Abstract 103: Intravenous Thrombolysis for In-Hospital Ischemic Stroke in the Endovascular Era: Findings From the National Get With the Guidelines-Stroke Registry

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Feras Akbik ◽  
Haolin Xu ◽  
Ying Xian ◽  
Shreyansh Shah ◽  
Eric E Smith ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Temporal Trends ◽  
Significant Proportion ◽  
Intravenous Thrombolysis ◽  
Patient Characteristics ◽  
National Registry ◽  
Process Measures ◽  
Get With The Guidelines ◽  
Community Onset ◽  
Iv Tpa

Introduction: A significant proportion of acute ischemic strokes occur while patients are hospitalized for other reasons. Limited data exist on the utilization of intravenous alteplase (IV tPA) for in-hospital stroke, particularly in the endovascular era. We compared temporal trends of IV tPA use, patient characteristics, process measures of quality, and outcomes for in-hospital versus community onset strokes in a national registry. Methods: We performed a retrospective cohort study of Get With The Guidelines-Stroke (GTWG-Stroke) from January 2008 to June 2018 from 2,333 participating sites that included 2,428,178 patients with acute ischemic stroke. In-hospital onset was reported in 67,493 patients. We examined the association between stroke onset location, patient characteristics, comorbidities, treatment with IV tPA and unadjusted and adjusted functional outcomes (Table, standardized differences >10% for significance). Results: Of 67,493 patients with in-hospital onset stroke, 11,123 received IV tPA. The rate of IV tPA administration steadily increased, from 9.5% in 2008 to 20.7% in 2017 (p<0.001). Compared with patients with community-onset strokes who were treated with IV tPA, patients with in-hospital onset stroke had longer times to cranial imaging and administration of IV tPA. Patients with in-hospital onset stroke were less likely to be treated within 60 minutes of recognition, and at discharge, ambulate independently or go directly home. They were more likely to die or be discharged to hospice after adjusting for patient and hospital characteristics. Conclusions: In this national cohort, in-hospital onset strokes are increasingly treated with intravenous tPA in a period that spans the endovascular era. Compared with community-onset stroke, patients with in-hospital onset stroke had longer intervals to thrombolysis and worse outcomes. These data highlight opportunities to improve inpatient systems of stroke care further.

Abstract WP46: Patient Characteristics, Quality and Outcomes After Endovascular Therapy for In-Hospital Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Feras Akbik ◽  
Haolin Xu ◽  
Ying Xian ◽  
Shreyansh Shah ◽  
Eric E Smith ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Therapy ◽  
Functional Outcomes ◽  
Patient Characteristics ◽  
National Registry ◽  
Arterial Puncture ◽  
Process Measures ◽  
Logistic Regression Models ◽  
Quality And Outcomes ◽  
Community Onset

Introduction: A significant number of acute ischemic strokes occur while patients are hospitalized for other reasons. No national data have been reported on endovascular therapy (EVT) for in-hospital onset stroke. Here we compare the patient characteristics, process measures of quality, and outcomes for in-hospital onset vs. community-onset of strokes in a large US national registry. Methods: We performed a retrospective cohort study of Get With The Guidelines-Stroke (GTWG-Stroke) from January 2008 to June 2018 from 2,333 participating sites that included 2,428,178 patients with acute ischemic stroke. Among 67,493 in-hospital onset strokes, 2494 (3.7%) underwent EVT. We examined the association between key patient characteristics (in-hospital onset, demographics, comorbidities, treatment with EVT) and functional outcomes using multivariable logistic regression models. Results: The rate of EVT increased from 2.5% in 2008 to 6.4% in 2018 (p<0.001), with a significant and sustained increase in EVT after the second quarter of 2015 (p<0.0001). Compared with patients with community-onset strokes, patients with in-hospital onset stroke had longer times to cranial imaging and arterial puncture but similar median NIHSS (16 (9 - 21) vs. 16 (10 - 21) Std Diff 1.9). Patients with in-hospital onset stroke were less likely to undergo EVT within 120 mins of symptom recognition, have symptomatic intracranial hemorrhage, or ambulate independently at discharge. They were more likely to die or be discharged to hospice. Conclusions: Though use of EVT in GWTG-Stroke for in-hospital stroke remains low, it more than doubled in the past decade. Compared with community onset stroke, these patients have longer intervals to CT and arterial puncture, with associated worse functional outcomes. While there may be important differences in baseline patient characteristics between the groups, efforts must still be made to shorten time to reperfusion for in-hospital strokes.

Abstract 203: Use of Endovascular Therapy and Trends in Clinical Outcomes within the Nationwide Get With The Guidelines-Stroke Registry

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Bijoy K Menon ◽  
Jeffrey L Saver ◽  
Mayank Goyal ◽  
Raul Noguiera ◽  
Shyam Prabhakaran ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcomes ◽  
Endovascular Therapy ◽  
Patient Characteristics ◽  
National Registry ◽  
Stroke Registry ◽  
Large Size ◽  
Symptomatic Intracranial Hemorrhage ◽  
Independent Ambulation ◽  
Get With The Guidelines

Purpose: To determine hospital and patient level characteristics associated with use of endovascular therapy for acute ischemic stroke and to analyze trends in clinical outcome. Methods: Data were from Get With The Guidelines-Stroke hospitals from 4/1/2003 to 6/30/2013. We looked at secular trends in number of hospitals providing endovascular therapy, use of endovascular therapy in these hospitals, and clinical outcomes. We also analyzed hospital and patient characteristics associated with endovascular therapy utilization. Results: Of 1087 hospitals, 454 provided endovascular therapy to at least one patient in the study period. From 2003 to 2012, the proportion of hospitals providing endovascular therapy increased by 1.6%/year (from 12.9% to 28.9%), with a modest drop in 2013 to 23.4%. Use in these hospitals increased from 0.7% to 2% of all ischemic stroke patients (p<0.001) with a modest drop in 2013 to 1.9%. In multivariable analyses, patient outcomes after endovascular therapy improved over time, with reductions in in-hospital mortality (29.6% in 2004 to 16.2% in 2013; p=0.002); and from late 2010, reduction in symptomatic intracranial hemorrhage (ICH) (11% in 2010 to 5% in 2013; p<0.0001) and increased independent ambulation at discharge (24.5% in 2010 to 33% in 2013; p<0.0001) and discharge home (17.7% in 2010 to 26.1% in 2013; p<0.0001) (Attached figure). Hospital characteristics associated with endovascular therapy use included large size, teaching status and urban location while patient characteristics included younger age, EMS transport, absence of prior stroke and white race. Conclusion: Use of endovascular therapy increased modestly in this national registry from 2003 to 2012 and decreased in 2013. Clinical outcomes improved notably from 2010 to 2013, coincident with the introduction of newer thrombectomy devices.

Abstract 214: Improvement Among All Hospital Types and Reduced Hospital Level Variation in Use of Intravenous tPA for Acute Ischemic Stroke 2003-2011: Findings from Get With The Guideline-Stroke

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Lee H Schwamm ◽  
Syed F Ali ◽  
Mathew J Reeves ◽  
Eric E Smith ◽  
Jeffrey L Saver ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Temporal Trends ◽  
Level Variation ◽  
Hospital Level ◽  
The Past ◽  
Teaching Status ◽  
Get With The Guidelines ◽  
Very High ◽  
Iv Tpa ◽  
Hospital Characteristics

Introduction: IV tPA delivery is challenging and use varies widely. We analyzed differences in patient and hospital characteristics at the hospital level in the Get with the Guidelines (GWTG) - Stroke database. Methods: We analyzed data on 73574 patients from 2003-2011 at 1231 hospitals with ≥10 tPA-eligible ischemic stroke (AIS) patients arriving < 2 hr of onset, divided into quartiles of rates of tPA delivered within 3 hrs of onset. Median percentages are reported, and temporal trends were calculated using absolute changes from 2010-2011 vs. 2003-2005. Results: Patients at hospitals with lower rates of tPA treatment within 3 hrs were older, more frequently white, used EMS less often, had lower NIHSS values with very high rates of missing NIHSSS, and greater door to imaging times as compared to better performing hospitals. Hospitals with lower rates of tPA treatment were smaller and more rural, had fewer ICU beds, and were less often teaching or primary stroke centers (Table 1). IV tPA use increased across all types of hospitals from 2003-2011, but increased to a greater degree in non-primary stroke centers and those in the South and West (Table 2). Teaching status, bed size and other measured variables were not different. Conclusion: Significant increases in IV tPA treatment among patients arriving < 2hr have occurred over the past decade, and rates of increase vary by hospital characteristics. The profile of tPA treated eligible patients also changes across the range of hospital tPA use rates, with highest performing sites reporting NIHSS in >90% of tPA patients, and treating greater numbers of patients who are non-white or with more severe strokes. Low performing sites may benefit from greater focus on NIHSS assessment and timeliness of care. .

Abstract P251: Estimates and Temporal Trends for US Nationwide 30-Day Hospital Readmission Among Patients With Ischemic Stroke Treated With Thrombolytic Therapy

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Saqib Chaudhry ◽  
Ibrahim Laleka ◽  
Zelalem Bahiru ◽  
Mohammad Rauf A Chaudhry ◽  
Hussan S Gill ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Thrombolytic Therapy ◽  
Acute Ischemic Stroke ◽  
Temporal Trend ◽  
Hospital Readmissions ◽  
Temporal Trends ◽  
Day Hospital ◽  
Patient Centered ◽  
Nationally Representative ◽  
Iv Tpa

Background: Avoidance of readmission is linked to improved quality of care, reduction in cost, and is a desirable patient-centered outcome. Nationally representative readmission metrics for patients with acute ischemic stroke treated with intravenous thrombolytic treatment (IV-tPA) are unavailable to date. Such estimates are necessary for benchmarking performance. Objectives: To identify US nationwide estimates and a temporal trend for 30-day hospital readmissions. Methods: We identified the cohort by year-wise analysis of the Nationwide Readmissions Database between January 1, 2010, and September 30, 2015. The database represents 50% of all US hospitalizations from 22 geographically dispersed states. Participants were adult (=>18 years) patients with a primary discharge diagnosis of acute ischemic (ICD-9-CM 433.x1 and 434.x1) who were treated with thrombolytic therapy (ICD-9-CM 9910). Readmission was defined as any admission within 30 days of index hospitalization discharge. Results: Based on study criteria, 57,676 eligible patients were included (mean [SE] age, 68.7 ± 14.4 years; 48.7% were women). Thirty-day readmission rate for acute ischemic stroke patients treated with IV-tPA was 11.17 % (95%CI, 10.92 %-11.43%). On average, there was a 4.4% annual decline in readmission between 2010 and 2014, which was statistically significant for the period of investigation (odds ratio, 0.95; 95%CI, 0.94-0.97). Age ≥ 65 years (OR 1.16 P <.0001), medical history of congestive heart failure (OR 1.11 P = 0.0056), chronic lung disease (OR 1.11 P = 0.0034) and renal failure (OR 1.35 P = <.0001) were independent predictors of readmission within 30 days. Conclusion: Nationally representative readmission metrics can be used to benchmark hospitals’ performance, and a temporal trend of 4.4 % may be used to evaluate the effectiveness of readmission reduction strategies.

Abstract 12096: Temporal Trends in Ischemic Stroke and Anticoagulation Therapy Among Medicare Beneficiaries Having Non-Valvular Atrial Fibrillation With and Without Diabetes Mellitus, 1992-2010

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Gautam R Shroff ◽  
Craig A Solid ◽  
Charles A Herzog
Keyword(s):  
Diabetes Mellitus ◽  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Temporal Trends ◽  
Significant Proportion ◽  
Anticoagulation Therapy ◽  
Medicare Beneficiaries ◽  
Similar Reduction ◽  
Increased Risk ◽  
Patients With Diabetes

Background: Patients with diabetes mellitus (DM) and non valvular atrial fibrillation (AF) are at increased risk of ischemic stroke; but evidence regarding ischemic stroke and warfarin use in the literature is limited. We evaluated temporal trends in ischemic stroke and warfarin use among the US Medicare population with and without DM. Methods: One-year cohorts of patients with Medicare as primary payer, 1992-2010, were created using the Medicare 5% sample. ICD-9-CM codes were used to identify AF, ischemic and hemorrhagic stroke and comorbidities; ≤3 consecutive prothrombin-time claims were used to identify warfarin use. Results: Demographic characteristics between 1992 (n=40255) and 2010 (n=80314) respectively were (proportions): age 65-74 years (37%, 32%); age ≤ 85 years (20%, 25%); white (94%, 93%); hypertension (46%, 80%); DM (20%, 32%), chronic kidney disease (5%, 18%). Ischemic stroke rates among Medicare AF patients with DM decreased by 71% (1992, 2010) from 65 to 19 /1000 patient-years; warfarin utilization increased from 28% to 62% respectively (Figure 1A). Among Medicare AF patients without DM, ischemic stroke rates decreased by 68% from 44 to 14/ 1000 patient-years; warfarin use increased 26% to 59% respectively (Figure 1B). About 38% Medicare AF pts with DM did not receive anticoagulation in 2010. Conclusion: Medicare patients with and without DM had a similar reduction in ischemic stroke rates; and similar increase in warfarin utilization over the study period. A significant proportion of Medicare pts with DM did not receive anticoagulation with warfarin for AF in 2010; this population deserves future attention.

Abstract 2779: The Safety of Intravenous Thrombolysis for Ischemic Stroke in Patients With Pre-Existing Cerebral Aneurysms: A Retrospective, Hospital-Based Study

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Nancy Edwards ◽  
Hooman Kamel ◽  
S. Andrew Josephson
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Cerebral Aneurysms ◽  
Intravenous Thrombolysis ◽  
Aneurysm Rupture ◽  
Exact Test ◽  
Intravenous Tissue Plasminogen Activator ◽  
Unruptured Cerebral Aneurysms ◽  
Risk Of Hemorrhage ◽  
Iv Tpa

Background and Purpose: Unruptured cerebral aneurysms are currently considered a contraindication to intravenous tissue plasminogen activator (IV tPA) for acute ischemic stroke. This is due to a theoretical increase in the risk of hemorrhage from aneurysm rupture, although it is unknown whether this risk is significant. We sought to determine the safety of IV tPA administration in a cohort of patients with pre-existing aneurysms. Methods: We reviewed the medical records of patients treated for acute ischemic stroke with IV tPA during an 11-year period at two academic medical centers. We identified a subset of patients with unruptured cerebral aneurysms present on pre-thrombolysis vascular imaging. Our outcomes of interest were any intracranial hemorrhage (ICH), symptomatic ICH, and subarachnoid hemorrhage (SAH). Fisher’s exact test was used to compare the rates of hemorrhage among patients with and without aneurysms. Results: We identified 236 eligible patients, of whom 22 had unruptured cerebral aneurysms. The rate of ICH among patients with aneurysms (14%, 95% CI 3-35%) did not significantly differ from the rate among patients without aneurysms (19%, 95% CI 14-25%). None of the patients with aneurysms developed symptomatic ICH (0%, 95% CI 0-15%), compared with 10 of 214 patients without aneurysms (5%, 95% CI 2-8%). Similar proportions of patients developed SAH (5%, 95% CI 0-23% versus 6%, 95% CI 3-10%). Conclusion: Our findings suggest that IV tPA for acute ischemic stroke is safe to administer in patients with pre-existing cerebral aneurysms as the risk of aneurysm rupture and symptomatic ICH is low.

Abstract 4: Variation and Temporal Trends in the Characteristics of US Hospitals Treating Acute Ischemic Stroke Patients with IV-tPA: Findings from GWTG-Stroke

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Lee H Schwamm ◽  
Syed F Ali ◽  
Mathew J Reeves ◽  
Eric E Smith ◽  
Jeffrey L Saver ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Systems Of Care ◽  
Team Building ◽  
Temporal Trends ◽  
High Volume ◽  
Wilcoxon Test ◽  
Chi Square ◽  
Over Time ◽  
Iv Tpa

Introduction: Utilization of IV tPA is challenging for many hospitals. Using data from the national Get With The Guidelines-Stroke program, we analyzed changes over time in the characteristics of the hospitals that treated patients with tPA. Methods: We analyzed patient-level data from 2003-2011 at 1600 GWTG hospitals that joined the program at any time during the study period and admitted any acute ischemic stroke (AIS) patients arriving ≤ 2 hr of onset and eligible for tPA. Descriptive trends by time were analyzed by chi-square or Wilcoxon test for continuous data. Results: IV tPA was given within 3 hr at 1394 sites to 50,798/ 75,115 (67.6%) eligible AIS patients arriving ≤ 2 hr; 206 (14.8%) sites had a least one eligible patients but no tPA use. IV tPA treatment rates varied substantially across hospitals (median 61.2%, range 0-100%), with > 200 hospitals providing tPA < 10% of the time (Figure). Over time, more patients and a larger proportion of patients were treated at smaller (median bed size 407 vs. 372, p< 0.001), non-academic, Southern hospitals, and those with lower annualized average ischemic stroke volumes (252.4 vs. 235.2, p< 0.001) (Table). While more than half of all tPA patients were treated at Primary Stroke Centers, this proportion did not change over time. The proportion of patients treated at high volume tPA treatment sites (average > 20/year) increased over time (31.9 vs. 34.5, p< 0.007). Conclusion: Over the past decade, while primary stroke centers still account for more than half of all treatments, tPA has been increasingly delivered in smaller, non-academic hospitals. These data support the continued emphasis on stroke team building and systems of care at US hospitals.

scholarly journals Acute Stroke Presentation, Care, and Outcomes in Community Hospitals in Northern California During the COVID-19 Pandemic

Stroke ◽  
2020 ◽  
Vol 51 (10) ◽  
pp. 2918-2924 ◽  
Author(s):  
Mai N. Nguyen-Huynh ◽  
Xian Nan Tang ◽  
David R. Vinson ◽  
Alexander C. Flint ◽  
Janet G. Alexander ◽  
...  
Keyword(s):  
Cohort Study ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Temporal Trends ◽  
Patient Characteristics ◽  
Large Vessel ◽  
Critical Conditions ◽  
Care Seeking ◽  
Northern California ◽  
Inpatient Mortality

Background and Purpose: Shelter-in-place (SIP) orders implemented to mitigate severe acute respiratory syndrome coronavirus 2 spread may inadvertently discourage patient care-seeking behavior for critical conditions like acute ischemic stroke. We aimed to compare temporal trends in volume of acute stroke alerts, patient characteristics, telestroke care, and short-term outcomes pre- and post-SIP orders. Methods: We conducted a cohort study in 21 stroke centers of an integrated healthcare system serving 4.4+ million members across Northern California. We included adult patients who presented with suspected acute stroke and were evaluated by telestroke between January 1, 2019, and May 9, 2020. SIP orders announced the week of March 15, 2020, created pre (January 1, 2019, to March 14, 2020) and post (March 15, 2020, to May 9, 2020) cohort for comparison. Main outcomes were stroke alert volumes and inpatient mortality for stroke. Results: Stroke alert weekly volume post-SIP (mean, 98 [95% CI, 92–104]) decreased significantly compared with pre-SIP (mean, 132 [95% CI, 130–136]; P <0.001). Stroke discharges also dropped, in concordance with acute stroke alerts decrease. In total, 9120 patients were included: 8337 in pre- and 783 in post-SIP cohorts. There were no differences in patient demographics. Compared with pre-SIP, post-SIP patients had higher National Institutes of Health Stroke Scale scores ( P =0.003), lower comorbidity score ( P <0.001), and arrived more often by ambulance ( P <0.001). Post-SIP, more patients had large vessel occlusions ( P =0.03), and there were fewer stroke mimics ( P =0.001). Discharge outcomes were similar for post-SIP and pre-SIP cohorts. Conclusions: In this cohort study, regional stroke alert and ischemic stroke discharge volumes decreased significantly in the early COVID-19 pandemic. Compared with pre-SIP, the post-SIP population showed no significant demographic differences but had lower comorbidity scores, more severe strokes, and more large vessel occlusions. The inpatient mortality was similar in both cohorts. Further studies are needed to understand the causes and implications of care avoidance to patients and healthcare systems.

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