Abstract W P289: Cost Burden of Stroke Mimics and Transient Ischemic Attacks Following Intravenous Tissue Plasminogen Activator Treatment

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Nitin Goyal ◽  
Shailesh Male ◽  
Sushma Bellamkonda ◽  
Ramin Zand
Keyword(s):  
Cost Analysis ◽  
Direct Cost ◽  
Hospital Costs ◽  
Final Diagnosis ◽  
The United States ◽  
Personnel Cost ◽  
Excess Cost ◽  
Average Hospital ◽  
Intravenous Tissue Plasminogen Activator ◽  
Iv Tpa

Objective: The decision to treat a patient with acute stroke symptoms is based on pertinent history, brief neurological examination, urgent labs, and head CT. In this setting, patients with stroke mimic (SM) may mistakenly receive IV-tPA. The main goal of this study was to investigate the excess direct and indirect hospital costs among patients who received IV-tPA when the final diagnosis was not ischemic stroke. Method: We reviewed the records of 538 IV-tPA treated patients who presented to our primary stroke centers. The excess cost analysis compared the actual direct and indirect hospital costs of an individual patient to what their direct and indirect hospital costs would have been had they primarily been diagnosed with SM or TIA. We obtained the actual and itemized direct and indirect hospital costs of each patient who had a diagnosis of SM or TIA. We determined the ‘calculated cost’ for each patient based on the projected direct and indirect hospital costs associated with each patient’s actual diagnosis, symptoms, severity of disease, other active clinical problems, and hospital course. Results: Seventy-four of 538 post IV-tPA patients had final diagnosis of SM and 21 had TIA. The excess direct and indirect hospital costs for SM was $257,975 and $152,813, respectively. The median excess cost was $5,401 per admission. The excess total cost for TIA was $85,026 with a median of $3,407 per admission. Considering the 2013 Wage Index report for Memphis, TN (WI: ∿ 0.93), and a 42% rate of direct personnel cost in our direct cost analysis, we can estimate that, in the United States, the excess direct hospital cost associated with administration of IV-tPA to patients with SM is approximately 15 million dollars per year with an average hospital direct cost of $3600 per admission. Conclusion: Our study reveals that administration of IV-tPA to patients with SM is associated with significant excess cost; mainly from the cost of unnecessary hospital admission, IV-tPA, and higher level of care.

Abstract WP72: Early Experience on Intravenous Tissue Plasminogen Activator Delivery in Mobile Stroke Unit Patients with Stroke Mimics

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Lila E Sheikhi ◽  
Stacey Winners ◽  
Pravin George ◽  
Andrew Russman ◽  
Zeshaun Khawaja ◽  
...  
Keyword(s):  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Stroke Unit ◽  
Early Experience ◽  
Final Diagnosis ◽  
Stroke Mimics ◽  
Intravenous Tissue Plasminogen Activator ◽  
Mobile Stroke Unit ◽  
Tissue Plasminogen ◽  
Iv Tpa

Background: A mobile stroke unit (MSU) allows for early delivery for intravenous tissue plasminogen activator (IV-tPA). A proportion of IV-tPA treated patients may turn out to be stroke mimics. We evaluated the rate and complications seen in stroke mimics treated with tPA from our early experience on MSU. Methods: Retrospective review of patients treated with IV-tPA on the MSU from 2014 to 2016. Charts were reviewed for confirmed strokes by imaging (MRI or CT) and hemorrhagic transformation. Stroke mimics were defined as those without imaging evidence of infarction and a final diagnosis which was not suspected to be stroke. Results: Among 62 patients treated with IV-tPA, 14 (28.6%) had a final diagnosis consistent with a stroke mimics. The majority of these occurred in the first year of the MSU program. Most common mimics included conversion disorder (n=5) and seizures (n=5). While the last known well to IV-tPA times were similar, the MSU door-to-needle time was significantly longer in stroke mimics (38 vs 31 minutes, p = 0.03). No intracerebral hemorrhages or other IV-tPA related complications were identified in the stroke mimics group. Conclusions: In our early experience with MSU, treatment of stroke mimics occurred without IV-tPA related complications. This does not appear to be due to rushed decision making.

Abstract 3967: Interdisciplinary Emergency Department (ED) Acute Stroke Case Review Decreases Door to Needle (DTN) Times

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Melissa T Fritz ◽  
Sandy Fritzlar
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
The United States ◽  
Case Review ◽  
Intravenous Tissue Plasminogen Activator ◽  
Stroke Team ◽  
Process Oriented ◽  
Stroke Case ◽  
Iv Tpa

Background: Stroke is one of the leading causes of death and the leading cause of disability in the United States. Previous studies suggest that the quicker that intravenous tissue plasminogen activator (IV tPA) is administered, the safer and more effective it is, thus lowering the odds of in hospital mortality and symptomatic intracranial hemorrhage. Objective: To investigate whether implementing a process oriented, interdisciplinary bimonthly review of acute ischemic stroke cases would decrease DTN times and ultimately lead to the consistent administration of IV tPA within 60 minutes of arrival to the ED. Methods: To decrease the IV tPA DTN times, the stroke team at United Hospital in St. Paul, Minnesota developed a new ED stroke review process in July 2010 to analyze each acute ischemic stroke case. The cases were compiled into a document that contained time specific goals for each step of the acute stroke code process. Members of the stroke team would review the data prior to the meeting and if there was a delay (ie outside of the timed goal for lab result) in their department they would investigate the cause. At the meeting, the team would identify best practice efficiencies and barriers, leading to changes in the process. Formal follow up with each department and key learnings were sent to staff on a monthly basis. Results: In 2010, there were 82 patients admitted with an acute ischemic stroke, within 3.5 hours from time last known well, and 28 patients received IV tPA 34% (28/82). From January to June, 2011 there have been 46 acute ischemic stroke patients and 18 patients received IV tPA (18/46) 39%. The mean DTN time was 88 minutes in 2010 vs. 70 minutes in 2011; mean age was 64 vs. 66.5; % female was 46% (13/28) vs. 67% (12/18); median NIH Stroke Scale was 6 vs. 6. The percentage of patients treated with IV tPA within 60 minutes of hospital arrival increased from 21.4% (6/28) in 2010 to 50% (9/18) from January to June 2011 (p=0.022). Conclusions: The DTN times significantly decreased after the implementation of a process oriented, interdisciplinary ED acute stroke case review. The percentage of patients receiving IV tPA within 60 minutes increased from 21.4% to 50% over a 18 month period.

Abstract WMP32: Variation in the Rates of Acute Ischemic Stroke Transfers Between Hospitals in the United States

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Syed F Ali ◽  
Gregg Fonarow ◽  
Eric Smith ◽  
Li Liang ◽  
Robert Sutter ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
High Volume ◽  
The United States ◽  
Teaching Hospitals ◽  
Large Sample Size ◽  
Stroke Registry ◽  
Intravenous Tissue Plasminogen Activator ◽  
The Us ◽  
Iv Tpa

Background: Many patients are transferred from emergency departments or inpatient units to stroke centers for advanced acute ischemic stroke (AIS) care, especially after intravenous tissue plasminogen activator (tPA). We sought to determine variation in the rates of AIS patient transfer in the US. Methods: Using data from the national Get With The Guidelines-Stroke registry, we analyzed AIS cases from 01/2010 to 03/14. Transfer-in was defined as transfer of AIS patients from other hospitals. Due to large sample size, instead of p-values, standardized differences were reported and a map of transfer-in rates across the US constructed. Results: Of the 970,390 patients discharged from 1,646 hospitals in the US, 87% were admitted via the ER or direct admission (front door) vs. 13% transferred-in. While most hospitals (61%) had transfer-in rates of < 5% of all AIS patients, a minority (17%) had high (>15%) transfer-in rates. High transfer-in hospitals were more often in the Midwest, were larger, and had higher annual AIS and IV tPA case volumes, and were also more often teaching hospitals and stroke centers (primary or comprehensive) (Table and Figure).. IV tPA was used more frequently in eligible patients in high-volume transfer-in hospitals (Table); otherwise, stroke quality of care was similar. Conclusions: There is significant regional- and state-level variability in the transfer of AIS patients. This may reflect differences in resource availability and the distribution of smaller, under-resourced hospitals that frequently transfer patients for advanced care after stabilization. Additional research is warranted to understand this variation.

Increased Prevalence, Complications, and Costs of Smokers Undergoing Total Knee Arthroplasty

2020 ◽  
Author(s):  
Sean S. Rajaee ◽  
Eytan M. Debbi ◽  
Guy D. Paiement ◽  
Andrew I. Spitzer
Keyword(s):  
Total Knee Arthroplasty ◽  
Knee Arthroplasty ◽  
Smoking Status ◽  
Hospital Costs ◽  
Patient Characteristics ◽  
The United States ◽  
Bundled Payment ◽  
Vein Thrombosis ◽  
Total Knee ◽  
Payment Models

AbstractGiven a national push toward bundled payment models, the purpose of this study was to examine the prevalence as well as the effect of smoking on early inpatient complications and cost following elective total knee arthroplasty (TKA) in the United States across multiple years. Using the nationwide inpatient sample, all primary elective TKA admissions were identified from 2012 to 2014. Patients were stratified by smoking status through a secondary diagnosis of “tobacco use disorder.” Patient characteristics as well as prevalence, costs, and incidence of complications were compared. There was a significant increase in the rate of smoking in TKA from 17.9% in 2012 to 19.2% in 2014 (p < 0.0001). The highest rate was seen in patients < 45 years of age (27.3%). Hospital resource usage was significantly higher for smokers, with a length of stay of 3.3 versus 2.9 days (p < 0.0001), and hospital costs of $16,752 versus $15,653 (p < 0.0001). A multivariable logistic model adjusting for age, gender, and comorbidities showed that smokers had an increased odds ratio for myocardial infarction (5.72), cardiac arrest (4.59), stroke (4.42), inpatient mortality (4.21), pneumonia (4.01), acute renal failure (2.95), deep vein thrombosis (2.74), urinary tract infection (2.43), transfusion (1.38) and sepsis (0.65) (all p < 0.0001). Smoking is common among patients undergoing elective TKA, and its prevalence continues to rise. Smoking is associated with higher hospital costs as well as higher rates of immediate inpatient complications. These findings are critical for risk stratification, improving of bundled payment models as well as patient education, and optimization prior to surgery to reduce costs and complications.

Abstract 14767: Thrombolysis of Stroke Mimics via Telestroke

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Ravyn Howell ◽  
Randheer S Yadav ◽  
Sushil Lakhani ◽  
Sharon Heaton ◽  
Karen L Wiles ◽  
...  
Keyword(s):  
Final Diagnosis ◽  
National Institutes Of Health ◽  
Factitious Disorder ◽  
Emergency Rooms ◽  
Stroke Mimics ◽  
Intravenous Tissue Plasminogen Activator ◽  
Stroke Diagnosis ◽  
History Of ◽  
Stroke Mimic ◽  
Similar Episode

Introduction: Telestroke allows stroke expertise for thrombolysis decision making remotely using high-quality bidirectional audiovisual technology. Hypothesis: Intravenous tissue plasminogen activator (IVtPA) is administered via telestroke network to a proportion of patients without a stroke diagnosis (i.e. stroke mimic) Methods: Our academic comprehensive stroke program telestroke program includes 26 spoke Emergency rooms (ERs) through which IVtPA is administered throughout central Ohio. From July 1, 2016 to Sept 30, 2017, nearly all patients who received IVtPA at the outside hospital telestroke ERs were transferred to our institution for post-IVtPA care. Data was collected on final diagnosis, demographics, National Institutes of Health Stroke Scale (NIHSS), door to needle (DTN) time, and outcomes. Results: Among 270 acute ischemic stroke patients who received IVtPA via telestroke, we identified 64 (23.7%) with a stroke mimic diagnosis. Stroke mimics were younger (mean age 56.4 vs 68.2, p <0.0001), more likely female (60.9% vs 45.6%, p 0.03), and had higher DTN times (85.3 vs 69.9 minutes, p 0.0008). The increase in DTN was due to longer time to recommend by the telestroke neurologist for stroke mimic (65.0 vs 53.2 minutes, p 0.0034). The stroke mimic diagnosis included Migraine 26 (40.6%), Factitious disorder 12 (18.8%), Encephalopathy 7 (10.9%), and Unmasking 6 (9.4%). The stroke mimics did not differ from each other based upon initial NIHSS, DTN, or sex. Compared to the other stroke mimics, Migraine and Factitious disorder patients were younger (51.2 vs 63.9 years, p <0.0006), more likely to have a personal history of migraines (42.1% vs 0%, p < 0.0001), and more likely to have functional exam findings (42.1% vs 3.8%, p 0.0007). There were no hemorrhagic complications in the stroke mimic patients. Among all stroke mimics, 26 (40.6%) had a history of similar prior episodes and 10 (15.6%) would have future recurrence of another similar episode, with 2 patients receiving IVtPA again in the future (1 Migraine and 1 Factitious disorder). Conclusions: In a tertiary academic telestroke network, nearly one-quarter of patients receive IVtPA for a non-stroke diagnosis, with migraine and factitious disorder being the most commonly seen.

A PEDIATRIC HOME CARE PROGRAM IN LONDON—TEN YEARS EXPERIENCE

PEDIATRICS ◽  
1965 ◽  
Vol 36 (3) ◽  
pp. 314-321
Author(s):  
A. B. Bergman ◽  
H. Shrand ◽  
T. E. Oppé
Keyword(s):  
Home Care ◽  
Home Environment ◽  
Hospital Costs ◽  
Care Program ◽  
Chronically Ill ◽  
The United States ◽  
Age Group ◽  
Small Children ◽  
Descriptive Account ◽  
Sick Children

RECENT YEARS have seen a resurgence of interest in organized Home Care programs as a variety of factors have spurred the search for alternatives to hospital care. Chief among them has been the economic burden of spiraling hospital costs. Many programs have been devised to enable chronically ill persons in the older age group—the "home-bound" geriatric patient—to be supervised in their own homes. There are, however, special reasons for attempting to control the admission of children to hospitals. Illness is a time when a child becomes more dependent than usual and seems to need the security of parents and the comfort of familiar home environment. Even though enlightened hospitals now encourage visiting, many parents cannot take advantage of this for such reasons as distance and having to care for the other children at home. There is debate as to the amount of emotional harm caused by hospitalization of small children; most workers would say it does no good, and, in some cases, can lead to serious sequelae. The Home Care Program for sick children at St. Mary's Hospital in London was started in April, 1954. One of us (A.B.B.) had the opportunity of participating in this program in 1961 while serving as an Exchange Registrar from Children's Hospital (Boston). It is felt that even though conditions in the United States and Great Britain may be different, there are enough similarities to make a descriptive account of the program of interest to American physicians. The Development of Home Care Schemes Historically, doctors looked after the sick in their own homes when private fees could be afforded.

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