Abstract 137: Neighborhood Income and 30-day Readmissions for Stroke and Transient Ischemic Attack

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Judith H Lichtman ◽  
Erica C Leifheit-Limson ◽  
Yun Wang ◽  
Larry B Goldstein
Keyword(s):  
Transient Ischemic Attack ◽  
Stroke Care ◽  
Stroke Incidence ◽  
Logistic Regression Models ◽  
Post Stroke ◽  
Explanatory Factors ◽  
Nationally Representative ◽  
Ischemic Attack ◽  
The Relationship ◽  
Income Quartile

Background: Residence in a socioeconomically challenged neighborhood is associated with increased stroke incidence and shorter post-stroke survival. Little is known about the relationship between socioeconomic status and 30-day post-stroke readmissions. We used a nationally representative readmission database that includes both insured and uninsured patients to determine whether there is a relationship between community-level income and 30-day readmissions after stroke and transient ischemic attack (TIA). Methods: Hospitalizations were identified in the 2013 Nationwide Readmissions Database for patients aged ≥18y with subarachnoid hemorrhage (SAH; ICD-9 430), intracerebral hemorrhage (ICH; ICD-9 431), ischemic stroke (IS; ICD-9 433, 434, 436), and TIA (ICD-9 435). We used mixed logistic regression models with hospital-specific random effects to assess the relationship between community income level (measured according to the median household income quartile for a patient’s ZIP code) and 30-day readmissions. Models were stratified by age and adjusted for demographic and clinical characteristics. Results: There were 7,061 hospitalizations for SAH, 17,325 for ICH, 212,306 for IS, and 67,606 for TIA. In unadjusted analyses, 30-day readmission rates decreased with increasing income quartile for younger patients hospitalized with IS and SAH (figure). In adjusted analyses, this association persisted only among those with IS aged 18-44y for whom each quartile increase in income was associated with a 7% decrease in 30-day readmission (figure). There were no significant associations between income and 30-day readmission for SAH, ICH, and TIA. Conclusions: Overall, community income was not associated with readmission for hemorrhagic stroke and TIA, but higher income was associated with lower 30-day readmission for younger IS patients. Possible explanatory factors such as better access to post-stroke care warrant further research for this subgroup.

Safety and feasibility of post-stroke care and exercise after minor ischemic stroke or transient ischemic attack: MotiveS & MoveIT

2014 ◽  
Vol 34 (3) ◽  
pp. 401-407 ◽  
Author(s):  
H.M. Boss ◽  
S.M. Van Schaik ◽  
I.A. Deijle ◽  
E.C. de Melker ◽  
B.T.J. van den Berg ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Transient Ischemic Attack ◽  
Stroke Care ◽  
Post Stroke ◽  
Minor Ischemic Stroke ◽  
Ischemic Attack

Abstract 20: Patterns of Stroke Center Certification and the Impact on Stroke Mortality in Counties of New York State

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Emily Chapman ◽  
Kurt A Yaeger ◽  
J D Mocco
Keyword(s):  
New York ◽  
Socioeconomic Status ◽  
Household Income ◽  
New York State ◽  
Stroke Care ◽  
Stroke Mortality ◽  
Median Household Income ◽  
Stroke Incidence ◽  
York State ◽  
The Relationship

Introduction: To establish a statewide stroke system in March 2019, New York State (NYS) created the Stroke Designation Program. Stroke centers (SCs) must be certified by a state-approved certifying organization (CO), which is tasked with initial designation and ongoing re-certification. Previous research has found an association at the national level between socioeconomic status and access to higher levels of acute stroke care. Objective: This study characterizes the relationship between socioeconomic status of NYS populations and stroke care level access by comparing median household income and wealth in counties with and without certified SCs. Methods: Population and median household income from the U.S. Census (2010), stroke epidemiological data from the Center for Disease Control, and Area Deprivation Index (ADI) data (ranked within NYS) from the Neighborhood Atlas, a project that quantifies disadvantage by census tract, were collected and averaged for each county. Income has been used to assess local wealth and ADI to analyze community health risks. Certification data were mined from quality check databases for The Joint Commission and Det Norske Veritas, the most commonly used COs. Student’s t-tests compared income and ADI in counties with at least one certified SC to those without. Linear regression characterized the relationship between income and ADI with number of certified SCs, stroke incidence and stroke mortality. Results: All 62 counties in NYS were investigated to yield 40 certified SCs. Counties with at least one certified SC had a significantly higher income ($68,183.63 vs. $57,155.12; p=0.03) and lower ADI (5.90 vs. 7.37; p=0.004) compared to counties with no certified SC. Higher income (p<0.001) and lower ADI (p<0.001) were also associated with more certified SCs. Counties with fewer certified SCs had significantly higher stroke mortality (p<0.001) despite having similar stroke incidence. Conclusion: Socioeconomic heterogeneity in NYS counties is correlated to differential access to certified SCs and quality stroke care, as fewer centers are found in lower-income and disadvantaged communities. Although populations with less access experience stroke at similar rates, this study finds higher death rates in these counties.

scholarly journals Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018

2018 ◽  
Vol 13 (9) ◽  
pp. 949-984 ◽  
Author(s):  
JM Boulanger ◽  
MP Lindsay ◽  
G Gubitz ◽  
EE Smith ◽  
G Stotts ◽  
...  
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Transient Ischemic Attack ◽  
Best Practice ◽  
Stroke Care ◽  
Stroke Management ◽  
Practice Recommendations ◽  
Prehospital Emergency ◽  
Ischemic Attack

The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider’s recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.

scholarly journals The Impact of Pre- and Post-Stroke Statin Use on Stroke Severity and Long-Term Outcomes: A Population-Based Cohort Study

2019 ◽  
Vol 47 (5-6) ◽  
pp. 260-267 ◽  
Author(s):  
Clare Flach ◽  
Maria Elstad ◽  
Walter Muruet ◽  
Charles D.A. Wolfe ◽  
Anthony G. Rudd ◽  
...  
Keyword(s):  
Population Based ◽  
Stroke Recurrence ◽  
Stroke Severity ◽  
Stroke Incidence ◽  
Post Stroke ◽  
Improvement Programs ◽  
The Impact ◽  
The Relationship ◽  
Statin Use

Background: The benefit of statins on stroke incidence is well known. However, data on the relationship between pre- and post-stroke statin use, recurrence, and survival outcomes are limited. We aim to investigate the short- and long-term relationships between statin prescription, stroke recurrence, and survival in patients with first-ever ischemic stroke. Methods: Data were collected from the population-based South London Stroke Register for the years 1995–2015. Patients were assessed at the time of first ever stroke, 3 months, and annually thereafter. Data on vascular risk factors, treatments prescribed, sociodemographic characteristics, stroke subtype, survival, and stroke recurrence were collected. Cox proportional hazard analyses were used to assess the relationship of statin prescriptions pre- and post-stroke on stroke severity, long-term recurrence and survival. Results: Patients prescribed statins both pre- and post-stroke showed a 24% reduction in mortality (adjusted Hazard Ratio [aHR] 0.76, 0.60–0.97), those who were prescribed statins pre-stroke and then stopped post-stroke showed greater risk of mortality (aHR 1.85, 1.10–3.12) and stroke recurrence (aHR 3.25, 1.35–7.84) compared to those that were not prescribed statins at any time. No associations were observed between pre-stroke statin and severity of the initial stroke overall, though a protective effect against moderate/severe stroke (Glasgow Coma Scale ≤12) was observed in those aged 75+ years (aOR 0.70, 0.52–0.95). Conclusions: Statins play a significant role in improving the survival rates after a stroke. Adherence to the National Guidelines that promote statin treatment, primary and secondary prevention of stroke should be monitored and a focus for quality improvement programs.

scholarly journals Systolic blood pressure as a predictor of transient ischemic attack/minor stroke in emergency department patients under age 80: a prospective cohort study

BMC Neurology ◽  
2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Andrew M. Penn ◽  
Nicole S. Croteau ◽  
Kristine Votova ◽  
Colin Sedgwick ◽  
Robert F. Balshaw ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Emergency Department ◽  
Transient Ischemic Attack ◽  
Final Diagnosis ◽  
Conditional Inference ◽  
Minor Stroke ◽  
Logistic Regression Models ◽  
Stroke Mimics ◽  
Stroke Mimic ◽  
Ischemic Attack

Abstract Background Elevated blood pressure (BP) at emergency department (ED) presentation and advancing age have been associated with risk of ischemic stroke; however, the relationship between BP, age, and transient ischemic attack/minor stroke (TIA/MS) is not clear. Methods A multi-site, prospective, observational study of 1084 ED patients screened for suspected TIA/MS (symptom onset < 24 h, NIHSS< 4) between December 2013 and April 2016. Systolic and diastolic BP measurements (SBP, DBP) were taken at ED presentation. Final diagnosis was consensus adjudication by stroke neurologists; patients were diagnosed as either TIA/MS or stroke-mimic (non-cerebrovascular conditions). Conditional inference trees were used to define age cut-points for predicting binary diagnosis (TIA/MS or stroke-mimic). Logistic regression models were used to estimate the effect of BP, age, sex, and the age-BP interaction on predicting TIA/MS diagnosis. Results Over a 28-month period, 768 (71%) patients were diagnosed with TIA/MS: these patients were older (mean 71.6 years) and more likely to be male (58%) than stroke-mimics (61.4 years, 41%; each p < 0.001). TIA/MS patients had higher SBP than stroke-mimics (p < 0.001). DBP did not differ between the two groups (p = 0.191). SBP was predictive of TIA/MS diagnosis in younger patients, after accounting for age and sex; an increase of 10 mmHg systolic increased the odds of TIA/MS 18% (odds ratio [OR] 1.18, 95% CI 1.00–1.39) in patients < 60 years, and 23% (OR 1.23, 95% CI 11.12–1.35) in those 60–79 years, while not affecting the odds of TIA/MS in patients ≥80 years (OR 0.99, 95% CI 0.89–1.07). Conclusions Raised SBP in patients younger than 80 with suspected TIA/MS may be a useful clinical indicator upon initial presentation to help increase clinicians’ suspicion of TIA/MS. Trial registration ClinicalTrials.gov NCT03050099 (10-Feb-2017) and NCT03070067 (3-Mar-2017). Retrospectively registered.

scholarly journals Exploring the Collateral Damage of the COVID-19 Pandemic on Stroke Care

Stroke ◽  
2021 ◽  
Author(s):  
Clotilde Balucani ◽  
J. Ricardo Carhuapoma ◽  
Joseph K. Canner ◽  
Roland Faigle ◽  
Brenda Johnson ◽  
...  
Keyword(s):  
Transient Ischemic Attack ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
Unintended Consequences ◽  
Stroke Subtype ◽  
Hospital Arrival ◽  
Time Period ◽  
Ischemic Attack ◽  
The Impact ◽  
Emergency Measures

Background and Purpose: During the coronavirus disease 2019 (COVID-19) pandemic, the various emergency measures implemented to contain the spread of the virus and to overcome the volume of affected patients presenting to hospitals may have had unintended consequences. Several studies reported a decrease in the number of stroke admissions. There are no data on the impact of the COVID-19 pandemic on stroke admissions and stroke care in Maryland. Methods: A retrospective analysis of quality improvement data reported by stroke centers in the State of Maryland. The number of admissions for stroke, overall and by stroke subtype, between March 1 and September 30, 2020 (pandemic) were compared with the same time period in 2019 (prepandemic). Median last known well to hospital arrival time, the number of intravenous thrombolysis and thrombectomy were also compared. Results: During the initial 7 months of the pandemic, there were 6529 total admissions for stroke and transient ischemic attack, monthly mean 938 (95% CI, 837.1–1038.9) versus prepandemic 8003, monthly mean 1156.3 (CI, 1121.3–1191.2), P <0.001. A significant decrease was observed in intravenous thrombolysis treatments, pandemic 617, monthly mean 88.1 (80.7–95.6) versus prepandemic 805, monthly mean 115 (CI, 104.3–125.6), P <0.001; there was no significant decrease for thrombectomies. The pandemic decreased the probability of admissions for stroke and transient ischemic attack by 19%, for acute ischemic stroke by 20%, for the number of intravenous thrombolysis performed by 23%. There was no difference in the number of admissions for subarachnoid hemorrhage, pandemic 199, monthly mean 28.4 (CI, 22.5–34.3) versus prepandemic 217, monthly mean 31 (CI, 23.9–38.1), respectively, P =0.507. Conclusions: Our findings suggest that the COVID-19 pandemic adversely affected the acute care of unrelated cerebrovascular emergencies.

scholarly journals Serum soluble ST2 is a predictor for poor long-term prognosis after transient ischemic attack and ischemic stroke: a cohort study

2019 ◽  
Author(s):  
Xuan Tian ◽  
Yinan Guo ◽  
Xiao Wang ◽  
Lulu Pei ◽  
Xin Wang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Adverse Events ◽  
Transient Ischemic Attack ◽  
Predictive Value ◽  
Adverse Outcomes ◽  
Soluble St2 ◽  
Logistic Regression Models ◽  
C Statistic ◽  
Kaplan Meier ◽  
Ischemic Attack

Abstract Background Soluble ST2 (sST2) is a novel inflammation marker for the prediction of adverse outcomes in patients with cardiovascular disease and diabetes mellitus. The aim of the present study was to examine the predictive value of serum sST2 for prognostic outcomes in patients with transient ischemic attack (TIA)/ischemic stroke.Methods Patients within 24 h after symptom onset were prospectively enrolled based on the TIA/ischemic stroke database of the First Affiliated Hospital of Zhengzhou University. The 1-year prognostic outcomes were composite adverse events (including ischemic and hemorrhagic stroke, myocardial infarction, and all-cause death) and a combination of major disability and death [modified Rankin Scale (mRS), 3-6]. Cox proportional hazard and logistic regression models were used to evaluate the association between serum sST2 and TIA/ischemic stroke prognosis. The C statistic, net reclassification index (NRI), and integrated discrimination index (IDI) were used to present improvement in risk classification.Results Serum sST2 levels were positively correlated with National Institutes of Health Stroke Scale (NIHSS) scores. Kaplan-Meier analysis indicated a significantly different risk in composite adverse events between patients with higher and those with lower levels of sST2 (P=0.006). Serum sST2 was an independent predictor for composite adverse events (HR: 2.517, 95% CI: 1.279-4.956, P=0.008) and major disability or death (OR: 3.126, 95% CI: 1.452-6.728, P=0.004) after multivariate adjustment. The addition of the sST2 to the NIHSS score significantly improved the predictive value for prognostic outcomes in patients with TIA/ischemic stroke (C statistic: 0.021, IDI: 1.91%, P=0.042 for composite adverse events; NRI: 32.82%, P=0.042 for major disability or death).Conclusions Serum sST2 levels were positively associated with the severity of TIA/ischemic stroke and could independently predict composite adverse events and major disability or death, indicating that sST2 may be a potential prognostic marker for TIA/ischemic stroke.

Impaired heart rate variability triangular index to identify clinically silent strokes in patients with atrial fibrillation

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
P Haemmerle ◽  
C Eick ◽  
A Bauer ◽  
K.D Rizas ◽  
M Coslovsky ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Heart Rate ◽  
Heart Rate Variability ◽  
Transient Ischemic Attack ◽  
Brain Mri ◽  
Binary Logistic Regression ◽  
Funding Source ◽  
Logistic Regression Models ◽  
History Of ◽  
Ischemic Attack

Abstract Introduction The identification of clinically silent strokes in patients with atrial fibrillation (AF) is of high clinical relevance as they have been linked to cognitive impairment. Overt strokes have been associated with disturbances of the autonomic nervous system. Purpose We therefore hypothesize that impaired heart rate variability (HRV) can identify AF patients with clinically silent strokes. Methods We enrolled 1358 patients with AF without a history of stroke or transient ischemic attack from the multicenter SWISS-AF cohort study who were in sinus rhythm (SR-group, n=816) or AF (AF-group, n=542) on a 5 minute resting ECG recording. HRV triangular index (HRVI), the standard deviation of normal-to-normal intervals (SDNN) and the mean heart rate (MHR) were calculated. Brain MRI was performed at baseline to assess the presence of large non-cortical or cortical infarcts, which were considered silent strokes without history of stroke or transient ischemic attack. We constructed binary logistic regression models to analyze the association between HRV parameters and silent strokes. Results At baseline, silent strokes were detected in 10.5% in the SR group and 19.9% in the AF group. In the SR-group, HRVI &lt;15 was the only parameter independently associated with the presence of silent strokes (odds ratio (OR) 1.69; 95% confidence interval (CI): 1.04–2.72; p=0.033) after adjustment for various clinical covariates (age, sex, systolic blood pressure, history of hypertension, history of diabetes, history of heart failure, prior myocardial infarction, prior major bleeding, intake of oral anticoagulation, antiarrhythmics or betablockers). Similarly, in the AF-group, HRVI&lt;15 was independently associated with the presence of silent strokes (OR 1.65, 95% CI: 1.05–2.57; p=0.028). SDNN&lt;70ms and MHR&lt;80 were not associated with silent strokes, neither in the SR group, nor in the AF group (Figure). Conclusions Reduced HRVI is independently associated with the presence of clinically silent strokes in an AF population, both when assessed during SR and during AF. Our data suggest that a short-term measurement of HRV in routine ECG recordings might contribute to identifying AF patients with clinically silent strokes. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Swiss National Science Foundation

Abstract TMP78: Heterogeneous Imaging Practices Associated With Emergency Department Work-Up of Transient Ischemic Attack

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Vincent Timpone ◽  
Alexandria Jensen ◽  
Sharon Poisson ◽  
Premal Trivedi
Keyword(s):  
Emergency Department ◽  
Trend Analysis ◽  
Transient Ischemic Attack ◽  
Primary Analysis ◽  
Icd 10 ◽  
Imaging Utilization ◽  
Nationally Representative ◽  
Type Data ◽  
Ischemic Attack ◽  
Neurovascular Imaging

Introduction: Multiple societal guidelines recommend urgent imaging in patients with transient ischemic attack (TIA) to identify and treat risk factors that may lead to future stroke. Recommended studies include brain imaging, preferably with MRI, and neurovascular imaging (cranio-cervical CTA, cranio-cervical MRA or carotid ultrasound). The purpose of this study was to evaluate whether emergency department (ED) imaging utilization practices comply with recommended guidelines. Methods: Analysis utilized the Nationwide Emergency Department Sample (NEDS), a comprehensive, nationally representative sample of ED visits. Primary analysis was performed on the 2016 cohort, and a secondary trend analysis was performed on cohorts from 2006-2016. Patients diagnosed and discharged from the emergency department with transient ischemic attack were identified using ICD-9 and ICD-10 codes. Brain and neurovascular imaging obtained during the encounter were identified using CPT codes. Demographics, health insurance, patient income, and hospital type data were analyzed and a survey weighted logistic regression analysis was performed to identify predictors of obtaining neurovascular imaging. Results: In 2016 there were 183,216 patients evaluated and discharged from emergency departments with TIA. The percentage of patients receiving brain and neurovascular imaging was 75.73% and 37.99% respectively. Of the top 5 imaging work-ups utilized, the most common (34.06% of cases) was a solitary noncontrast head CT without any neurovascular imaging. Decreased odds of obtaining neurovascular imaging was observed in Medicaid patients (OR: 0.73, 95%CI: 0.66-0.80), non-trauma centers (OR: 0.42, 95%CI: 0.38-0.45), and rural hospital locations (OR: 0.30, 95%CI: 0.27-0.33). Trend analysis demonstrated a steady rise in brain and neurovascular imaging from 34.02% and 6.51% of encounters respectively in 2006 to 75.73% and 37.99% of encounters in 2016. Conclusion: The majority of TIA patients discharged from the ED do not receive recommended neurovascular imaging during their encounter. Follow-up studies are needed to determine whether delayed or incomplete vascular screening increases the risk of future stroke.

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