Abstract WP285: Sex Disparities in Stroke Care in Puerto Rico Hospitals Participating in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Juan C Zevallos ◽  
Maria A Ciliberti-Vargas ◽  
Kefeng Wang ◽  
Carolina M Gutierrez ◽  
Enid J Garcia-Rivera ◽  
...  
Keyword(s):  
Puerto Rico ◽  
Antithrombotic Therapy ◽  
Performance Metrics ◽  
Stroke Care ◽  
Smoking Cessation Counseling ◽  
Hospital Arrival ◽  
Free Care ◽  
Sex Disparities ◽  
To Receive ◽  
Iv Tpa

Background: Sex is a contributing factor to inequalities in stroke care. In line with the aims of the FL-PR CReSD Study to assess Get With The Guidelines-Stroke (GWTG-S) quality improvement data, we sought to compare stroke performance metrics by sex among 9 GWTG-S participating Puerto Rico hospitals from 2010-2014. Methods: Age and NIHSS-adjusted hierarchical generalized linear models, stratified by sex, were evaluated for the following GWTG-S performance metrics: IV tPA treatment, early antithrombotic therapy, DVT prophylaxis, antithrombotic therapy at discharge, anticoagulation therapy for atrial fibrillation (AF) at discharge, statin medication at discharge, smoking cessation counseling, defect-free care (compliance with all performance measures), in addition to CT scan ≤25 minutes and door-to-IV tPA administration ≤60 minutes of hospital arrival. Results: Among 3,277 acute ischemic stroke cases, 48% were women. As compared to men, women were older (72±14 vs. 68±13 years, P<0.0001) with higher NIHSS scores (10±8.5 vs. 9±7.7, P=0.005). Women were less likely to receive IV tPA ≤ 4.5 hours among eligible patients arriving ≤ 3.5 hours (OR 0.71, 95% CI 0.51-0.98, P=0.04), early antithrombotic therapy (OR 0.86, 95% CI 0.75-0.97, P=0.02), DVT prophylaxis (OR 0.93, 95% CI 0.88-0.99, P=0.03), statin medication at discharge (OR 0.85, 95% CI 0.78-0.93, P=0.0001), and anticoagulation for AF at discharge (OR 0.67, 95% CI 0.49-0.92, P=0.01) despite having higher rates of AF at admission (11% vs. 7%, P=0.001). Rates of IV tPA for patients arriving ≤ 2 hours, antithrombotic therapy at discharge, and smoking cessation counseling showed no sex differences. While women were less likely to have a CT scan ≤ 25 minutes of hospital arrival compared to men (OR 0.83, 95% CI 0.74-0.93, P=0.002), no difference was found in door-to-IV tPA administration ≤ 60 minutes. Although an overall temporal improvement in defect-free care was observed from 2010-2014 (31% to 63%, P<.0001), women were less likely to receive this measure than men (OR 0.91, 95% CI 0.85-0.97, P=0.007). Conclusions: Overall, stroke care remains lower for Puerto Rican women than men. Continued adoption of the GWTG-S quality improvement program may help reduce sex disparities in quality of care across the island.

Abstract 89: Differences in Acute Stroke Care in Primary and Comprehensive Stroke Centers in Florida: An Analysis of the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study- the NINDS Stroke Prevention Intervention Research Program

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Erika T Marulanda-Londoño ◽  
Maria A Ciliberti-Vargas ◽  
Kefeng Wang ◽  
Negar Asdaghi ◽  
Maranatha Ayodele ◽  
...  
Keyword(s):  
Puerto Rico ◽  
Ischemic Stroke ◽  
Performance Metrics ◽  
Ethnic Disparities ◽  
Stroke Care ◽  
Acute Stroke Care ◽  
Delivery Of Care ◽  
Primary Stroke Center ◽  
Free Care ◽  
Stroke Center

Introduction: Primary stroke center (PSC) and comprehensive stroke center (CSC) designation in Florida aims to improve delivery of care and outcomes for stroke patients. In line with the goals of the NINDS funded Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study, we sought to compare ischemic stroke performance metrics by stroke center designation in participating Florida hospitals. Methods: We analyzed 74,623 cases with acute ischemic stroke from 26 CSC and 40 PSC from January 2010-April 2016. We described patient demographics, comorbidities and Get With The Guidelines-Stroke performance metrics of defect free care (compliance with 7 pre-defined performance core measures), door to CT time (DTCT) ≤25 mins and door to needle time (DTN) ≤60 mins. Results: Compared with PSC patients, CSC patients were younger (70 ± 15 vs. 71 ± 14 years, p<.0001), more likely male (51% vs. 50%, p=.0008), more likely Hispanic (17% vs. 10%, p<.0001) and Black (21% vs. 17%, p<.0001), had more severe strokes (NIHSS median 5 (IQR 2-12) vs. 4 (IQR 1-9); NIHSS ≥16, 12% vs. 9%, p <.0001), were more likely to have atrial fibrillation (19% vs. 17%, p<.0001), and were more likely to arrive by EMS (55% vs. 46%, p<.0001). CSC cases were more likely to have faster DTCT (44 vs. 48 mins, p=.0124 ; < 25 mins 33% vs. 31%, p<.0001). More patients in CSC received thrombolysis (12% vs. 9%, p<.0001), with faster DTN (59 vs. 71 min, p <.0001; ≤60 minutes 53% vs. 37%, p <.0001). Patients in CSC had greater rates of defect free care (85% vs. 82.4%, p<.0001). Blacks had longer median DTCT than Whites and Hispanics in both CSC (56 mins Blacks vs. 41 mins Whites and Hispanics) and PSC (60 mins Blacks, 44 mins Whites, 57 mins Hispanics). Blacks in CSC had longer median DTN (63 mins) than Whites (60 mins) and Hispanics (53 mins). Hispanics had longer median DTN (73 mins) in PSC than Blacks (70 mins) and Whites (70 mins). Conclusion: Patients treated in CSC, compared with those treated in PSC, received better defect-free care and had lower DTCT and DTN times. Race-ethnic disparities in performance metrics are still evident in both CSC and PSC. Identification of these disparities is important to design interventions to reduce disparities and improve stroke quality of care for all.

Abstract 2260: Interhospital Transfers in the Colorado Stroke System

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Don B Smith ◽  
Richard L Hughes
Keyword(s):  
Stroke Care ◽  
Acute Stroke Care ◽  
Medical Problems ◽  
Stroke Registry ◽  
Informal System ◽  
Multivariate Logistic Model ◽  
Clinically Significant ◽  
Using Data ◽  
To Receive ◽  
Iv Tpa

Background: Stroke systems have been called a “critical next step in improving patient outcomes.” A desired feature is for hospitals unable to function as primary stroke centers to transfer appropriate patients for timely acute care. Recommendations imply that systems should be deliberately designed, but in Colorado an informal system is emerging without coordinated statewide action. We sought to assess the performance of this system with regard to hospital transfers. Methods: The Colorado Stroke Registry (CSR), a Get With The Guidelines-Stroke® database, shared by 39 hospitals, captures clinical data for ∼70% of Colorado strokes. Using data from CSR and the Colorado Hospital Association, we examined transfers during 2007-2009 to assess the effect of transfer on acute thrombolysis and to gain insight into factors that may determine whether transfer occurs. Results: 12,241 records had stroke-events during 2007-2009. Ischemic strokes (IS) were 56.7% of these. Transient ischemic attacks (TIA), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) and non-specified stroke accounted for 23.7%, 4.6%, 11.3%, and 3.7%, respectively. Hospital transfers were noted in 1,487 records (12.1%). Nearly 80% of transfers were to only 6 (15%) of the 39 hospitals. The likelihood of transfer to a hospital was significantly correlated with hospital volume (P = 0.0045). Compared to IS, transfer was less likely for TIA but more likely for ICH and SAH (OR: 0.28, 1.59, 4.37, respectively; P <0.0001 for each). Transfer was more likely for: men than women (13.4% v 11.0%, P <0.0001); whites than blacks (11.8% v 5.3%, P <0.0001); and Hispanics than non-Hispanics (13.3% v 12.1%, P=0.002). Transfers were younger with higher NIHSS scores (mean age: 63.9 v 70; mean NIHSS 9.7 v 7.1, P <0.0001 for both). Transfer was less likely if additional medical problems were recorded (11% v 20.1%, P< 0.0001) or if primary insurance was Medicare rather than commercial (5.9% v 10.1%, P<0.0001). Day of week did not predict transfer. In a multivariate logistic model of transfer for IS, these variables were independently predictive: age, NIHSS and absence of additional problems. IS transfers were more likely to receive IV tPA (22.9% v 10.7%, P<0.0001) and more likely to die in-hospital (8.6% v 4.5%, P<0.0001), but no more likely to have clinically significant ICH following tPA (3.7% v 5.7%, P=0.324). Conclusions: Without centralized planning, a system of acute stroke care is evolving in Colorado. In the system, transfers are common for IS, SAH, and ICH. 15% of hospitals receive nearly 80% of transfers. Transfer is more common for IS patients who: are younger, have higher NIHSS scores and lack additional problems. Transferred IS patients are more likely to receive IV tPA but not to have clinically significant ICH after thrombolysis.

Abstract 58: Do Ischemic Stroke Patients Treated With Thrombolysis Receive Better Quality Multidisciplinary Stroke Care Than Patients Who Do Not?

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Lizz Paley ◽  
Benjamin Bray ◽  
Martin James ◽  
James Campbell ◽  
Geoffrey Cloud ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Time Window ◽  
Multidisciplinary Care ◽  
Stroke Care ◽  
Hospital Arrival ◽  
Stroke Services ◽  
To Receive ◽  
Stroke Register

Background: Over recent years many stroke services have developed fast track services for stroke thrombolysis. We aimed to identity if such hyperacute provision also improved other aspects of multidisciplinary care by comparison to non-thrombolysed patients. Methods: Data were extracted from the national stroke register (Sentinel Stroke National Audit Programme (SSNAP)) of adults with acute ischemic stroke admitted to all hospitals in England and Wales from April 2013-March 2014. The quality of care received was compared across three groups: patients treated with IV-tPA, patients arriving at hospital within a 4h time window of onset but who were not treated with tPA, and patients who arrived outside the 4h time window and who were not treated with tPA. Results: Of 65 194 adults admitted with acute ischemic stroke to 194 hospitals, 8 602 (13.2%) were treated with tPA, 20 361 (31.2%) arrived within 4h of onset but were not treated with tPA, and 36 231 (55.6%) arrived outside the time window. A greater proportion of patients treated with tPA were admitted to a stroke unit within 4 hours of hospital arrival (85%) compared to those within the time window but not treated with tPA (57%) or those outside the time window (54%), Chi2 p<0.0001. A similar pattern was observed for being seen by a stroke consultant within 24 hours (92%, 72%, 72% respectively, Chi2 p<0.0001), and for the proportion of patients scanned within 12 hours (100%, 87%, 81% respectively, Chi2 p<0.0001). tPA recipients were more likely to receive a swallow assessment within 4h (83%, 64%, 60%, p<0.0001), and to be assessed by speech and language therapists with 72h (85%, 77%, 78%, p<0.0001). Smaller differences were found for occupational therapy (91%, 85%, 86%, p<0.0001) and physiotherapy assessments within 72h (97%, 93%, 94%, p<0.0001). Conclusions: Patients treated with tPA receive faster access to specialist stroke services, and were more likely to receive various aspects of multidisciplinary stroke care. Stroke services should ensure that all patients have rapid access to good quality multidisciplinary stroke care, not just those in receipt of thrombolysis.

Abstract 3097: Acute In-hospital Stroke: How Do We Do Compared To Strokes In The Emergency Department?

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Dolora Wisco ◽  
Christopher Newey ◽  
Pravin George ◽  
James Gebel
Keyword(s):  
Emergency Department ◽  
Time Window ◽  
Stroke Treatment ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tertiary Center ◽  
Neuro Imaging ◽  
One Year ◽  
To Receive ◽  
Iv Tpa ◽  
Arterial Thrombolysis

Introduction: Intravenous tissue plasminogen activator (IV tPA) has been approved for treating strokes up to 3 hours after onset of symptoms and may be beneficial up to 4.5 hours in patients who qualify. Additionally, neuro-intervention, i.e., intra-arterial thrombolysis or thrombectomy, is also an approved treatment option. Population studies show that 6% receive IV tPA within 3 hours of stroke onset. However, in-hospital strokes present challenges to treating within an adequate time. We present here our experience with in-hospital strokes, treatments, and identifiable delays in treatments. Methods: Single, tertiary center retrospective study of 55 in-hospital strokes over a one-year period from January 2009 to January 2010, and strokes in the Emergency Department over 6 month period from January 2010 to June 2010. Results: Twenty-nine in-hospital strokes were evaluated within 3 hours of symptoms onset. Two (6.9%) received IV tPA, and four (13.8%) received neuro-intervention (either intra-arterial thrombolysis or thrombectomy). None of the patients who presented greater than 3 hours after symptom onset was treated with any treatment (n=28). When compared to patients who present to the ED within 3 hours, in-hospital strokes were less likely to get IV tPA (6.9% vs. 20.8%), and they were more likely to receive neuro-intervention (13.8% vs. 10.3%). Neuro-intervention was performed on 9.09% of all in-hospital strokes (1 of 5 presented beyond the 3 hour time window). For in-hospital strokes that receive any treatment within 3 hours, the average time to neurology evaluation, to CT, and to treatment are 35 min, 68 min, and 237 min, respectively. For strokes in the Ed, the average time to evaluation, to CT, and to treatment are 90 min, 28 min, and 66 min respectively. The delay for in-hospital strokes is in obtaining the CT and initiating the treatment. Discussion: In-hospital stroke patients wait longer than their ED counterparts to be taken to CT and to receive stroke treatment. They are also less likely to receive IV tPA, and more likely to receive neuro-intervention. The longer time to neuro-imaging and thrombolytic treatment may reflect the fact that patients suffering in-hospital strokes have more complex medical co-morbidities that must be taken account during the evaluation and administration of thrombolytic therapy.

Abstract TP369: EMS and ED Feedback Tool: Improving Metrics and Patient Outcome

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Angelia F Russell ◽  
Matthew E Tilem ◽  
Barbara V Voetsch
Keyword(s):  
Patient Outcome ◽  
Emergency Department ◽  
Stroke Patient ◽  
Stroke Care ◽  
Time Of Arrival ◽  
Modified Rankin Scale ◽  
Discharge Diagnosis ◽  
Cat Scan ◽  
Free Care ◽  
Patient’S Outcome

Background: Prompt recognition by emergency medical services (EMS) and emergency department (ED) triage is paramount in the treatment and survival of the stroke patient. We hypothesized that providing prompt feedback to EMS and ED on stroke care may improve EMS and hospital metrics and raise the hospital’s defect free care. Objective: To determine if the feedback provided to EMS and ED would improve the metrics and patient outcome. Method: A retrospective analysis comparing the percent of patients met the metrics prior to and after initiation of the feedback tools. Feedback forms were developed May 2015, education provided on forms Jun 2015, and implemented Jul 2015. Feedback was provided on all patients called in as a SA, BA on arrival, and/or patients with a discharge diagnosis of stroke. Results: Comparing the first six months prior to the feedback tool (127 BA in ED and 31 EMS SA) with the six months after (173 BA in the ED and 79 EMS SA) the Get with the Guideline (GWTG) timeline goals in the ED improved (Time of Arrival (TOA) to MD, goal 10 minutes, May 2015 35% to Dec 2015 100%; TOA to Neurology Consult, goal 15 minutes, May 2015 65% to Dec 2015 82%; TOA to Cat Scan (CT), goal 25 minutes, May 2015 41% to Dec 2015 79%; TOA to CT read, goal 45 minutes, May 2015 12% to Dec 2015 71%; TOA to t-PA, goal 60 minutes, May 2015 0% to Dec 2015 80%; CT ordered as a stroke, May 2015 21% to Dec 2015 84%; dysphagia screening prior to by mouth, May 2015 29% to Dec 93%) and the number of stroke alerts increased (pre-notification rates Q1/Q2 26.3%; Q3/Q4 56.8%). The hospital’s stroke defect free care in Q1/Q2 (77.3%) increased in Q1/Q2 2016 (97.2%). With the improvements in the EMS, ED, and hospital metrics, length of stay (LOS) decreased (Q1/Q2 5.77 days to Q3/Q4 5.05 days) and more patients were discharged with a lower modified Rankin Scale (mRS) (Q1/Q2 mRS 0-3 33%; Q3/Q4 mRS 0-3 48%). Conclusion: The EMS and ED metrics improved and continue to improve despite a growing and thriving neurology service. By providing the stroke care feedback, EMS and ED developed a more vested interested in the patient’s outcome. Based on the response from the EMS and ED staff on the stroke feedback tools, it is the most expedient and efficient way to communicate and continually educate on the care of the stroke patient both pre-hospital and in hospital.

Abstract TMP77: Race and Sex Differences in tPA Utilization Among Older Ischemic Stroke Patients

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Michael Lyerly ◽  
Farhaan Vahidy ◽  
John Donnelly ◽  
Katrina Booth ◽  
Karen C Albright
Keyword(s):  
Ischemic Stroke ◽  
Nationwide Inpatient Sample ◽  
Stroke Care ◽  
Acute Stroke Care ◽  
Older Americans ◽  
Lower Odds ◽  
Medical Comorbidities ◽  
Procedure Code ◽  
Receive Treatment ◽  
Iv Tpa

Introduction: The risk of ischemic stroke doubles for each decade beyond the age of 55. While disparities, particularly racial disparities, have been described for many aspects of acute stroke care, these disparities have not been well characterized among older adults. The purpose of this analysis was to evaluate potential differences in IV-tPA utilization among acute ischemic stroke (AIS) patients aged ≥65 years. Methods: We used the Nationwide Inpatient Sample (NIS) to examine primary AIS diagnosis discharges (ICD-9 codes 433.x1, 434.x1 and 436) from US hospitals over 2006-2011, among those aged ≥ 65 years. Utilization of IV-tPA was identified using procedure code 99.10. Multivariate logistic regression was conducted to determine age and race associations with IV tPA utilization. Results: Over the 6 year study period, we identified 1.5 million ischemic stroke discharges, with 3.9% receiving IV-tPA. Compared to discharges who did not receive treatment, those receiving IV-tPA were less likely to be female and black. The odds of women receiving IV-tPA were 10% lower than men. After adjusting for demographics, insurance, and medical comorbidities, the odds of women receiving IV-tPA were still 5% lower (Table). When compared to non-black discharges, older blacks were at 25% lower odds of receiving IV-tPA. After adjusting for demographics, insurance and medical comorbidities, older blacks were at 22% lower odds of receiving IV-tPA (Table). Conclusions: Among older Americans, women and blacks have lower odds of being treated with IV-tPA, even after adjusting for age, insurance and comorbidities. A greater understanding of the reasons for these unexplained differences in the fastest growing proportion of our population is needed.

Abstract 21: Are Stroke Outcomes Influenced by New Starting Residents? The July Effect: Myth or Reality?

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Tai Hwan Park ◽  
Jitphapa Pongmoragot ◽  
Shudong Li ◽  
Gustavo Saposnik ◽  
Keyword(s):  
Functional Outcome ◽  
Performance Measures ◽  
Stroke Care ◽  
Teaching Hospitals ◽  
Stroke Severity ◽  
Acute Stroke Care ◽  
Stroke Outcomes ◽  
July Effect ◽  
Negative Effect ◽  
To Receive

Background: Acute stroke care provided by comprehensive stroke centers usually follows prespecified protocols. However, there are concerns about lower quality of care and poorer stroke outcomes early after new trainnees (e.g.) residents start in July in academic/teaching hospitals. This has been called ‘the July effect’. Objective: To evaluate access to specialized care and outcomes among patients admitted with an acute ischemic stroke (AIS) in July and other months. Hypothesis: We hypothesized that there were no significant differences in access to stroke care and outcomes for patients admitted in July when new trainees start at academic centers. Methods: Patients presenting with an AIS at 11 stroke centers in Ontario, Canada, between 2003 and 2009 were identified from the Registry of the Canadian Stroke Network. We compared performance measures and functional outcomes (death at 30 days, modified Rankin Scale 3 to 5 at discharge) between AIS patients admitted in July of each studied year and those who admitted during other months. Results: Of 10,319 eligible patients with an AIS, 882 (8.5%) were admitted in July. There was not difference in age, sex, or baseline stroke severity between patients admitted in July or other months. Among the performance measures analyzed, AIS admitted in July were less likely to receive thrombolysis (12.1% vs. 16.0%, p=0.002), swallowing test (64.4% vs. 67.9%, p=0.033), and admission to stroke unit (61.9% vs. 67.6%, <0.001). There was no difference in death at 30-days (16.4% vs. 16.1%, p=0.823) or poor functional outcome (61.0% vs. 63.5%, p=0.14) between two groups (Table). Conclusion: AIS patients admitted in July were less likely to receive thrombolysis and be admitted to stroke units compared to patients admitted on the rest of the year. However, there was no negative effect of “admission on July” on functional outcome or death.

Abstract TP227: Outcomes of a Regionalized Stroke Care System

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Denisse Sequeira ◽  
Christian Martin-Gill ◽  
Gregory Lowry ◽  
Marcus Robinson ◽  
Hinnah Siddiqui ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Functional Outcome ◽  
Stroke Care ◽  
Discharge Diagnosis ◽  
Hospital Data ◽  
Exact Test ◽  
Endovascular Interventions ◽  
Good Functional Outcome ◽  
Suspected Stroke ◽  
Iv Tpa

Introduction: Strokes are one of the leading causes of death and disability. Time-sensitive therapies are available including IV-TPA and endovascular therapies which require rapid and effective triage. Endovascular therapies are available at comprehensive stroke centers (CSC). We evaluated if there was any improvement in outcomes for patients who are transported directly to a CSC. Hypothesis: Patients that receive acute interventions for stroke have improved outcomes when transferred directly to CSC as compared to transport to a PSC and then transferred to a interventional facility. Methods: A retrospective cohort study of 5,188 patients transported from January 2012 to December 2013 with an EMS provider impression of suspected stroke via both air and ground transport. Of these, data was complete for 1,196 patients with a confirmed discharge diagnosis of ischemic stroke. Pre-hospital data was abstracted from EMS charts. Ischemic strokes were identified by final hospital discharge diagnosis and good functional status was defined as a modified Rankin scale <3 at discharge. Categorical outcomes were tested using Fishers Exact Test and Ordinal outcomes using the Mann Whitney Test. Results: For those with complete data mortality was 10% (CI 8.3-11.7) in this cohort with good functional outcomes in 37% (CI 34.3-39.7) of patients. IV- TPA was administered to 293 (24%) and endovascular interventions were performed in 167 (14%). There were 739 (63%) inter-facility transfers and 442 (37%) received directly from the scene. Transport to the CSC occurred by air in 798 (67%) cases as compared to 398 (33%) by ground. Mortality and good functional outcome did not differ between patients transferred and those taken directly to the CSC. Among patients receiving either TPA or endovascular therapy, direct transport to the CSC is associated with good functional outcome (Fisher’s exact= 0.041) but not with mortality. Conclusions: Among patients with a diagnosis of ischemic stroke presenting to a CSC, there is no difference in mortality and good functional outcome as a function of transfer from the scene or transfer from another facility. However, among those who received tPA or endovascular intervention good functional outcome was associated with direct presentation to the CSC.

Abstract P258: Factors Associated With Imaging Choice of Acute Ischemic Stroke Patients and the Related Health Outcomes

Circulation ◽  
2020 ◽  
Vol 141 (Suppl_1) ◽  
Author(s):  
Jason J Wang ◽  
Artem Boltyenkov ◽  
Gabriela Martinez ◽  
Jeffrey M Katz ◽  
Angela Hoang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Health Outcomes ◽  
Acute Ischemic Stroke ◽  
Regression Models ◽  
Critical Role ◽  
Clear Understanding ◽  
Negatively Associated ◽  
Factors Associated ◽  
To Receive ◽  
Iv Tpa

Introduction: Acute ischemic stroke (AIS) presents an ongoing challenge for population health and availability of healthcare resources. Imaging plays a critical role in both diagnosis and treatment decisions in AIS, but optimal utilization regarding advanced imaging with angiography and perfusion using either CTAP or MRAP remain uncertain according to national guidelines. Consequently, wide variation in AIS imaging exists in clinical practice, mostly defaulted to physician preferences and institutional factors, without a clear understanding of the benefits and risks involved in stroke care. Although CTAP and MRAP each have unique benefits and risks in the AIS setting, the effect of this risk-benefit tradeoff on health outcomes and utilization of resources is unknown. This study analyses the factors associated with imaging preferences and the related health outcomes. Method: We performed a retrospective study on an AIS registry consisting of consecutive patients admitted to our institution from November 1, 2011, through October 1, 2018. Imaging and treatment selections and modified Rankin Score (mRS) at discharge were the main outcomes. Independent variables include age, gender, race-ethnicity, and NIH stroke score (NIHSS) at admission. Multivariable logistic regression models were performed. P<0.05 was considered statistically significant. Results: 1884 patients with curated imaging data during hospitalization were included. Among them, 32% were ≥80 years old, 47.4% female, 15.53% black, 60.3% white, and 24.4% with NIHSS≥10 at admission. CTAP and MRAP were performed in 21.1% and 72.2% patients, respectively. 46.1% received thrombolytics (IV-tPA), 1.3% had endovascular therapy (EVT), and 52.7% were not treated. The two clinical outcomes were independent functionality at discharge (mRS0-2) at 48.4%, and patients expired in hospital at 7.1%. Adjusted by all the factors, regression models showed that patients with NIHSS≥10 were more likely to receive CTAP (p<0.0001, OR=3.39) and less likely to receive MRAP (p<0.0001, OR=0.48); whereas age ≥80 was less likely to receive CTAP (p<0.0001, OR=0.37) or MRAP (p<0.0001, OR=0.37). NIHSS≥10 (p<0.0001, OR=0.15) and IV-tPA (p=0.0006, OR=0.69) were negatively related to independent functionality at discharge, and MRAP (p<0.0001, OR=1.97) was positively related to it. NIHSS≥10 (p=0.0212, OR=1.69) were positively related to mortality, while utilization of MRAP showed a negative relationship (p<0.0001, OR=0.26) with it. Conclusion: Higher NIHSS was positively associated with mortality and utilization of CTAP, while it is negatively associated with MRAP. MRAP was positively related to independent functionality at discharge. Older age was negatively associated with CTAP or MRAP utilization.

A decade of health assessments in Appalachia

2017 ◽  
Vol 30 (4) ◽  
pp. 312-318
Author(s):  
E. Scott Sills ◽  
Xiang Li
Keyword(s):  
Emergency Services ◽  
Performance Metrics ◽  
Medical Center ◽  
Stroke Care ◽  
Assessment Instrument ◽  
Additional Stress ◽  
Process Of Care ◽  
Underserved Area ◽  
Content Type ◽  
Over Time

Purpose The purpose of this paper is to describe standardized clinical process of care and quality performance metrics at Roane Medical Center (RMC) and compare data from 2005 to 2015. Design/methodology/approach Information was extracted from a nationwide sample of short-term acute care hospitals using the Hospital Quality Alliance (HQA) database, evaluating multiple parameters measured at RMC. HQA data from RMC were matched against state and national benchmarks; findings were also compared with similar reports from the same facility in 2005. Findings Information collected by HQA expanded substantially in ten years and queried different parameters over time, thus exact comparisons between 2005 and 2015 cannot be easily calculated. Nevertheless, analysis of process of care data for 2015 placed RMC at or above state- and national-average performance in 64.9 percent (24 of 37) and 56.5 percent (26 of 46) categories, respectively. RMC registered superior process of care scores in heart failure care, pneumonia care, thrombus prevention and care, as well as stroke care. While RMC continues to perform favorably against state and national reference groups, the differences between RMC vs state and RMC vs national averages using current reporting metrics were both statistically smaller in 2015 compared to 2005 (p<0.05). Research limitations/implications Perhaps the most significant interval health event for the RMC service area since 2005 was a coal ash spill at the nearby Tennessee Valley Authority facility in December 2008. Although reports on environmental and health effects following one of the largest domestic industrial toxin releases reached a number of important conclusions, the consequences for RMC in terms of potential added clinical burden on emergency services and impact on chronic health conditions have not been specifically studied. This could explain data reported on emergency department services at RMC but additional research will be needed to establish causality. Practical implications While tracking of care processes at all US hospitals will be facilitated by refinements in HQA tools, longitudinal evaluations for any specific unit will be more meaningful if the assessment instrument undergoes limited change over time. Social implications Appalachia remains one of several regions in the USA often identified as medically underserved. Hospitals here have confronted the challenge of diminished reimbursement, high expenses, limited staffing and other financial hardships in a variety of ways. Since the last published report on RMC, a particularly severe global recession has placed additional stress on organizations offering crucial health services in the region. Originality/value As a follow-up study to track potential changes which have been registered in the decade 2005-2015, this is the first report to provide original, longitudinal analysis on RMC, an institution operating in a rural and underserved area.

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