prior to care home entry. The median [interquartile range (IQR)] age of the participants was 86.0 (80.8, 90.6) and 68.1% were female (Table 1). Of the total participants, 0.7% (n = 644) had missing data for the Welsh Index of Multiple Deprivation.
      Table 1Characteristics of Adults Age ≥65 Years on Admission to Care Homes Within the SAIL Databank by Prior Stroke Status
      All Participants (n = 86,602)Participants with Stroke in 12 Mo Prior to Care Home Entry (n = 6055)Participants with no S Stroke in 12 Mo Prior to Care Home Entry (n = 80,547)
      Age, median (IQR)86.0 (80.8, 90.6)84.4 (79.0, 88.9)86.1 (80.9, 90.7)
      Female58,941 (68.1%)3869 (63.9%)55,072 (68.4%)
      WIMD-2014 quintile
       1 most deprived14,695 (17.1%)1082 (18.0%)13,613 (17.0%)
       218,375 (21.4%)1204 (20.0%)17,171 (21.5%)
       320,340 (23.7%)1370 (22.8%)18,970 (23.7%)
       417,395 (20.2%)1314 (21.9%)16,081 (20.1%)
       5 least deprived15,123 (17.6%)1043 (17.3%)14,080 (17.6%)
      Frailty
       No frailty28,870 (33.3%)1938 (32.0%)26,932 (33.4%)
       Mild26,505 (30.6%)1915 (31.6%)24,590 (30.5%)
       Moderate21,433 (24.7%)1525 (25.2%)19,908 (24.7%)
       Severe9794 (11.3%)677 (11.2%)9117 (11.3%)
      Smoking history20,775 (24.0%)1609 (26.6%)19,166 (23.8%)
      Hypertension31,850 (36.8%)2653 (43.8%)29,197 (36.2%)
      Atrial fibrillation14,528 (16.8%)1559 (25.8%)12,969 (16.1%)
      Diabetes mellitus3631 (4.2%)223 (3.7%)3408 (4.2%)
      Heart failure9502 (11.0%)609 (10.1%)8893 (11.0%)
      Myocardial infarction4469 (5.2%)330 (5.5%)4139 (5.1%)
      Peripheral vascular disease3308 (3.8%)298 (4.9%)3010 (3.7%)
      Renal disease4158 (5.0%)252 (4.2%)3906 (4.9%)
      Pulmonary embolism1656 (1.9%)113 (1.9%)1543 (1.9%)
      WIMD, Welsh Index of multiple deprivation.
      Frailty determined with the electronic frailty index. All characteristics are n (%), unless otherwise stated.
      Trends in the proportion of people with stroke at time of entry to a care home.
      Of the individuals who moved to a care home in Wales between 2003 and 2018, 7.0% [95% confidence interval (CI) 6.8%, 7.2%, n = 6055] had a stroke in the 12 months prior to moving to a care home (4.8% (95% CI 4.6%, 4.9%, n = 4141) had an ischemic stroke, 1.1% (95% CI 1.0%, 1.2%, n = 959) had a hemorrhagic stroke and 1.4% (95% CI 1.3%, 1.5%, n = 1202) had a stroke of unspecified origin).
      There was no statistically significant change over time in the annual and absolute proportions of participants with a stroke in the 12 months prior to care home entry [age and sex-standardized estimate 6.2% (95% CI 5.5%, 6.9%) in 2003 vs 5.5% (95% CI 4.9%, 6.1%) in 2018; absolute change 2018 vs 2003 adjusted for age and sex: −0.6% (95% CI −1.6%, 0.4%), and annual change adjusted for age and sex: 0.03% (95% CI −0.1%, 0.1%)] (Figure 1).
      Figure thumbnail gr1
      Fig. 1Changes over time in the proportion of older people entering a care home with a stroke in the 12 months prior to moving to a care home (n = 86,602).

      Time Between Stroke and Care Home Entry

      The median (IQR) number of days between the date of stroke and date of care home entry was 109 days (68‒172). There was a statistically significant decline in the number of days between stroke and care home entry over time [median (IQR) 135 (75‒197) days in 2003 and 97 (70‒150) days in 2018; absolute change 2018 vs 2003 adjusted for age and sex −25.1 days (95% CI -38.2, −12.0) and annual change adjusted for age and sex −1.49 days (95% CI -1.95, −1.02) (Figure 2)]. Being in a higher quintile of the Welsh Index of Multiple Deprivation (less deprived) was associated with fewer days between date of stroke and date of care home entry [-2.42 days per increasing quintile (95% CI -3.98, −0.87) after adjusting for covariates].
      Figure thumbnail gr2
      Fig. 2Changes over time in the median number of days between a stroke and moving to a care home (n = 86,602).

      Trends in the Incidence of Stroke after Care Home Entry

      The incidence of stroke within 12 months after entry to a care home was 26.2 per 1000 person-years (95% CI 25.0, 27.5). The incidence of stroke was 24.6 per 1000 person-years (95% CI 23.4, 25.9) for people with no prior stroke in the 12 months before care home entry, and the incidence of recurrent stroke was 47.1 per 1000 person-years (95% CI 41.1, 54.0) for people with prior stroke.
      There was no statistically significant change over time in the annual and absolute incidence of stroke in the 12 months after care home entry [age and sex-adjusted incidence 26.4 per 1000 person-years (95% CI 21.5, 32.3) in 2003 vs 26.5 per 1000 person-years (95% CI 22.0, 32.0) in 2017; incidence rate ratio (IRR) 2017 vs 2003 adjusted for age and sex: 0.94 (95% CI 0.72, 1.24) and annual IRR adjusted for age and sex: 0.99 (95% CI 0.98, 1.00) (Figure 3)].
      Figure thumbnail gr3
      Fig. 3Changes over time in the incidence of stroke within 12 months of moving to a care home (n = 80,681).

      Associations Between Prior Stroke and Incident Stroke and Mortality

      Mortality within 12 months of entry to a care home was similar for individuals entering a care home with and without history of stroke in the previous 12 months before care home entry (36.0% vs 34.8%). Of the 1653 individuals who experienced an incident stroke within 12 months of entry to a care home, 30-day mortality after the stroke was 49.3% (95% CI 46.9%, 51.7%, n = 815). Stroke in the 12 months prior to care home entry was significantly associated with both a higher risk of incident stroke after care home entry (adjusted subdistribution hazard ratio 1.83 95% CI 1.57, 2.13), and 30-day mortality after incident stroke [65.2% (95% CI 58.4%, 71.7%, n = 137) vs 47.0% (95% CI 44.4%, 49.6%, n = 678), adjusted odds ratio (OR) 2.18 (95% CI 1.59, 2.98)].

      Frailty and Stroke Risk

      After adjusting for potential confounding factors, severe frailty was not significantly associated with a higher risk of incident stroke after care home entry or 30-day mortality after incident stroke (Supplementary Table 3).

      Secondary Stroke Prevention at Time of Entry to a Care Home

      At the time of entry to care home, 61.2% (n = 3707) of individuals with a stroke in the previous 12 months were prescribed antiplatelets, and 51.0% (n = 3087) were prescribed statins. Of those with a stroke in the previous 12 months, 25.8% had a diagnosis of atrial fibrillation (n = 1559) and 43.8% had a diagnosis of hypertension (n = 2653). Of individuals with prior stroke and hypertension, 92.1% (n = 2292) were prescribed antihypertensives. Of individuals with prior stroke and atrial fibrillation, 52.4% (n = 817) were prescribed oral anticoagulants, 46.1% (n = 718) were prescribed vitamin-K antagonists (VKA), 11.7% (n = 183) were prescribed non-VKA oral anticoagulants (NOACs), and 5.4% (n = 84) individuals had a record of both VKA and NOACs prescribed in the 6 months before care home entry. Over time, there was a marked increase in the use of oral anticoagulants in those with prior stroke and atrial fibrillation, from 35.0% (n = 14) in 2003 to 75.0% (n = 66) in 2018. Of all individuals with prior stroke 7.2% (n = 323) were receiving oral anticoagulants with no recorded diagnosis of atrial fibrillation.
      The proportions of people with prior stroke receiving medicines for secondary stroke prevention, by type of most recent stroke recorded before care home entry (ischemic, hemorrhagic, or unspecified), are shown in Table 2. Hemorrhagic stroke was associated with significantly lower odds of receiving antiplatelets and statins compared with ischemic stroke [adjusted ORs 0.44 (95% CI 0.37, 0.52) and 0.61 (95% CI 0.51, 0.72), respectively], but there was no significant association for receiving oral anticoagulants or antihypertensives. Unspecified stroke was associated with significantly lower odds of receiving statins [adjusted OR (95% CI 0.59) (0.50, 0.70)] and antihypertensives [adjusted OR 0.59 (95% CI: 0.39, 0.88)] compared with ischemic stroke.
      Table 2Proportions of Individuals With Prior Stroke Receiving Medicines for Secondary Stroke Prevention Management in the 6 Months Before Care Home Entry by Type of Stroke
      Any Prior Stroke (n = 6055)Ischemic Stroke (n = 4088)Hemorrhagic Stroke (n = 959)Unspecified Stroke (n = 1008)Odds of Receiving Medicines Hemorrhagic vs Ischemic Stroke

      Adjusted OR (95% CI)
      Odds of Receiving Medicines Unspecified vs Ischemic Stroke

      Adjusted OR (95% CI)
      Antiplatelet61.2 (3707)63.7 (2602)48.0 (460)64.0 (645)0.44 (0.37, 0.52)0.88 (0.74, 1.04)
      Statin51.0 (3087)54.1 (2210)43.5 (417)45.6 (460)0.61 (0.51, 0.72)0.59 (0.50, 0.70)
      Any prior stroke and hypertension (n = 2653)Ischemic stroke and hypertension (n = 1185)Hemorrhagic stroke and hypertension (n = 394)Unspecified stroke and hypertension (n = 444)
      Antihypertensive92.1 (2292)92.8 (1684)92.1 (363)90.5 (402)0.84 (0.54, 1.30)0.59 (0.39, 0.88)
      Any prior stroke and AF (n = 1559)Ischemic stroke and AF (n = 1156)Hemorrhagic stroke and AF (n = 195)Unspecified stroke and AF (n = 208)
      Oral anticoagulant52.4 (817)52.4 (606)58.0 (113)47.1 (98)1.19 (0.85, 1.67)0.78 (0.57, 1.07)
      AF, atrial fibrillation.
      Only including individuals who experienced a stroke within 12 months before care home entry. If multiple types of stroke recorded in this time period then the most recent type of stroke was used. All values are % (n), unless otherwise specified.
      Odds ratios adjusted for age, sex, Welsh Index of Multiple Deprivation (quintiles), frailty, smoking status, diabetes, hypertension, atrial fibrillation, renal disease, pulmonary embolism and prior cardiovascular disease (peripheral vascular disease, myocardial infarction or heart failure).

      Discussion

      This study provides several novel findings in a population where there is a relative paucity of outcome data available. Over time, there was no statistically significant change in the proportion of people moving to care homes with a recent stroke or in the incidence of stroke after care home entry. However, there was a decline in the median number of days from experiencing a stroke to moving to a care home. Individuals who moved to a care home with a stroke in the previous 12 months had a higher risk of incident stroke and mortality following an incident stroke. Treatments to reduce risk of secondary stroke were frequently not prescribed in this population.
      Previous evidence from data provided by the SSNAP has suggested there has been a decline nationally in the proportion of people moving directly to a care home following a hospitalization with stroke.
      Sentinel Stroke National Audit Program (SSNAP)
      Clinical audit April 2013—March 2018 Annual Public Report National results.
      In the current study, there was no significant decline observed in the proportion of people with stroke in the 12-month period prior to moving to a care home. In the current study, there was a significant reduction over time in the number of days between previous stroke and care home entry. This could have important implications for the level of care required by individuals entering a care home following a recent stroke; however, data were not available to determine the functional status of the participants, therefore, this could not be explored further. Furthermore, being in a higher quintile of the Welsh Index of Multiple Deprivation (less deprived) was associated with fewer days between stroke and moving to a care home. This may be due to differences in accessibility for care homes depending on socioeconomic status. Previous research using the SAIL Databank has also shown living in less deprived areas was associated with a faster rate of care home admission for people living with dementia.
      • Giebel C.
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      Socio-economic predictors of time to care home admission in people living with dementia in Wales: A routine data linkage study.
      In Wales, annually approximately 7000 people are hospitalized with stroke and 1900 people die from stroke.
      British Heart Foundation Cymru
      Wales Cardiovascular Disease Factsheet.
      People with history of stroke are at high-risk of recurrent stroke, with 1 in 4 people experiencing a recurrent stroke within 5 years.
      Stroke Association
      State of the Nation: Stroke Statistics.
      The results of this study show people with a prior stroke living in care homes are at higher risk not only for a stroke, but also of mortality following incident stroke. It is, therefore, important to ensure that secondary stroke risk reduction strategies are optimized for all individuals with prior stroke. Decision making regarding optimal stroke prevention pathways in older care home residents is complicated due to high levels of polypharmacy and multimorbidity within this population.
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      There has been increased interest in the potential to deprescribe medicines in the older population to reduce inappropriate polypharmacy and reduce the potential burden of medicines which may not be adding quality or length of life. For instance, in a randomized controlled trial, deprescribing statins in older adults with limited life expectancy and no recent active cardiovascular disease resulted in no significant difference in mortality and a potential improvement in quality of life.
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      Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: A randomized clinical trial.
      However, in a recent large observational study of older adults with polypharmacy, deprescribing statins was associated with an increased risk of fatal and non-fatal cardiovascular outcomes.
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      Discontinuation of statin therapy between 3 and 6 months after stroke has been associated with higher risk of recurrent stroke within 1 year,
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      • et al.
      Utilization of statins beyond the initial period after stroke and 1-year risk of recurrent stroke.
      but the evidence for the long-term use of statins for secondary stroke prevention in older people living in care homes who often have frailty, multimorbidity and polypharmacy is unclear.
      The results of this study suggest that many residents with a stroke in the previous 12 months before care home entry were not receiving secondary stroke prevention treatments. Overall, we did find higher rates of secondary stroke prevention prescribing compared with a previous study of the South London Stroke Register, which showed in 427 stroke survivors discharged to care homes, rates of secondary stroke prevention prescribing were lower at 1-year follow-up compared with individuals living in their own homes.
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      Survival and outcomes for stroke survivors living in care homes: A prospective cohort study.
      Consideration of the use of oral anticoagulants for people with prior stroke and atrial fibrillation is important to optimize risk reduction of future ischemic stroke.
      National Institute for Health and Care Excellence
      Treatment summary: Stroke.
      In this study, there was a substantial increase in the proportion of people with prior stroke and atrial fibrillation receiving oral anticoagulants, and the introduction of NOACs within the last 10 years will likely have contributed to the observed increase. In the current study, prescription of antiplatelets was significantly lower for people with prior hemorrhagic stroke compared with ischemic stroke. This may be expected as the National Institute for Health and Care Excellence (NICE) guidelines for stroke state that for long-term management following intracerebral hemorrhage, the use of aspirin and oral anticoagulants are not normally recommended, but specialist advice should be sought for individuals with atrial fibrillation and those at a high-risk of future ischemic stroke.
      National Institute for Health and Care Excellence
      Treatment summary: Stroke.
      In this study there was also an observed small proportion of participants with prior stroke receiving oral anticoagulants but with no recorded diagnosis of atrial fibrillation. This may be due to other indications for oral anticoagulants following stroke, such as cardiac source of embolism, cerebral venous thrombosis, or arterial dissection,
      National Institute for Health and Care Excellence
      Treatment summary: Stroke.
      but within the available data it was not possible to explore this further.
      Nonpharmacologic strategies to reduce risk of recurrent stroke may be challenging to promote to older adults living in care homes. Physical inactivity may be an important risk factor for primary and recurrent stroke but could not be explored in the current study.
      • Goldstein L.B.
      • Bushnell C.D.
      • Adams R.J.
      • et al.
      Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
      Physical rehabilitation interventions in older care home residents may have a small effect on reducing disability with few adverse events.
      • Crocker T.
      • Forster A.
      • Young J.
      • et al.
      Physical rehabilitation for older people in long-term care.
      A recent review of available evidence suggested improvements in diet quality is likely to reduce recurrent stroke risk.
      • English C.
      • MacDonald-Wicks L.
      • Patterson A.
      • et al.
      The role of diet in secondary stroke prevention.
      However, dietary modifications for older care home residents can be complex as inadequate food intake and malnutrition is common in older care home residents.
      • Gordon A.L.
      • Franklin M.
      • Bradshaw L.
      • et al.
      Health status of UK care home residents: A cohort study.
      ,
      • Bunn D.
      • Hooper L.
      • Welch A.
      Dehydration and malnutrition in residential care: recommendations for strategies for improving practice derived from a scoping review of existing policies and guidelines.
      Further research is needed to determine the impact of physical rehabilitation, dietary interventions, or multifaceted nonpharmacologic intervention strategies for older adults living in care homes to reduce risk of recurrent stroke. However, insufficient funding and staffing availability may also limit the ability of care home providers to support physical activity and dietary interventions for residents.
      Rehabilitation for people following a stroke should be patient-centered and include multidisciplinary assessment, identification of functional difficulties and their measurement, and treatment planning.
      National Institute for Health and Care Excellence
      Stroke rehabilitation in adults: Clinical guidelines.
      People with stroke who are transferred from hospital to care homes should be offered assessment and treatment from stroke rehabilitation and social care services to the same standards that they would receive in their own home.
      National Institute for Health and Care Excellence
      Stroke rehabilitation in adults: Clinical guidelines.
      A structured health and social care review should be offered to people with stroke living in care homes at 6 months and 12 months following the stroke, in addition to community stroke rehabilitation support to identify activities or adaptations to improve quality of life.
      Royal College of Physicians
      National clinical guideline for stroke.
      Indeed, a survey of 60 care homes in Ireland suggested almost three-quarters of residents with previous stroke had a high level of dependency, but stroke rehabilitation guidelines were lacking and there was little structured care specifically for stroke survivors.
      • Cowman S.
      • Royston M.
      • Hickey A.
      • et al.
      Stroke and Nursing Home care: A national survey of nursing homes.
      This study suggests that although there has been a decline in stroke prevalence in the general population, there has not been a decline in the proportion of older people entering care homes with a recent history of stroke, and 30-day mortality following stroke in older care home residents is high. For those at the highest-risk of stroke, the consideration of care priorities following a stroke in advance care planning is warranted. Further research should determine the level of funding, recognition, and resources required to ensure optimal care for these individuals.

      Strengths and Limitations

      This study uses a national-level databank with linked data from multiple sources including primary and secondary care data. There are several limitations to consider. The study uses routinely collected health data and, therefore, some variables of interest were not available such as data about the functional status of participants and stroke severity. Within the SAIL Databank records are linked using an individual's NHS number that is supplied in routine NHS data. The use of this as a unique identifier has previously been shown to have specificity values >99.8% and sensitivity values >94.6%, and error rates were <0.2%.
      • Lyons R.A.
      • Jones K.H.
      • John G.
      • et al.
      The SAIL databank: Linking multiple health and social care datasets.
      Previous studies have shown recording of ICD codes in electronic medical records may vary by factors such as age, number of comorbidities, severity of illness, length of hospitalization, and whether in-hospital death occurred
      • Chong W.F.
      • Ding Y.Y.
      • Heng B.H.
      A comparison of comorbidities obtained from hospital administrative data and medical charts in older patients with pneumonia.
      ; however, using multiple linked data sources, rather than relying on a single data source will have improved the accuracy of the dataset to identify the different health conditions of interest. Identification of care homes in the SAIL Databank was based on anonymized addresses of care homes from Care Inspectorate Wales, but the study may not capture all care home residents. However, the results are deemed to be generalizable to the wider population of Wales.

      Conclusions and Implications

      Older people moving to a care home with a recent stroke are at a higher risk of incident stroke and mortality with incident stroke. Medications to reduce risk of secondary stroke are often not prescribed in this population. Further evidence is needed to determine the optimal care pathways for older people living in care homes with history of stroke. A greater understanding of the epidemiology of stroke in older care home residents is useful to improve planning and provision of services.

      Supplementary Data

      Supplementary Table 1ICD-10 Codes to Identify Conditions in the PEDW
      ICD-10 CodeICD-10 Definition
      Hemorrhagic stroke
       I600Subarachnoid hemorrhage from carotid siphon and bifurcation
       I601Subarachnoid hemorrhage from middle cerebral artery
       I602Subarachnoid hemorrhage from anterior communicating artery
       I603Subarachnoid hemorrhage from posterior communicating artery
       I604Subarachnoid hemorrhage from basilar artery
       I605Subarachnoid hemorrhage from vertebral artery
       I606Subarachnoid hemorrhage from other intracranial arteries
       I607Subarachnoid hemorrhage from intracranial artery unspecified
       I608Other subarachnoid hemorrhage
       I609Subarachnoid hemorrhage unspecified
       I610Intracerebral hemorrhage in hemisphere subcortical
       I611Intracerebral hemorrhage in hemisphere cortical
       I612Intracerebral hemorrhage in hemisphere unspecified
       I613Intracerebral hemorrhage in brain stem
       I614Intracerebral hemorrhage in cerebellum
       I615Intracerebral hemorrhage intraventricular
       I616Intracerebral hemorrhage multiple localized
       I618Other intracerebral hemorrhage
       I619Intracerebral hemorrhage unspecified
       I620Subdural hemorrhage (acute) (nontraumatic)
       I621Nontraumatic extradural hemorrhage, Nontraumatic epidural hemorrhage
       I629Intracranial hemorrhage (nontraumatic)unspecified
      Ischemic stroke
       I630Cerebral infarct due to thrombosis of precerebral arteries
       I631Cerebral infarction due to embolism of precerebral arteries
       I632Cerebral infarction due to unspecified occlusion or stenosis of precerebral arteries
       I633Cerebral infarction due to thrombosis of cerebral arteries
       I634Cerebral infarction due to embolism of cerebral arteries
       I635Cerebral infarction due to unspecified occlusion or stenosis of cerebral arteries
       I636Cerebral infarction due to cerebral venous thrombosis, nonpyogenic
       I638Other cerebral infarction
       I639Cerebral infarction unspecified
       G460Middle cerebral artery syndrome
       G461Anterior cerebral artery syndrome
       G462Posterior cerebral artery syndrome
       G463Brain stem stroke syndrome
       G464Cerebellar stroke syndrome
       G465Pure motor lacunar stroke syndrome
       G466Pure sensory lacunar syndrome
       G467Other lacunar syndromes
       G468Other vascular syndromes of brain in cerebrovascular diseases
       G450Vertebro-basilar artery syndrome
       G451Carotid artery syndrome (hemispheric)
       G452Multiple and bilateral precerebral artery syndromes
      Unspecified stroke
       I64XStroke not specified as hemorrhage or infarction
       I678Other specified cerebrovascular diseases
       I679Cerebrovascular disease, unspecified
       I688Other cerebrovascular disorders in diseases classified elsewhere
      Hypertension
       I10Essential [primary] hypertension
       I11Hypertensive heart disease
       I12Hypertensive renal disease
       I13Hypertensive heart and renal disease
       I15Secondary hypertension
      Atrial fibrillation
       I48Atrial fibrillation and flutter
      Diabetes mellitus
       E10Insulin-dependent diabetes mellitus
       E11Non-insulin-dependent diabetes mellitus
       E12Malnutrition-related diabetes mellitus
       E13Other specified diabetes mellitus
       E14Unspecified diabetes mellitus
      Heart failure
       I50Congestive heart failure
       I110Left ventricular failure
       I130Hypertensive heart disease with congestive heart failure
       I132Hypertensive heart and renal disease with congestive heart failure and renal failure
       I420Dilated cardiomyopathy
      Myocardial infarction
       I210Acute transmural myocardial infarction of anterior wall
       I211Acute transmural myocardial infarction of inferior wall
       I212Acute transmural myocardial infarction of other sites
       I213Acute transmural myocardial infarction of unspecified site
       I214Acute subendocardial myocardial infarction
       I219Acute myocardial infarction unspecified
       I220Subsequent myocardial infarction of anterior wall
       I221Subsequent myocardial infarction of inferior wall
       I228Subsequent myocardial infarction of other sites
       I229Subsequent myocardial infarction of unspecified site
       I230Hemopericardium as current complication following acute myocardial infarction
       I231Atrial septal defect as current complication following acute myocardial infarction
       I232Ventricular septal defect as current complication following acute myocardial infarction
       I233Rupture of cardiac wall without hemopericardium as current complication following acute myocardial infarction
       I234Rupture of chordae tendineae as current complication following acute myocardial infarction
       I235Rupture of papillary muscle as current complication following acute myocardial infarction
       I236Thrombosis of atrium, auricular appendage, and ventricle as current complications following acute myocardial infarction
       I238Other current complications following acute myocardial infarction
       I252Old myocardial infarction
       I241Dressler syndrome (post myocardial infarction syndrome)
      Peripheral vascular disease
       I702Atherosclerosis of arteries of extremities
       I710Dissection of aorta any part
       I711Thoracic aortic aneurysm, ruptured
       I712Thoracic aortic aneurysm, without mention of rupture
       I713Abdominal aortic aneurysm, ruptured
       I714Abdominal aortic aneurysm, without mention of rupture
       I715Thoracoabdominal aortic aneurysm ruptured
       I716Thoracoabdominal aortic aneurysm, without mention of rupture
       I718Aortic aneurysm of unspecified site, ruptured
       1719Aortic aneurysm of unspecified site, without mention of rupture
       I790Aneurysm of aorta in diseases classified elsewhere
      Renal disease
       I12Hypertensive renal disease
       I13Hypertensive heart and renal disease
       N01Rapidly progressive nephritic syndrome
       N03Chronic nephritic syndrome
       N18Chronic kidney disease
       N19Unspecified kidney failure
       N25Disorders resulting from impaired renal tubular function
       N00Acute nephritic syndrome
       N04Nephrotic syndrome
       N05Unspecified nephritic syndrome
       N07Hereditary nephropathy, not elsewhere classified
       N11Chronic tubulo-interstitial nephritis
       N14Drug- and heavy-metal-induced tubulo-interstitial and tubular conditions
       N17Acute renal failure
       Q61Cystic kidney disease
      Pulmonary embolism
       I260Pulmonary embolism with mention of acute cor pulmonale
       I269Pulmonary embolism without mention of acute cor pulmonale
      Supplementary Table 2Read Codes Version 2 to Identify Conditions in the WLGP Data Source
      Read CodeRead Code Definition
      Hemorrhagic stroke
       G60Subarachnoid hemorrhage
       G61zIntracerebral hemorrhage not otherwise specified
       G621Subdural hemorrhage - nontraumatic
       G61Intracerebral hemorrhage
       G614Pontine hemorrhage
       G604Subarachnoid hemorrhage from posterior communicating artery
       G613Cerebellar hemorrhage
       G60XSubarachnoid hemorrhage from intracranial artery, unspecified
       G622Subdural hematoma - nontraumatic
       G623Subdural hemorrhage not otherwise specified
       G61X1Right sided intracerebral hemorrhage, unspecified
       G602Subarachnoid hemorrhage from middle cerebral artery
       G60zSubarachnoid hemorrhage not otherwise specified
       G61X0Left sided intracerebral hemorrhage, unspecified
       G600Ruptured berry aneurysm
       G616External capsule hemorrhage
       G617Intracerebral hemorrhage, intraventricular
       G61XIntracerebral hemorrhage in hemisphere, unspecified
       G610Cortical hemorrhage
       G620Extradural hemorrhage - nontraumatic
       G611Internal capsule hemorrhage
       G605Subarachnoid hemorrhage from basilar artery
       G603Subarachnoid hemorrhage from anterior communicating artery
       G612Basal nucleus hemorrhage
       G601Subarachnoid hemorrhage from carotid siphon and bifurcation
       G618Intracerebral hemorrhage, multiple localized
       G606Subarachnoid hemorrhage from vertebral artery
       G615Bulbar hemorrhage
       G61CVA - cerebrovascular accident due to intracerebral hemorrhage
       G62zIntracranial hemorrhage not otherwise specified
       G61Stroke due to intracerebral hemorrhage
       G62Other and unspecified intracranial hemorrhage
       G619Lobar cerebral hemorrhage
      Ischemic stroke
       G64zCerebral infarction not otherwise specified
       G64Cerebral arterial occlusion
       G64z2Left sided cerebral infarction
       G64z3Right sided cerebral infarction
       G641Cerebral embolism
       G640Cerebral thrombosis
       G64z0Brainstem infarction
       G64z4Infarction of basal ganglia
       G6410Cerebral infarction due to embolism of cerebral arteries
       G6400Cerebral infarction due to thrombosis of cerebral arteries
       G64Infarction - cerebral
       G64CVA - cerebral artery occlusion
       G64zCerebellar infarction
       G64Stroke due to cerebral arterial occlusion
       G64zBrainstem infarction not otherwise specified
       G63y0Cerebral infarct due to thrombosis of precerebral arteries
       G63y1Cerebral infarction due to embolism of precerebral arteries
       G6XCerebral infarction due to unspecified occlusion or stenosis of cerebral arteries
       G641Cerebral embolus
       G6760Cerebral infarction due to cerebral venous thrombosis, nonpyogenic
       G6WCerebral infarction due to unspecified occlusion or stenosis of precerebral arteries
       G63Infarction – precerebral
       G64z1Wallenberg syndrome
       G663Brain stem stroke syndrome
       G664Cerebellar stroke syndrome
       G661Anterior cerebral artery syndrome
       G662Posterior cerebral artery syndrome
       G665.Pure motor lacunar syndrome
       G666Pure sensory lacunar syndrome
      Unspecified stroke
       G66CVA unspecified
       G66CVA - Cerebrovascular accident unspecified
       G667Left sided CVA
       G668Right sided CVA
       G66Stroke and cerebrovascular accident unspecified
       G66Stroke unspecified
       13YAStroke group member
       G6Cerebrovascular disease
       G6zCerebrovascular disease not otherwise specified
       G67Other cerebrovascular disease
       8HBJStroke/transient ischemic attack referral
       L440Stroke in the puerperium
       14A7H/O: CVA/stroke
      Hypertension
       14A2H/O: hypertension
       G2Hypertensive disease
       G20Essential hypertension
       G200Malignant essential hypertension
       G201Benign essential hypertension
       G202Systolic hypertension
       G203Diastolic hypertension
       G20zEssential hypertension not otherwise specified
       G21Hypertensive heart disease
       G210Malignant hypertension heart disease
       G2100Malignant hypertension heart disease-no congestive cardiac failure
       G2101Malignant hypertension heart disease + - congestive cardiac failure
       G210zMalignant hypertension heart disease Not otherwise specified
       G211Benign hypertensive heart disease
       G2110Benign hypertensive heart disease - congestive cardiac failure
       G2111Benign hypertensive heart disease + - congestive cardiac failure
       G211zBenign hypertension heart disease Not otherwise specified
       G21z.Hypertensive heart disease Not otherwise specified
       G21z0Hypertensive heart disease Not otherwise specified-no congestive cardiac failure
       G21z1Hypertensive heart disease Not otherwise specified- + congestive cardiac failure
       G21zzHypertensive heart disease Not otherwise specified
       G22Hypertensive renal disease
       G220Malignant hypertensive renal disease
       G221Benign hypertensive renal disease
       G222Hypertensive renal disease + renal failure
       G22zHypertensive renal disease Not otherwise specified
       G23Hypertensive heart + renal disease
       G230Malignant hypertensive heart + renal disease
       G231Benign hypertensive heart + renal disease
       G232Hypertensive heart + renal disease + heart failure
       G233Hypertensive heart + renal disease + renal fail
       G234Hypertensive heart + renal disease + both heart + renal failure
       G23zHypertensive heart + renal disease not otherwise specified
       G24Secondary hypertension
       G240Secondary malignant hypertension
       G2400Secondary malign renovascular hypertension
       G240zSecondary malign hypertension not otherwise specified
       G241Secondary benign hypertension
       G2410Secondary benign renovascular hypertension
       G241zSecondary benign hypertension not otherwise specified
       G244Hypertension secondary endocrine disorder
       G24zSecondary hypertension not otherwise specified
       G24z0Secondary renovascular hypertension not otherwise specified
       G24z1Hypertension secondary to drug
       G24zzSecondary hypertension not otherwise specified
       G25Stage 1 hypertension (NICE 2011)
       G250Stage 1 hypertension without end organ damage
       G251Stage 1 hypertension with end organ damage
       G26Severe hypertension (NICE 2011)
       G27Hypertension resistant to drug therapy
       G28Stage 2 hypertension (NICE 2011)
       G2yHypertensive disease otherwise specified
       G2zHypertensive disease not otherwise specified
      Atrial fibrillation
       14ANH/O: atrial fibrillation
       14ARHistory of atrial flutter
       3272ECG: atrial fibrillation
       3273ECG: atrial flutter
       8CMW2Atrial fibrillation care pathway
       G573Atrial fibrillation/flutter
       G5730Atrial fibrillation
       G5731Atrial flutter
       G5732Paroxysmal atrial fibrillation
       G5733Non-rheumatic atrial fibrillation
       G5734Permanent atrial fibrillation
       G5735Persistent atrial fibrillation
       G5736Paroxysmal atrial flutter
       G5737Chronic atrial fibrillation
       G5738Typical atrial flutter
       G5739Atypical atrial flutter
       G573zAtrial fibrillation/flutter Not otherwise specified
      Diabetes mellitus
       C1001Non-insulin dependent diabetes mellitus
       C10Diabetes mellitus
       C10FType 2 diabetes mellitus
       C1000Insulin dependent diabetes mellitus
       C10FJInsulin treated Type 2 diabetes mellitus
       C10EType 1 diabetes mellitus
       C108Insulin dependent diabetes mellitus
       C101Diabetes mellitus with ketoacidosis
       C104Diabetic nephropathy
       C109Non-insulin dependent diabetes mellitus
       C109NIDDM - Non-insulin dependent diabetes mellitus
       C1087Insulin dependent diabetes mellitus with retinopathy
       C1088Insulin dependent diabetes mellitus - poor control
       C106Diabetes mellitus with neuropathy
       C1097Noninsulin dependent diabetes mellitus - poor control
       C10yyOther specified diabetes mellitus with other spec comps
       C10EDType 1 diabetes mellitus with nephropathy
       C10EMType 1 diabetes mellitus with ketoacidosis
       C10BDiabetes mellitus induced by steroids
       C10EType I diabetes mellitus
       C10FCType 2 diabetes mellitus with nephropathy
       C10F5Type 2 diabetes mellitus with gangrene
       C104yOther specified diabetes mellitus with renal complications
       C1001Diabetes mellitus, adult onset, no mention of complication
       C1001Maturity onset diabetes
       C103Diabetes mellitus with ketoacidotic coma
       C106Diabetes mellitus with neurological manifestation
       C106Diabetes mellitus with polyneuropathy
       C104Diabetes mellitus with renal manifestation
       C1096Non-insulin-dependent diabetes mellitus with retinopathy
       C108FType I diabetes mellitus with diabetic cataract
       C108Type 1 diabetes mellitus
       C109Type 2 diabetes mellitus
       C109GType II diabetes mellitus with arthropathy
       C1090Type 2 diabetes mellitus with renal complications
       C109Type II diabetes mellitus
       C108JType 1 diabetes mellitus with neuropathic arthropathy
       C109JInsulin treated Type II diabetes mellitus
       C109JInsulin treated Type 2 diabetes mellitus
       C10E7Type 1 diabetes mellitus with retinopathy
       C10FMType 2 diabetes mellitus with persistent microalbuminuria
       C10FBType 2 diabetes mellitus with polyneuropathy
       C10F6Type 2 diabetes mellitus with retinopathy
       C108IDDM-Insulin dependent diabetes mellitus
       C10EHType 1 diabetes mellitus with arthropathy
       C10E5Type 1 diabetes mellitus with ulcer
       C10F0Type 2 diabetes mellitus with renal complications
       9OLADiabetes monitored
       C102Diabetes mellitus with hyperosmolar coma
       C1080Type 1 diabetes mellitus with renal complications
       C10NSecondary diabetes mellitus
       C106zDiabetes mellitus not otherwise specified with neurological manifestation
       C10EPType 1 diabetes mellitus with exudative maculopathy
       C10FType II diabetes mellitus
       C108Type I diabetes mellitus
       C1097Type II diabetes mellitus - poor control
       C1000Diabetes mellitus, juvenile type, no mention of complication
       C109GNon-insulin dependent diabetes mellitus with arthropathy
       C108BInsulin dependent diabetes mellitus with mononeuropathy
       C109CType 2 diabetes mellitus with nephropathy
       C10FQType 2 diabetes mellitus with exudative maculopathy
       C10F7Type 2 diabetes mellitus - poor control
       C10FLType 2 diabetes mellitus with persistent proteinuria
       C10B0Steroid induced diabetes mellitus without complication
       C1084Unstable insulin dependent diabetes mellitus
       C1099Non-insulin-dependent diabetes mellitus without complication
       C10ELType 1 diabetes mellitus with persistent microalbuminuria
       C10EKType 1 diabetes mellitus with persistent proteinuria
       C1089Insulin dependent diabetes maturity onset
       C107Diabetes mellitus with gangrene
       C107Diabetes with gangrene
       C10FNType 2 diabetes mellitus with ketoacidosis
       C105Diabetes mellitus with ophthalmic manifestation
       C10yDiabetes mellitus with other specified manifestation
       C1072Diabetes mellitus, adult with gangrene
       C10A1Malnutrition-related diabetes mellitus with ketoacidosis
       C10F2Type 2 diabetes mellitus with neurological complications
       C105zDiabetes mellitus not otherwise specified with ophthalmic manifestation
       C10FKHyperosmolar non-ketotic state in type 2 diabetes mellitus
       C1094Non-insulin dependent diabetes mellitus with ulcer
       C1041Diabetes mellitus, adult onset, with renal manifestation
       C104zDiabetes mellitus with nephropathy not otherwise specified
       C10E8Type 1 diabetes mellitus - poor control
       C10FHType 2 diabetes mellitus with neuropathic arthropathy
       C107Diabetes mellitus with peripheral circulatory disorder
       C109KHyperosmolar non-ketotic state in type 2 diabetes mellitus
       C10DDiabetes mellitus autosomal dominant type 2
       C109JInsulin treated non-insulin dependent diabetes mellitus
       C10FFType 2 diabetes mellitus with peripheral angiopathy
       C10KType A insulin resistance
       C1087Type I diabetes mellitus with retinopathy
       C101yOther specified diabetes mellitus with ketoacidosis
       C100Diabetes mellitus with no mention of complication
       C10EEType 1 diabetes mellitus with hypoglycemic coma
       C1061Diabetes mellitus, adult onset, + neurological manifestation
       C108JInsulin dependent diabetes mellitus with neuropathic arthropathy
       C1020Diabetes mellitus, juvenile type, with hyperosmolar coma
       C1095Non-insulin dependent diabetes mellitus with gangrene
       C10E9Type 1 diabetes mellitus maturity onset
       C10ENType 1 diabetes mellitus with ketoacidotic coma
       C109HNon-insulin dependent d m with neuropathic arthropathy
       C1087Type 1 diabetes mellitus with retinopathy
       C1051Diabetes mellitus, adult onset, + ophthalmic manifestation
       C108CInsulin dependent diabetes mellitus with polyneuropathy
       C101zDiabetes mellitus not otherwise specified with ketoacidosis
       C1030Diabetes mellitus, juvenile type, with ketoacidotic coma
       C108EType I diabetes mellitus with hypoglycemic coma
       C1096Type 2 diabetes mellitus with retinopathy
       C10E2Type 1 diabetes mellitus with neurological complications
       C1021Diabetes mellitus, adult onset, with hyperosmolar coma
       C10F3Type II diabetes mellitus with multiple complications
       C10CDiabetes mellitus autosomal dominant
       C109DNoninsulin dependent diabetes mellitus with hypoglycemic coma
       C10M.Lipoatrophic diabetes mellitus
       C10E4Unstable type 1 diabetes mellitus
       C108FInsulin dependent diabetes mellitus with diabetic cataract
       C108EInsulin dependent diabetes mellitus with hypoglycemic coma
       C1085Insulin dependent diabetes mellitus with ulcer
       C109EType 2 diabetes mellitus with diabetic cataract
       C10FEType 2 diabetes mellitus with diabetic cataract
       C10E3Insulin dependent diabetes mellitus with multiple complications
       C109BNon-insulin dependent diabetes mellitus with polyneuropathy
       C10zDiabetes mellitus with unspecified complication
       C1097Type 2 diabetes mellitus - poor control
       C1088Type 1 diabetes mellitus - poor control
       C1092Type 2 diabetes mellitus with neurological complications
       C1095Type 2 diabetes mellitus with gangrene
       C108yOther specified diabetes mellitus with multiple comps
       C10ECType 1 diabetes mellitus with polyneuropathy
       C10CMaturity onset diabetes in youth
       C1088Type I diabetes mellitus - poor control
       C10FDType 2 diabetes mellitus with hypoglycemic coma
       C1080Insulin-dependent diabetes mellitus with renal complications
       C10F7Type II diabetes mellitus - poor control
       C10F1Type 2 diabetes mellitus with ophthalmic complications
       C105yOther specified diabetes mellitus with ophthalmic complications
       C109BType II diabetes mellitus with polyneuropathy
       C10E0Type 1 diabetes mellitus with renal complications
       C10E1Type 1 diabetes mellitus with ophthalmic complications
       C10E3Type 1 diabetes mellitus with multiple complications
       C109HType II diabetes mellitus with neuropathic arthropathy
       C10F9Type 2 diabetes mellitus without complication
       C109EType II diabetes mellitus with diabetic cataract
       C10F4Type 2 diabetes mellitus with ulcer
       C1082Type I diabetes mellitus with neurological complications
       C1081Insulin-dependent diabetes mellitus with ophthalmic comps
       C10EFType 1 diabetes mellitus with diabetic cataract
       C10F6Type II diabetes mellitus with retinopathy
       C109GType 2 diabetes mellitus with arthropathy
       C10E4Unstable type I diabetes mellitus
       C1090Type II diabetes mellitus with renal complications
       C1091Non-insulin-dependent diabetes mellitus with ophthalmic complications
       C10FBType II diabetes mellitus with polyneuropathy
       C109AType II diabetes mellitus with mononeuropathy
       C100zDiabetes mellitus not otherwise specified with no mention of complication
       C10EInsulin dependent diabetes mellitus
       C10GSecondary pancreatic diabetes mellitus
       C10FPType 2 diabetes mellitus with ketoacidotic coma
       C1085Type I diabetes mellitus with ulcer
       C1083Insulin dependent diabetes mellitus with multiple complications
       C10AMalnutrition-related diabetes mellitus
       C1082Insulin-dependent diabetes mellitus with neurological comps
       C1090Non-insulin-dependent diabetes mellitus with renal comps
       C1010Diabetes mellitus, juvenile type, with ketoacidosis
       C10F9Type II diabetes mellitus without complication
       C10EJType 1 diabetes mellitus with neuropathic arthropathy
       C109FNon-insulin-dependent d m with peripheral angiopathy
       C10E4Unstable insulin dependent diabetes mellitus
       C1011Diabetes mellitus, adult onset, with ketoacidosis
       C109FType II diabetes mellitus with peripheral angiopathy
       C1094Type II diabetes mellitus with ulcer
       C10EQType 1 diabetes mellitus with gastroparesis
       C1092Non-insulin-dependent diabetes mellitus with neuro comps
       C109DType II diabetes mellitus with hypoglycemic coma
       C108AInsulin-dependent diabetes without complication
       C1074NIDDM with peripheral circulatory disorder
       C10K0Type A insulin resistance without complication
       C10F0Type II diabetes mellitus with renal complications
       C108DInsulin dependent diabetes mellitus with nephropathy
       C1096Type II diabetes mellitus with retinopathy
       C10FGType 2 diabetes mellitus with arthropathy
       C103yOther specified diabetes mellitus with coma
       C109CNon-insulin dependent diabetes mellitus with nephropathy
       C1091Type II diabetes mellitus with ophthalmic complications
       C106Diabetic amyotrophy
       C10DMaturity onset diabetes in youth type 2
       C1084Unstable type I diabetes mellitus
       C108JType I diabetes mellitus with neuropathic arthropathy
       C1086Insulin dependent diabetes mellitus with gangrene
       C109FType 2 diabetes mellitus with peripheral angiopathy
       C10FLType II diabetes mellitus with persistent proteinuria
       C109DType 2 diabetes mellitus with hypoglycemic coma
       C10HDiabetes mellitus induced by nonsteroid drugs
       C1080Type I diabetes mellitus with renal complications
       C106yOther specified diabetes mellitus with neurological comps
       C1082Type 1 diabetes mellitus with neurological complications
       C1095Type II diabetes mellitus with gangrene
       C1093Non-insulin-dependent diabetes mellitus with multiple comps
       C10EMType I diabetes mellitus with ketoacidosis
       C108HType I diabetes mellitus with arthropathy
       C10EAType I diabetes mellitus without complication
       C10FAType 2 diabetes mellitus with mononeuropathy
       C1089Type I diabetes mellitus maturity onset
       C1071Diabetes mellitus, adult, + peripheral circulatory disorder
       C10y1Diabetes mellitus, adult, + other specified manifestation
       8CR2Diabetes clinical management plan
       C10FRType 2 diabetes mellitus with gastroparesis
       C10z1Diabetes mellitus, adult onset, + unspecified complication
       C10zyOther specified diabetes mellitus with unspecified comps
       C10zzDiabetes mellitus not otherwise specified with unspecified complication
       C108GInsulin dependent diabetes mellitus with peripheral angiopathy
       C108zUnspecified diabetes mellitus with multiple complications
       C109CType II diabetes mellitus with nephropathy
       C10FJInsulin treated Type II diabetes mellitus
       C107zDiabetes mellitus not otherwise specified with peripheral circulatory disorder
       C103zDiabetes mellitus not otherwise specified with ketoacidotic coma
       C10F3Type 2 diabetes mellitus with multiple complications
       C108HInsulin dependent diabetes mellitus with arthropathy
       C1094Type 2 diabetes mellitus with ulcer
       C10ENType I diabetes mellitus with ketoacidotic coma
       C10A0Malnutrition-related diabetes mellitus with coma
       C108DType I diabetes mellitus with nephropathy
       C109HType 2 diabetes mellitus with neuropathic arthropathy
       C10H0DM induced by non-steroid drugs without complication
       C1060Diabetes mellitus, juvenile, + neurological manifestation
       C1092Type II diabetes mellitus with neurological complications
       C10EBType 1 diabetes mellitus with mononeuropathy
       C1085Type 1 diabetes mellitus with ulcer
       C10z0Diabetes mellitus, juvenile type, + unspecified complication
       C1031Diabetes mellitus, adult onset, with ketoacidotic coma
       C1073IDDM with peripheral circulatory disorder
       C109ENon-insulin dependent diabetes mellitus with diabetic cataract
       C10EAType 1 diabetes mellitus without complication
       C1050Diabetes mellitus, juvenile type, + ophthalmic manifestation
       C10E6Type 1 diabetes mellitus with gangrene
       C1091Type 2 diabetes mellitus with ophthalmic complications
       C1070Diabetes mellitus, juvenile + peripheral circulatory disorder
       C108EType 1 diabetes mellitus with hypoglycemic coma
       C10yzDiabetes mellitus not otherwise specified with other specified manifestation
       C109ANon-insulin dependent diabetes mellitus with mononeuropathy
       C102zDiabetes mellitus not otherwise specified with hyperosmolar coma
       C10E8Insulin dependent diabetes mellitus - poor control
       66AoDiabetes type 2 review
       66AnDiabetes type 1 review
       C10FMType II diabetes mellitus with persistent microalbuminuria
       C10F4Type II diabetes mellitus with ulcer
       C10E3Type I diabetes mellitus with multiple complications
       C10ECType I diabetes mellitus with polyneuropathy
       C10N1Cystic fibrosis related diabetes mellitus
       C10EGType 1 diabetes mellitus with peripheral angiopathy
       C10FEType II diabetes mellitus with diabetic cataract
       C10E7Insulin dependent diabetes mellitus with retinopathy
       C10E5Type I diabetes mellitus with ulcer
       C1040Diabetes mellitus, juvenile type, with renal manifestation
       C10N0Secondary diabetes mellitus without complication
       C10E7Type I diabetes mellitus with retinopathy
       C10FAType II diabetes mellitus with mononeuropathy
       C10FSMaternally inherited diabetes mellitus
       C10ERLatent autoimmune diabetes mellitus in adult
       C108AType I diabetes mellitus without complication
       C10E9Type I diabetes mellitus maturity onset
       C10G0Secondary pancreatic diabetes mellitus without complication
       C1089Type 1 diabetes mellitus maturity onset
       C1084Unstable type 1 diabetes mellitus
       C10E9Insulin dependent diabetes maturity onset
       C10EPType I diabetes mellitus with exudative maculopathy
       C10E1Insulin-dependent diabetes mellitus with ophthalmic comps
       C10C.Maturity onset diabetes in youth type 1
       C10F2Type II diabetes mellitus with neurological complications
       C10E5Insulin dependent diabetes mellitus with ulcer
       C10FDType II diabetes mellitus with hypoglycemic coma
       C108BType I diabetes mellitus with mononeuropathy
       C10E1Type I diabetes mellitus with ophthalmic complications
       C10EEInsulin dependent diabetes mellitus with hypoglycemic coma
       C10EAInsulin-dependent diabetes without complication
       C10A5Malnutrition-related diabetes mellitus with peripheral circulatory complications
       C10EFInsulin dependent diabetes mellitus with diabetic cataract
       C10F1Type II diabetes mellitus with ophthalmic complications
       1434H/O: diabetes mellitus
       66AJDiabetic - poor control
       66AJ0Chronic hyperglycemia
       66AJ1Brittle diabetes
       66AJzDiabetic - poor control not otherwise specified
       C1001Diab.mell.no comp. - adult
       C100zDiab.mell.no comp. - onset not otherwise specified
       C107yOther specified diabetes mellitus + peripheral circulatory complications
       C1085Insulin dependent diabetes mellitus + ulcer
       C108BInsulin dependent diabetes mellitus with mononeuropathy
       C10A2Malnutrition-related diabetes mellitus + renal complications
       C10A3Malnutrition-related diabetes mellitus + ophthalmic complications
       C10A4Malnutrition-related diabetes mellitus + neurologic complications
       C10A5Malnutrition-related diabetes mellitus + peripheral circulatory complications
       C10A6Malnutrition-related diabetes mellitus + multiple complications
       C10A7Malnutrition-related diabetes mellitus without complications
       C10AWMalnutrition-related diabetes mellitus + unspecified complications
       C10AXMalnutrition-related diabetes mellitus + other specified complications
       C10LFibrocalculous pancreatopathy
       C10L0Fibrocalculous pancreatopathy without complications
       C10M0Lipoatrophic diabetes mellitus without complications
       F372Polyneuropathy in diabetes
       F3720Acute painful diabetic neuropathy
       F3721Chron painful diabetic neuropathy
       F3722Asymptomatic diabetic neuropathy
      Heart failure
       G58Heart failure
       G580Congestive heart failure
       G5800Acute congestive heart failure
       G5801Chroncongestive heart failure
       G5802Decompensated cardiac failure
       G5803Compensated cardiac failure
       G5804Cong heart failure due to valve disease
       G581Left ventricular failure
       G5810Acute left ventricular failure
       G582Acute heart failure
       G583Heart failure norm eject frac
       G584Right ventricular failure
       G58zHeart failure not otherwise specified
      Myocardial infarction
       G32Old myocardial infarction
      Peripheral vascular disease
       G73Other peripheral vascular disease
       G734Peripheral arterial disease
       G73yOther specified peripheral vascular disease
       G73zPeripheral vascular disease not otherwise specified
       G73z0Intermittent claudication
       G73zzPeripheral vascular disease not otherwise specified
       Gyu74Other specified peripheral vascular disease
      Renal disease
       K05Chronic renal failure
       K050End stage renal failure
       K060Impaired renal function
       K0DEnd-stage renal disease
       K060Renal impairment
       K03Nephropathy, unspecified
       K032Membranoproliferative nephritis unspecified
       K08zImpaired renal function disorder not otherwise specified
       K05End stage renal failure
       1Z13Chronic kidney disease stage 4
       1Z14Chronic kidney disease stage 5
       1Z1HCKD stage 4 with proteinuria
       1Z1JCKD stage 4 without proteinuria
       1Z1KCKD stage 5 with proteinuria
       1Z1LCKD stage 5 without proteinuria
       K054Chronic kidney disease stage 4
       K055Chronic kidney disease stage 5
      Pulmonary embolism
       14ACH/O: pulmonary embolus
       G401Pulmonary embolism
       G4010Postoperative pulmonary embolism
       G4011Recurrent pulmonary embolism
      Read codes shown up to fifth character.
      Supplementary Table 3Associations Between Prior Stroke or Severe Frailty, Incident Stroke and 30-Day Mortality Following Incident Stroke
      Unadjusted Estimate (95% CI)Adjusted Estimate (95% CI)
      Prior stroke in 12 mo before care home entry
       Incident strokesHR 1.92 (1.65, 2.22)sHR 1.83 (1.57, 2.13)
       30-d mortality following incident strokeOR 2.12 (1.57, 2.86)OR 2.18 (1.59, 2.98)
      Severe frailty
       Incident strokesHR 1.27 (1.11, 1.46)sHR 1.10 (0.95, 1.28)
       30-d mortality following incident strokeOR 0.98 (0.74, 1.30)OR 0.95 (0.69, 1.29)
      sHR, subdistribution hazard ratio.
      Incident stroke refers to any incident stroke in the 12-months after care home entry. Frailty determined with the electronic frailty index.

      Supplementary Methods

      Covariates

      Demographic information was taken from the Welsh Demographic Service Dataset. The Welsh Demographic Service Dataset includes the week of birth, sex, and the Lower-layer Super Output Area used to derive the Welsh Index of Multiple Deprivation, version 2014. The age of each individual was calculated based on the week of birth and date of entry to a care home. Health conditions including hypertension, diabetes mellitus, renal disease, pulmonary embolism, atrial fibrillation, peripheral vascular disease, myocardial infarction, and heart failure were determined at the time of entry to a care home from PEDW and WLGP records. History of smoking was also determined from WLGP records.
      Frailty was determined using the electronic frailty index (eFI), which was calculated using the WLGP data for 10-years prior to the date of care home entry.
      • Hollinghurst J.
      • Fry R.
      • Akbari A.
      • et al.
      External validation of the electronic Frailty Index using the population of Wales within the Secure Anonymised Information Linkage Databank.
      The eFI is based on the internationally established cumulative deficit model and assigns a frailty score to an individual calculated using 36 variables from primary care data including symptoms, signs, diseases, disabilities, and abnormal laboratory values, referred to as deficits.
      • Hollinghurst J.
      • Fry R.
      • Akbari A.
      • et al.
      External validation of the electronic Frailty Index using the population of Wales within the Secure Anonymised Information Linkage Databank.
      • Mitnitski A.B.
      • Mogilner A.J.
      • Rockwood K.
      Accumulation of deficits as a proxy measure of aging.
      • Clegg A.
      • Bates C.
      • Young J.
      • et al.
      Development and validation of an electronic frailty index using routine primary care electronic health record data.
      The 36 eFI deficits are activity limitation, anemia and hematinic deficiency, arthritis, atrial fibrillation, cerebrovascular disease, chronic kidney disease, diabetes, dizziness, dyspnea, falls, foot problems, fragility fracture, hearing impairment, heart failure, heart valve disease, housebound, hypertension, hypotension/syncope, ischemic heart disease, memory and cognitive problems, mobility and transfer problems, osteoporosis, Parkinsonism and tremor, peptic ulcer, peripheral vascular disease, polypharmacy, requirement for care, respiratory disease, skin ulcer, sleep disturbance, social vulnerability, thyroid disease, urinary incontinence, urinary system disease, visual impairment, and weight loss and anorexia.
      The eFI score is the number of deficits present, expressed as an equally weighted proportion of the total. An individual with a single deficit would be assigned an eFI of 1/36 (0.03); another with nine deficits would be assigned an eFI of 9/36 (0.25). The eFI score is then used to categorize individuals as fit (eFI value of 0‒0.12), mild (>0.12–0.24), moderate (>0.24–0.36), or severely frail (>0.36).

      Information Governance Review Panel

      The Information Governance Review Panel (IGRP) has a membership comprised of senior representatives from the British Medical Association, the National Research Ethics Service, Public Health Wales and NHS Wales Informatics Service. Usage of additional data was granted by data owner. The SAIL Databank is General Data Protection Regulations and the UK Data Protection Act compliant. Before any data can be accessed, approval must be given by the IGRP. The IGRP gives careful consideration to each project to ensure proper and appropriate use of SAIL data. When access has been granted, it is gained through a privacy protecting safe haven and remote access system referred to as the SAIL Gateway. SAIL has established an application process to be followed by anyone who would like to access data via SAIL at https://www.saildatabank.com/application-process.

      Supplementary Material. Funding

      No specific funding was received for this work. This work was supported by Health Data Research UK, which receives its funding from HDR UK Ltd (HDR-9006) funded by the UK Medical Research Council, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Department of Health and Social Care (England), Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Health and Social Care Research and Development Division (Welsh Government), Public Health Agency (Northern Ireland), British Heart Foundation (BHF) and the Wellcome Trust. This work was supported by the ADR Wales program of work. The ADR Wales program of work is aligned to the priority themes as identified in the Welsh Government's national strategy: Prosperity for All. ADR Wales brings together data science experts at Swansea University Medical School, staff from the Wales Institute of Social and Economic Research, Data and Methods (WISERD) at Cardiff University and specialist teams within the Welsh Government to develop new evidence which supports Prosperity for All by using the SAIL Databank at Swansea University, to link and Analyse anonymized data. ADR Wales is part of the Economic and Social Research Council (part of UK Research and Innovation) funded ADR UK (grant ES/S007393/1). Sarah Rodgers is part-funded by the National Institute for Health Research (NIHR) Applied Research Collaboration North West Coast (ARC NWC). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

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