scholarly journals Regional Disparity of Reperfusion Therapy for Acute Ischemic Stroke in Japan: A Retrospective Analysis of Nationwide Claims Data from 2010 to 2015

2021 ◽  
Author(s):  
Megumi Maeda ◽  
Haruhisa Fukuda ◽  
Ryu Matsuo ◽  
Tetsuro Ago ◽  
Takanari Kitazono ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Fixed Effects ◽  
Claims Data ◽  
Recombinant Tissue Plasminogen Activator ◽  
Reperfusion Therapy ◽  
Regional Disparity ◽  
Hospital Death ◽  
Gini Coefficients ◽  
Regional Factors

Background We aimed to determine whether a regional disparity exists in usage of reperfusion therapy (intravenous recombinant tissue plasminogen activator [IV rt‐PA] and endovascular thrombectomy [EVT]) and post‐reperfusion 30‐day mortality in patients with acute ischemic stroke, and which regional factors are associated with their usage. Methods and Results We retrospectively investigated 69 948 patients (mean age±SD, 74.9±12.0 years; women, 41.4%) with acute ischemic stroke treated with reperfusion therapy between April 2010 and March 2016 in Japan using nationwide claims data. Regional disparity was evaluated using Gini coefficients for age‐ and sex‐adjusted usage of reperfusion therapy and 30‐day post‐reperfusion in‐hospital death ratio in 47 administrative regions. The association between regional factors and reperfusion therapy usage was evaluated with fixed‐effects regression models. During the study period, Gini coefficients showed low inequality (0.11–0.15) for use of IV rt‐PA monotherapy and IV rt‐PA and/or EVT and extreme inequality (0.49) for EVT usage in 2010, which became moderate inequality (0.25) by 2015. The densities of stroke centers and endovascular specialists, as well as market concentration, were associated with increased usage of reperfusion therapy whereas the proportion of rural residents and delayed ambulance transport were negatively associated with usage. Inequality in the standardized death ratio after EVT was extreme (0.86) in 2010 but became moderate (0.29) by 2015; inequality was low to moderate (0.17–0.23) for IV rt‐PA monotherapy and IV rt‐PA and/or EVT. Conclusions Scrutinizing existing data sources revealed regional disparity in reperfusion therapy for acute ischemic stroke and its associated regional factors in Japan.

Safety and efficacy of mechanical thrombectomy in acute ischemic stroke of anticoagulated patients

2018 ◽  
Vol 10 (12) ◽  
pp. e29-e29 ◽  
Author(s):  
Vincent L’Allinec ◽  
Marielle Ernst ◽  
Mathieu Sevin-Allouet ◽  
Nathalie Testard ◽  
Béatrice Delasalle-Guyomarch ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Mechanical Thrombectomy ◽  
Univariate Analysis ◽  
Recombinant Tissue Plasminogen Activator ◽  
Reperfusion Therapy ◽  
Safety And Efficacy ◽  
Risk Of Death ◽  
Anticoagulated Patients

BackgroundAnticoagulated patients (APs) are currently excluded from acute ischemic stroke reperfusion therapy with intravenous recombinant tissue plasminogen activator (IV-rtPA); however, these patients could benefit from mechanical thrombectomy (MT). Evidence for MT in this condition remains scarce. The aim of this study was to analyze the safety and efficacy of MT in APs.MethodsWe analyzed three patient groups from two prospective registries: APs with MT (AP-MT group), non-anticoagulated patients treated with MT (NAP-MT group), and non-anticoagulated patients treated with IV-rtPA and MT (NAP-IVTMT group). Univariate and multivariate logistic regression were used to evaluate treatment efficacy with modified Rankin Scale (mRS) ≤2 and safety (radiologic intracranial hemorrhage (rICH), symptomatic intracranial hemorrhage (sICH) and death rate at 3 months) between groups.Results333 patients were included in the study, with 44 (12%) in the AP-MT group, 105 (31%) in the NAP-MT group, and 188 (57%) in the NAP-IVTMT group. Univariate analysis showed that the AP-MT group was older (P<0.001), more often had atrial fibrillation (P<0001), and had a higher ASPECTS (P<0.006 and P<0.002) compared with the NAP-MT group and NAP-IVTMT groups, respectively. Multivariate analysis showed that the AP-MT group had a lower risk of rICH (OR 2.77, 95% CI 1.01 to 7.61, P=0.05) but a higher risk of death at 3 months (OR 0.26, 95% CI 0.09 to 0.76, P=0.01) compared with the NAP-IVTMT group. No difference was found between the AP-MT and NAP-MT groups.ConclusionsWith regard to intracranial bleeding and functional outcome at 3 months, MT in APs seems as safe and efficient as in NAPs. However, there is a higher risk of death at 3 months in the AP-MT group compared with the NAP-IVTMT group.

Abstract P85: Impact of Covid-19 Pandemic on Hospitalizations and Outcomes of Acute Ischemic Stroke Patients, Paul Coverdell National Acute Stroke Program (pcnasp)

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Xin Tong ◽  
Sallyann Coleman King ◽  
Erika Odom ◽  
Quanhe Yang
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Reperfusion Therapy ◽  
The United States ◽  
Emergency Department Visits ◽  
National Institutes Of Health ◽  
Hospital Death ◽  
Stroke Patients ◽  
Stroke Treatment

Introduction: Studies suggest a significant reduction in emergency department visits and hospitalizations for acute ischemic stroke (AIS) during the COVID-19 pandemic in the United States. Few studies have examined AIS hospitalizations, treatments, and outcomes during the pandemic period. The present study compared the demographic and clinical characteristics of patients hospitalized with AIS before and during the COVID-19 pandemic (weeks 11-24 in 2019 vs. 2020). Method: We identified 42,371 admissions with a clinical diagnosis of AIS, from 370 participating hospitals who contributed data during weeks 11-24 in both 2019 and 2020 to the Paul Coverdell National Acute Stroke Program (PCNASP). Results: During weeks 11-24 of the COVID-19 period, AIS hospitalizations declined by 24.5% compared to the same period in 2019 (18,233 in 2020 vs. 24,138 in 2019). In 2020, the percentage of individuals aged <65 years who were hospitalized with AIS was higher compared with the same period in 2019 (34.6% vs. 32.7%, p<0.001); arriving by EMS were higher in 2020 compared with 2019 (47.7% vs. 44.8%, p<0.001). Individuals admitted with AIS in 2020 had a higher mean National Institutes of Health Stroke Scale (NIHSS) score compared with 2019 (6.7 vs. 6.3, p<0.001). In 2020, the in-hospital death rates increased by 16% compared to 2019 (5.0% vs. 4.3%, p<0.001). However, there were no differences in rates of alteplase use, achievement of door to needle in 60 minutes, or complications from reperfusion therapy between the two time periods. Conclusion: A higher percentage of younger (<65 years) individuals and more severe AIS cases were admitted to the participating hospitals during weeks 11 to 24 of the COVID-19 pandemic in 2020 compared to the same period in 2019. The AIS in-hospital death rate increased 16% during the pandemic weeks as compared to the same weeks in 2019. Additional studies are needed to examine the impacts of the COVID-19 pandemic on stroke treatment and outcomes.

Abstract TP298: Measuring Quality of Care for Acute Ischemic Stroke Treated With Acute Reperfusion Therapy in Japan: A Nationwide Quality Improvement Initiative of the J-aspect Study

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Nice Ren ◽  
Ataru Nishimura ◽  
Kunihiro Nishimura ◽  
Koichi Arimura ◽  
Ai Kurogi ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Stroke Unit ◽  
Recombinant Tissue Plasminogen Activator ◽  
Reperfusion Therapy ◽  
Medical Chart ◽  
Quality Improvement Initiative ◽  
Novel Approach ◽  
Total Data ◽  
Stroke Unit Care

Background and Purpose: There is no consensus about efficiently measuring quality indicators (QIs) of acute ischemic stroke (AIS) in Japan. To evaluate feasibility and reliability of measuring QIs for AIS patients who received intravenous recombinant tissue plasminogen activator (rt-PA) or endovascular therapy (ET), by combining information from health insurance claims database and medical chart. Methods: AIS patients who received rt-PA or ET between 2013 and 2015 were identified from the J-ASPECT Diagnosis Procedure Combination (DPC) database. The 17 and 8 QI measures for primary and comprehensive stroke centers (PSCs and CSCs) were selected for AIS, respectively. More than 60% of data for calculating the QIs were obtained from the DPC database and preset in the tool. Responsible physicians were asked to review accuracy of preset data and add necessary information from medical chart. Adherence rates or performance measures for each QI were calculated for patient- and hospital-levels. Associations between adherence rates and hospital characteristics were analyzed using hierarchical logistic regression analysis. Result: In total, data of 8,506 patients (rt-PA 83.5%, ET 34.9%) from 173 hospitals were obtained. The median age was 76 (interquartile range 65–83) years, and 42.1% were women. Median National Institute of Health Stroke Scale (NIHSS) score at admission was 14 (7-21). All of the target QIs were successfully measured. Among PSC QIs, adherence rates were low (<50%) (e.g. door-to-needle time < 60 minutes 37.9%) and intermediate (50-75%) (e.g. stroke unit care 58.7%) in 4 each. For CSC QIs, median door-to-puncture time was 105 (76-147) minutes and TICI grade 2b and 3 recanalization were achieved in 73%. A higher number of stroke discharge was associated with greater adherence to stroke unit care, early rehabilitation and stroke education. Conclusion: Measuring QIs of AIS by this novel approach was feasible and reliable to provide a national benchmark.

Association of admission leukocyte count with clinical outcomes in acute ischemic stroke patients undergoing intravenous thrombolysis with recombinant tissue plasminogen activator

2020 ◽  
Vol 17 ◽  
Author(s):  
Jie Chen ◽  
Fu-Liang Zhang ◽  
Shan Lv ◽  
Hang Jin ◽  
Yun Luo ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Leukocyte Count ◽  
Intravenous Thrombolysis ◽  
Recombinant Tissue Plasminogen Activator ◽  
Functional Independence ◽  
Tissue Plasminogen ◽  
Poor Outcomes

Objective:: Increased leukocyte count are positively associated with poor outcomes and all-cause mortality in coronary heart disease, cancer, and ischemic stroke. The role of leukocyte count in acute ischemic stroke (AIS) remains important. We aimed to investigate the association between admission leukocyte count before thrombolysis with recombinant tissue plasminogen activator (rt-PA) and 3-month outcomes in AIS patients. Methods:: This retrospective study included consecutive AIS patients who received intravenous (IV) rt-PA within 4.5 h of symptom onset between January 2016 and December 2018. We assessed outcomes including short-term hemorrhagic transformation (HT), 3-month mortality, and functional independence (modified Rankin Scale [mRS] score of 0–2 or 0–1). Results:: Among 579 patients who received IV rt-PA, 77 (13.3%) exhibited HT at 24 h, 43 (7.4%) died within 3 months, and 211 (36.4%) exhibited functional independence (mRS score: 0–2). Multivariable logistic regression revealed admission leukocyte count as an independent predictor of good and excellent outcomes at 3 months. Each 1-point increase in admission leukocyte count increased the odds of poor outcomes at 3 months by 7.6% (mRS score: 3–6, odds ratio (OR): 1.076, 95% confidence interval (CI): 1.003–1.154, p=0.041) and 7.8% (mRS score: 2–6, OR: 1.078, 95% CI: 1.006–1.154, p=0.033). Multivariable regression analysis revealed no association between HT and 3-month mortality. Admission neutrophil and lymphocyte count were not associated with 3-month functional outcomes or 3-month mortality. Conclusion:: Lower admission leukocyte count independently predicts good and excellent outcomes at 3 months in AIS patients undergoing rt-PA treatment.

Abstract TP161: Gastrointestinal Bowel Obstruction in Acute Ischemic Stroke: Incidence, Risk Factors, and Outcomes

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Kavelin Rumalla ◽  
Adithi Y Reddy ◽  
Vijay Letchuman ◽  
Paul A Berger ◽  
Manoj K Mittal
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Bowel Obstruction ◽  
Kidney Injury ◽  
Hospital Death ◽  
Stroke Incidence ◽  
Black Race ◽  
Electrolyte Disorder ◽  
Incidence Risk

Introduction: The prognosis of patients suffering acute ischemic stroke (AIS) is worsened by medical complications that occur during subsequent hospitalization. The incidence, risk factors, and outcomes of gastrointestinal bowel obstruction (GIBO) in AIS have not been previously reported. Methods: We employed the Nationwide Inpatient Sample from 2002 to 2011 to identify all patients admitted with a primary diagnosis of AIS and subsets with and without a secondary diagnosis of GIBO without hernia. Multivariate logistic regression was utilized to analyze predictors of GIBO in AIS patients and the association between GIBO, in-hospital complications, and outcomes. Results: We identified 16,987 patients with GIBO (425 per 100,000) among 3,988,667 AIS hospitalizations and 4.2% of patients of these patients underwent repair surgery for intestinal obstruction. Multivariate predictors of GIBO included: age 55-64 (OR: 1.52, 95% CI: 1.40-1.64), age 65-74 (OR: 1.69, 95% CI: 1.56-1.84), age 75+ (OR: 1.97, 95% CI: 1.81-2.13), black race (OR: 1.42, 95% CI: 1.36-1.49), coagulopathy (OR: 1.39, 95% CI: 1.29-1.50), cancer (OR: 1.59, 95% CI: 1.44-1.75), blood loss anemia (OR: 2.51, 95% CI: 2.22-2.84), fluid/electrolyte disorder (OR: 2.91, 95% CI: 2.81-3.02), weight loss (OR: 3.08, 95% CI: 2.93-3.25), and thrombolytic therapy (OR: 1.30, 95% CI: 1.20-1.42) (all p<0.0001). Patients with GIBO had a greater likelihood of suffering intubation (OR: 1.79, 95% CI: 1.70-1.90), deep vein thrombosis (OR: 1.35, 95% CI: 1.25-1.46), pulmonary embolism (OR: 1.84, 95% CI: 1.53-2.21), sepsis (OR: 2.39, 95% CI: 2.22-2.56), acute kidney injury (OR: 1.85, 95% CI: 1.76-1.95), gastrointestinal hemorrhage (OR: 2.82, 95% CI: 2.63-3.03), and blood transfusions (OR: 2.02, 95% CI: 1.90-2.15) (all p<0.0001). In adjusted analyses, AIS patients with GIBO were 284% and 39% more likely to face moderate to severe disability and in-hospital death, respectively (p<0.0001). GIBO occurrence increased length of stay and total costs by an average of 9.7 days and $22,342 (p<0.0001). Conclusion: Advanced age, black race, and several pre-existing comorbidities increase the likelihood of post-AIS GIBO, which is an independent predictor of in-hospital complications, disability, and mortality.

Abstract TP286: A Literature Review of Cost-effectiveness of Intravenous Recombinant Tissue Plasminogen Activator for Treating Acute Ischemic Stroke

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Guijing Wang ◽  
Heesoo Joo ◽  
Mary G George
Keyword(s):  
Ischemic Stroke ◽  
Cost Effectiveness ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Cost Effective ◽  
Recombinant Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
The Cost ◽  
Effectiveness Studies

Introduction: Intravenous recombinant tissue plasminogen activator (IV rtPA) is recommended treatment for acute ischemic stroke patients, but the cost-effectiveness of IV rtPA within different time windows after the onset of acute ischemic stroke is not well reviewed. Objectives: We conducted a literature review of the cost-effectiveness studies about IV rtPA. Methods: A literature search was conducted using PubMed, MEDLINE, and EconLit, with the key words stroke, cost, economic benefit, saving, cost-effectiveness, tissue plasminogen activator, and rtPA. The review is limited to original research articles published during 1995–2014 in English-language peer-reviewed journals. Results: We found 15 studies meeting our criteria for this review. Nine of them were cost-effectiveness studies of IV rtPA treatment within 0-3 hours after stroke onset, 2 studies within 3-4.5 hours, 3 studies within 0-4.5 hours, and 1 study within 0-6 hours. IV rtPA is a cost-saving or a cost-effectiveness strategy from most of the study results. Only one study showed incremental cost-effectiveness ratio of IV rtPA within one year was marginally above $50,000 per QALY threshold. IV rtPA within 0-3 hours after stroke led to cost savings for lifetime or 30 years, and IV rtPA within 3-4.5 hours after stroke increased costs but still was cost-effective. Conclusions: The literature generally showed that intravenous IV rtPA was a dominant or a cost-effective strategy compared to traditional treatment for acute ischemic stroke patients without IV rtPA. The findings from the literature lacked generalizability because of limited data and various assumptions.

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