Abstract TP318: The Hospital Level Variation in Interhospital Transfer in Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Murali K Kolikonda ◽  
Anne S Tang ◽  
Jesse D Schold ◽  
Ken Uchino ◽  
Shumei Man
Keyword(s):  
Ischemic Stroke ◽  
Low Flow ◽  
Teaching Hospitals ◽  
Categorical Variables ◽  
Fee For Service ◽  
Continuous Variables ◽  
American Hospital ◽  
American Hospital Association ◽  
Hospital Size ◽  
Interhospital Transfer

Background: Interhospital transfer of patients with stroke to higher level of care is a resource intensive practice. This study aimed to understand the patterns of interhospital transfer in the context of hospital characteristics. Methods: This study included Medicare fee-for-service beneficiaries aged ≥65 years who were hospitalized in 2012 for ischemic stroke and underwent interhospital transfers. The data obtained from the American Hospital Association Annual Survey were linked to the 2012 Medicare inpatient and outpatient files. This study included patients admitted to the hospitals which were categorized as “general hospitals” with emergency departments. Hospitals were classified into receiving (high transfer in rate), sending (high transfer out rate), low flow (low transfer in or out rates), and high flow (both high transfer in and out) hospitals. Pearson’s chi-square tests were used for categorical variables and Wilcoxon Rank-Sum tests for continuous variables. Results: Interhospital transfers for ischemic stroke occurred in 2876 out of 4198 hospitals (68.5%), and 5.7% of ischemic stroke admissions (19,283 of 338,306 admissions). Using national average of 5.7% as cut off, the four hospital groups : 411 receiving hospitals (14.3%), 559 sending hospitals (19.4%), 1863 low-flow hospitals (64.8%). Receiving hospitals were larger than low-flow and sending hospitals by the number of beds (Median 371, 189, and 88, respectively, p<0.001) and by annual stroke volume (median 205, 86, and 26, respectively, p<0.001). The majority of receiving (75%) and low-flow hospitals (54%) were in the Metropolitan area, while sending hospital were more evenly distributed in both urban and rural area. Higher proportion of teaching hospitals were in receiving hospitals(28%) compared to low-flow(6%) and sending hospitals (1%) with p<0.001. Higher proportion of receiving (75%) and low-flow (47%) hospitals were certified stroke centers, compared to sending hospitals (16%) with p<0.001. Conclusions: The national patterns of interhospital transfer for ischemic stroke varies depending on the hospital size, geographical location, academic status, and stroke certification. Further study of the associated outcomes will aid in health care resource utilization.

Abstract W P224: Higher Pre-Hospital Blood Pressure Prolongs Door to Needle Thrombolysis Times

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Digvijaya Navalkele ◽  
Chunyan Cai ◽  
Mohammad Rahbar ◽  
Renganayaki Pandurengan ◽  
Tzu-Ching Wu ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Small Sample Size ◽  
Heart Association ◽  
Small Sample ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Intravenous Tissue Plasminogen Activator ◽  
Number Of Patients

Background: Per American Heart Association guidelines, blood pressure (BP) should be < 185/110 to be eligible for intravenous tissue plasminogen activator (tPA). It is shown that door to needle (DTN) time is prolonged in patients who require anti-hypertensive medications prior to thrombolysis in the emergency department (ED). To our knowledge, no studies have focused on pre-hospital BP and its impact on DTN times. We hypothesize that DTN times are longer for patients with higher pre-hospital BP. Methods: We conducted a retrospective review of acute ischemic stroke patients who presented between 1/2010 and 12/2010 to our ED through Emergency Medical Services (EMS) within 3-hrs of symptom onset. Patients were identified from our registry and categorized into two groups: Pre-hospital BP ≥ 185/110 (Pre-hsp HBP) and < 185/110 (Pre-hsp LBP). BP records were abstracted from EMS sheets. Two groups were compared using two-sample t-test or Wilcoxon rank sum test for continuous variables and Chi-square test or Fisher’s exact test for categorical variables. Results: A total of 107 consecutive patients were identified. Out of these, 75 patients (70%) were treated with tPA. Among the patients who received thrombolysis, 35% had pre-hospital BP ≥ 185/110 (n= 26/75). Greater number of patients required anti-hypertensive medications in ED in high BP group compared to low BP group (Pre-hsp HBP n= 14/26, 54%; Pre-hsp LBP n= 13/49, 27%, p < 0.02). Mean door to needle times were significantly higher in Pre-hsp HBP group. (mean ± SD 87.5± 34.2 Vs. 59.7±18.3, p<0.0001). Analysis of patients only within the Pre-hsp HBP group (n= 26) revealed that DTN times were shorter if patients received pre-hsp BP medications compared to patients in the same group who did not receive pre-hsp BP medication (n= 10 vs 16; mean ± SD 76.5 ± 25.7 Vs. 94.3 ± 37.7, p = 0.20) Conclusion: Higher pre-hospital BP is associated with prolonged DTN times and it stays prolonged if pre-hospital high BP remains untreated. Although the later finding was not statistical significant due to small sample size, pre-hospital blood pressure control could be a potential area for improvement to reduce door to needle times in acute ischemic stroke.

Antifungal Susceptibility Testing in Teaching Hospitals

2003 ◽  
Vol 37 (2) ◽  
pp. 192-196 ◽  
Author(s):  
Manjunath P Pai ◽  
Susan L Pendland
Keyword(s):  
Susceptibility Testing ◽  
Clinical Laboratory ◽  
Antifungal Susceptibility ◽  
Antifungal Susceptibility Testing ◽  
Teaching Hospitals ◽  
National Committee ◽  
American Hospital ◽  
American Hospital Association ◽  
Initial Mailing ◽  
Blood Specimens

BACKGROUND: An assessment of antifungal susceptibility testing (AST) has not been conducted since the introduction of the National Committee for Clinical Laboratory Standards (NCCLS) M27-A document. OBJECTIVE: To determine AST practices in teaching hospitals. METHODS: A questionnaire was mailed to the heads of 386 randomly assigned microbiology departments from teaching hospitals identified through the 2000 American Hospital Association Guide. Identifiers were used to delineate responders from nonresponders. A reminder letter was mailed 3 weeks after the initial mailing to all nonresponders. The hospital bed-size and number of inpatient days for respondents were obtained through the American Hospital Directory. RESULTS: The questionnaire was returned by 171 (44.3%) institutions. The total and median (range) number of candida isolates were 137 088 and 8.5 (1–145)/1000 inpatient days for the year 2000, respectively. Approximately 1% (1300) of candida isolates, from predominantly blood specimens, underwent AST. AST was reported by 115 (67.2%) hospitals, with testing on site at 27 hospitals and off site for 88 hospitals. NCCLS methodology (80% broth microdilution) was used by 75% of the hospitals performing on-site AST. The median time to obtain AST results was significantly lower when testing was performed on site (3 d) compared with off site (7–10 d). SUMMARY: A large number of candida bloodstream isolates undergoes AST annually. AST results are obtained sooner when performed on site compared with off site.

Abstract WMP12: Does IV tPA Improve Outcomes in Stroke Patients with Large Vessel Occlusions Treated with Intra-arterial Therapy?

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Joseph T Ho ◽  
Jason W Tarpley ◽  
Hsin-Fang Li
Keyword(s):  
Ischemic Stroke ◽  
Length Of Stay ◽  
Time Frame ◽  
Large Vessel ◽  
Categorical Variables ◽  
Complication Rates ◽  
Continuous Variables ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Iv Tpa

Introduction: The benefit of endovascular therapy (IAT) for the treatment of emergent large vessel occlusion (ELVO) in stroke patients has been established. However, it is not known whether administration of IV tPA prior to IAT is beneficial in these patients. Methods: A retrospective review of ischemic stroke patients in the Providence Health & Services Get with the Guidelines (GWTG) database was performed from 01/2012 to 05/2016. The analysis was limited to patients who presented within 4.5 hours of last known well time (LKWT) and treatment included any form of IAT. End points were limited to data available in the GWTG database, including discharge mRS, discharge NIHSS, change in NIHSS from admission to discharge, and length of stay. Continuous variables were summarized using means and standard deviation while categorical variables were summarized using frequencies and percentages. To yield a more robust estimate against outliers for the time-related variables, medians and interquartile range (IQR) were computed and assessed using Wilcoxon rank sum tests. Chi-square tests and independent two-sample t-tests were used to evaluate the demographic and outcome differences for categorical and continuous variables, respectively. Results: A total of 10,868 patients with an ischemic stroke diagnosis were found in the specified time frame and presented within 4.5 hours of LKWT. Of these, 461 patients were treated with some form of IAT, 235 received IV tPA prior to IAT, 226 had IAT alone due to contraindication to IV tPA. There was no statistical difference in patient demographics, complication rates, TICI score, discharge NIHSS or mRS at discharge. There was a significantly higher NIHSS on admission (18.3 vs 16.7, p = 0.026), greater improvement in NIHSS (11.6 vs. 7.9, p=0.012), longer door to IAT (146 vs 101.5 min, p < 0.0001), and shorter length of stay (5 vs 6 days, p = 0.016) in the IV tPA group. Conclusions: These data suggest that IV tPA, when administered to eligible patients with ELVO, provided some benefit over IAT alone, even though it delayed IAT. Future prospective randomized trials are planned that may better address this question, but these results underscore the need for retrospective analysis of existing data.

Abstract TP69: Safety and Outcomes of IV Thrombolysis with Alteplase for Acute Ischemic Stroke Patients with Thrombocytopenia

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Haris Kamal ◽  
Nour Abdelhamid ◽  
Liang Zhu ◽  
Sean Savitz ◽  
James Grotta ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Strong Evidence ◽  
Demographic Data ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Chi Square ◽  
Exact Test ◽  
Chi Square Test ◽  
Iv Tpa

Background: Intravenous tPA (IV tPA) has been the mainstay for reperfusion therapies for acute ischemic stroke (AIS) patients for 2 decades. Many contraindications from the initial NINDS trial were derived from experts’ consensus and not tested in the trial. Many AIS patients present with thrombocytopenia (< 100,000) and may be excluded from treatment in spite of lack of strong evidence. Some clinicians opt to treat these patients weighing the benefits and risks along with the lack of strong evidence behind this exclusion. We sought to evaluate the safety in AIS patients with low platelets receiving IV tPA as compared to those who do not. Methods: Restrospective chart review of all patients presenting with AIS between 1/2006 to 7/2016 at our center. We analyzed patients who had platelets <100,000 among this cohort and stratified them into those who were treated with IV tPA and those who received antiplatelet therapy only. Demographic data, medical history, medications, presence of sICH after treatment, presenting NIHSS were collected. Two sample Wilcoxon rank sum test was used to compare continuous variables between the two groups, and chi-square test or Fisher’s exact test used to compare categorical variables. Results: 21 patients were treated with IV tPA while 122 patients were treated with antiplatelets. Table 1 lists the demographic variables of the two groups with and without IV tPA. Patients included had moderate thrombocytopenia with very few <50,000. No significant differences were found in presenting NIHSS, race, gender, and history of atrial fibrillation between the two groups except platelets (p=0.0128), age (p=0.0462) and glucose (p=0.0279). Table 2 lists the outcome variables of mRS and symptomatic ICH. There was no petechial or sICH among 21 treated patients. Conclusion: While limited by small numbers and lack of randomization, our data suggest that IV tPA is safe in patients with moderately reduced platelet counts.

Abstract 266: No Impact of Electronic Health Records on Quality of Care and Outcomes for Ischemic Stroke

2014 ◽  
Vol 7 (suppl_1) ◽  
Author(s):  
Karen E Joynt ◽  
Deepak L Bhatt ◽  
Lee H Schwamm ◽  
Ying Xian ◽  
Paul A Heidenreich ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Length Of Stay ◽  
Electronic Health Records ◽  
Clinical Outcomes ◽  
Quality Care ◽  
Health Records ◽  
American Hospital ◽  
American Hospital Association ◽  
Electronic Health

Background: Electronic Health Records (EHRs) may be a key tool for improving the quality of healthcare. They may be particularly important for conditions such as ischemic stroke, in which guidelines are rapidly evolving and timely care of the patient is critical. Methods: We used data from 1,236 hospitals participating in Get With The Guidelines-Stroke, representing 626,473 ischemic strokes between 2007 and 2010, and linked this with the American Hospital Association annual survey to characterize which study hospitals had an EHR. We conducted regression analyses to determine whether hospitals with an EHR demonstrated better performance on quality metrics, length of stay, discharge to home, and mortality. Results: 511 hospitals had an EHR by the end of the study period. Stroke patients at hospitals with EHRs were younger, more often male and non-white, and had a lower burden of medical comorbidities. Hospitals with EHRs were larger, and more often teaching hospitals and stroke centers than hospitals without EHRs. In unadjusted analyses, patients at hospitals with EHRs were more likely to receive “all-or-none” care (87.9% versus 82.6%, p<0.001), and less likely to have a length of stay over 4 days (42.4% versus 43.9%, p<0.001). However, there were no differences in discharge to a site other than home (50.9% versus 51.1%, p=0.12) or in-hospital mortality (5.3% versus 5.2%, p=0.40). In multivariate analyses, after controlling for patient and hospital characteristics, the presence of an EHR was no longer associated with better quality care, and continued to have no association with clinical outcomes (Table). Conclusions: In our sample of GWTG-Stroke hospitals, EHRs were not associated with higher-quality care or better clinical outcomes. Given that these systems often create significant added burden for clinicians, further work to ensure that they are better integrated with care and fully evidence-driven is critical.

Prevalence, screening, treatment, and complications of osteoporosis and osteopenia in Medicare patients with chronic lymphocytic leukemia (CLL).

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. e24050-e24050
Author(s):  
Danielle M. Brander ◽  
Kevin C. Oeffinger ◽  
Melissa A. Greiner ◽  
Michaela Ann Dinan
Keyword(s):  
Cumulative Incidence ◽  
Fragility Fractures ◽  
National Sample ◽  
Adverse Outcomes ◽  
Lymphocytic Leukemia ◽  
Categorical Variables ◽  
Fee For Service ◽  
Continuous Variables ◽  
Mineral Density ◽  
Health Maintenance

e24050 Background: Despite treatment advances, patients (pts) with CLL, a common chronic cancer affecting the elderly, often experience adverse outcomes due to their comorbidities and frequent lack of routine health maintenance. We examined osteoporosis/osteopenia (OSTEO) prevalence, rates of bone mineral density (BMD, g/cm2) screening by dual-energy x-ray absorptiometry (DXA), use of bisphosphonates, and fragility fractures among Medicare pts with CLL. Methods: We identified a cohort of CLL pts >65 years with Medicare fee-for-service between 1/1/2011-12/31/2015 using the Medicare 5% national sample. Controls (5:1) were matched based on age, sex, race, and year of eligibility. Among those with OSTEO, we compared rates of bisphosphonates. Chi-square tests for categorical variables and Wilcoxon Rank-sum tests for continuous variables were used to compare CLL vs controls. Cumulative incidence of BMD screening and fragility fractures were estimated using the cumulative incidence function and compared to controls using Gray tests. For fragility fractures, we compared among subgroups with and without OSTEO. Results: Baseline characteristics are in the Table. Compared to controls, CLL pts were more likely to have OSTEO (p < .001) but less bisphosphonate use (p = .006). The 3-yr cumulative incidence of fragility fractures was higher among CLL pts (8.0%, 95% CI 7.5%-8.6%) vs controls (7.2%, 6.9%-7.4%; p = .002) as well as among those without an OSTEO diagnosis (p = .02). Cumulative 3-yr DXA use was higher among CLL pts vs controls ( < .001); however, DXA 3-yr incidence was lower in CLL pts who had chemotherapy (13.2%, 11.4%-15.4%) vs none (17.0%, 16.2%-17.9%, p = .002). Conclusions: It appears that CLL pts may have a higher risk of osteoporosis and higher rates of fragility fractures than non-CLL individuals. Fragility fractures are higher even in the subgroup of CLL pts without OSTEO, suggesting that pts may be underdiagnosed. [Table: see text]

scholarly journals Practice variation in the management of children hospitalized with bronchiolitis: A Canadian perspective

2018 ◽  
Vol 24 (5) ◽  
pp. 306-312 ◽  
Author(s):  
Radha Jetty ◽  
Mary-Ann Harrison ◽  
Franco Momoli ◽  
Catherine Pound
Keyword(s):  
Implementation Strategies ◽  
Practice Variation ◽  
Teaching Hospitals ◽  
Categorical Variables ◽  
Future Research ◽  
Hospital Inpatient ◽  
Continuous Variables ◽  
Frequency Distributions ◽  
Time Required ◽  
Monitoring Treatment

Abstract Objectives To describe variations in the monitoring, treatment, and discharge of children hospitalized with bronchiolitis among physicians across Canadian paediatric teaching hospitals. Methods We conducted an electronic survey of paediatricians with experience in the management of inpatient bronchiolitis at 20 Canadian paediatric teaching hospitals. Only physicians who worked a minimum of 6 weeks on their hospital inpatient unit in the 2015 calendar year were eligible to participate in the study. The questionnaire explored the monitoring, treatment, and discharge of children with bronchiolitis. Central tendency (mean) and dispersion (SD) statistics were produced for continuous variables and frequency distributions for categorical variables. Results A total of 142 respondents were included in the analysis. 45.1% reported the routine use of continuous oxygen saturation monitoring. 27.5% used a higher cut-off for oxygen supplementation of 92% and 12.7% use a lower cut-off of 88%. 29.6% routinely used deep nasal suctioning. Seventy-three per cent reported using nebulized therapies. 55.6% reported having preprinted order sheets or guidelines for management of inpatient bronchiolitis at their institutions and 28.2% reported having specific discharge criteria. The length of time required to be off oxygen prior to discharge varied (31% at 12 hours, 27.5% at 24 hours, and 24.6% after the last sleep period without oxygen). Conclusion There is significant practice variation in the monitoring, treatment, and discharge of children hospitalized with bronchiolitis within and between Canadian paediatric teaching hospitals. Future research is needed to establish best practices, effective knowledge translation, and implementation strategies to standardize care and decrease length of stay.

scholarly journals Bundled payments for care improvement initiative – insights from the test pilots of payment reform

2015 ◽  
Vol 4 (2) ◽  
pp. 37
Author(s):  
Jason M Sutherland ◽  
William B. Borden
Keyword(s):  
Teaching Hospitals ◽  
Single Bundle ◽  
Payment Reform ◽  
Value Based Purchasing ◽  
American Hospital ◽  
American Hospital Association ◽  
Non Profit ◽  
Bundled Payments ◽  
Episodes Of Care ◽  
Care Improvement

Background: The Medicare Bundled Payments for Care Improvement (BPCI) pilot program aims to reward high-value providers by setting a global payment target for particular episodes of care. The representativeness of BPCI participants will influence the ability of this pilot to inform policy decisions.Methods: We linked the Medicare lists of participants in the risk-bearing portion of BPCI Model 2, encompassing acute and post-acute care, to the American Hospital Association resource file and the 2013 Hospital Value-Based Purchasing quality performance data. We classified episode-initiating hospitals by the number of bundles in which they were participating into “narrow”, “medium” and “comprehensive”. The analysis described the characteristics of hospitals in each of these categories.Results: The 105 hospitals with linkable data were predominantly large, urban, non-profit, teaching hospitals. These hospitals were quite similar to the general population in terms of disproportionate share, Medicare, and Medicaid percentages. Most participants selected a narrow number of bundles, with the majority selecting a single bundle around joint replacement. There were only minor differences in quality between Model 2 participants and non-participants.Conclusions: Informing the decision about whether to scale the BPCI program nationally will require evaluation of the pilot’s performance by participants’ characteristics to understand in what conditions and for which providers the program is most effective.

The changing role of the institution in health care

1970 ◽  
Vol 33 (6) ◽  
pp. 625-631
Author(s):  
Edwin L. Crosby
Keyword(s):  
Health Care ◽  
Medical Profession ◽  
Fee For Service ◽  
American Hospital ◽  
American Hospital Association ◽  
Content Type ◽  
Straight Line ◽  
Solo Practice ◽  
Organizational Pattern ◽  
Heath Care

✓ The dramatic changes in institutional health care since Harvey Cushing's era are reviewed by the director of the American Hospital Association, and predictions made concerning the even greater changes in the years ahead. The author sees the hospital's role in health care as growing rather than diminishing and urges the medical profession to actively shape its future. He calls outmoded the concept of the hospital as a set of walls but believes its influence must spread into all segments of heath care. Its role as the guarantor of the quality of care must likewise be spread, and he believes that the traditional fee-for-service solo practice will not be acceptable to the large purchasers of health care except in those instances where there is a close physical and organizational tie to the central institution, the hospital. He asks in view of the importance of the hospital, that those who work in it and for it should look to see if the traditional organizational pattern of our voluntary hospital can meet the demands to be placed upon it by such sophisticated purchasers as Blue Cross, insurance, and government. He foresees increasing adoption of the straight-line organization in the hospital rather than the orthodox triad of governing board, medical staff, and administration.

Abstract P268: Hospital Transfer of Ischemic Stroke Patients: Prevalence and Outcomes

2011 ◽  
Vol 4 (suppl_2) ◽  
Author(s):  
Amresh D Hanchate ◽  
Lee H Schwamm ◽  
Elaine M Hylek
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Safety Net ◽  
Outcome Evaluation ◽  
Inpatient Mortality ◽  
American Hospital ◽  
American Hospital Association ◽  
Transfer Rates ◽  
Hospital Transfer ◽  
Transferred Patients

BACKGROUND Little is known about transfers of patients across hospitals; inpatient outcome evaluation (report card) protocols are inconsistent in how transfers are accounted. For patients admitted for ischemic stroke in Massachusetts (MA), we estimated prevalence of transfers across hospitals, over time, and differences in inpatient mortality rates compared to patients not transferred. METHODS Discharge and American Hospital Association data were merged for all hospitalizations (2004-09) for ischemic stroke among adults (N=49,789) in all MA acute care hospitals (N=67). We linked all ischemic stroke hospitalizations with preceding and subsequent hospitalizations to obtain ischemic stroke episodes. A transfer was defined as an episode with >=2 hospitalizations such that discharge date for one coincided with admission date for another. We compared transferred and untransferred patients (episodes) in terms of patient risk factors for stroke, hospital characteristics and year. We also compared risk-adjusted inpatient mortality difference for transferred patients using a logistic regression model adjusting for patient demographics and clinical risk factors. RESULTS We identified 47,212 ischemic stroke episodes, of which 9.5% involved a transfer. This rate did not vary significantly during 2004-09. Blacks had higher transfer rates (13%; p<0.001) than Whites (9.3%) and Hispanics (9.6%). Weekend admission did not increase the risk of transfer. Transferred patients had significantly higher prevalence of risk factors for inpatient mortality: atrial fibrillation, hypertension, diabetes mellitus, heart failure and coronary heart disease. Risk-adjusted inpatient mortality among transferred patients was 26% higher than for untransferred patients (9.7% versus 7.3%; p<0.001). While transfer rates were higher for non-teaching and safety-net hospitals, and for hospitals with smaller general care and ICU bed size, substantial numbers of transfers occurred across all hospital types. CONCLUSIONS 9.5% of patients admitted for ischemic stroke experienced a hospital transfer, and were at higher risk for inpatient mortality. Further study needs to explore causal pathways linking hospital transfers and risk of adverse stroke inpatient outcomes.

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