Abstract P284: Coordinating Options for Acute Stroke Therapy (COAST): Demonstrating Patient Autonomy by Examining Preferences for Acute Stroke Treatment From a Stroke Advance Directive

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Kunal Agrawal ◽  
Ilana Spokoyny ◽  
Chia-Chun Chiang ◽  
Kevin McGehrin ◽  
Brett C Meyer
Keyword(s):  
Acute Stroke ◽  
Advance Directive ◽  
Patient Autonomy ◽  
Standard Of Care ◽  
Stroke Therapy ◽  
Stroke Treatment ◽  
Fda Approval ◽  
Acute Stroke Treatment ◽  
Current Guidelines ◽  
Acute Stroke Therapy

Introduction: Respect for patient autonomy is critical, and patients/surrogates may have various preferences about acute stroke treatment that are not fully appreciated during a stroke code. COAST (Coordinating Options for Acute Stroke Therapy) is a stroke advance directive formalizing advanced consent for thrombolysis (tPA) and endovascular therapy (EVT). We examine the distribution of patient preferences to improve understanding and respect for patient autonomy in acute stroke. Methods: In our IRB-approved study, we collected COAST forms at UC San Diego from 12/1/2014-2/29/2020. Patients chose one of five tPA preferences: not under any circumstance (tPA 1); up to 3 hours only, based on FDA approval (tPA 2); up to 4.5 hours only, based on current guidelines (tPA 3); anytime per provider discretion (tPA 4); or other answer (tPA treatment under specific conditions written by the patient/surrogate) (tPA 5). Patients also chose one of five EVT preferences: not under any circumstance (EVT 1); up to 6 hours only (EVT 2); up to 12 hours only (EVT 3); up to 24 hours only (this option replaced "up to 12 hours only" on 3/1/2018 when the 6-24 hour window became standard of care) (EVT 4); anytime at provider discretion (EVT 5); or other answer (EVT treatment under specific conditions written by the patient/surrogate) (EVT 6). Frequency of preferences was calculated for each option. Results: In total, 342 COASTs were completed. Frequency of tPA preferences were: 3.2% for tPA 1 (11/342), 1.5% for tPA 2 (5/342), 25.7% for tPA 3 (88/342), 55.6% for tPA 4 (190/342), 14.0% for tPA 5 (48/342). Frequency of EVT preferences were: 1.8% for EVT 1 (6/342), 9.6% for EVT 2 (33/342), 3.2% for EVT 3 (11/342), 10.8% for EVT 4 (37/342), 62.3% for EVT 5 (213/342), 12.3% for EVT 6 (42/342). When the 6-24 hour window became standard of care, 0% (0/342) chose EVT 2. Total 81.6% (n=279) of COASTs had the same tPA and EVT preferences, and 18.4% (n=63) had tPA preferences that were different from EVT preferences. Conclusion: Preferences vary regarding tPA and EVT treatment. Most patients defer to provider discretion, though some patients have preferences that are different from current provider expectations and/or stroke guidelines. COAST is pivotal to inform respect for patient autonomy for acute stroke codes.

scholarly journals The COAST stroke advance directive

2018 ◽  
Vol 8 (6) ◽  
pp. 521-526 ◽  
Author(s):  
Kevin McGehrin ◽  
Ilana Spokoyny ◽  
Brett C. Meyer ◽  
Kunal Agrawal
Keyword(s):  
Acute Stroke ◽  
Advance Directive ◽  
Patient Autonomy ◽  
Stroke Care ◽  
Time Constraints ◽  
Stroke Therapy ◽  
Acute Stroke Care ◽  
Medical Decisions ◽  
Language And Cognition ◽  
Acute Stroke Therapy

Within the field of neurology, there has been limited discussion of how to best respect patient autonomy in patients presenting with an acute stroke, who often have impairments in language and cognition. In addition to performing a detailed neurologic examination and providing a thorough timeline of their current presentation and medical history, these patients and their families are then asked to quickly make critical medical decisions regarding acute stroke therapies (thrombolysis and endovascular therapy). These discussions are often limited by time constraints and inadequate opportunities for patient education regarding acute stroke care. This article discusses some of the challenges of preserving patient autonomy in patients presenting with acute stroke and the advent of a stroke advance directive (Coordinating Options for Acute Stroke Therapy [COAST]) aimed to overcome these obstacles.

Turning Point of Acute Stroke Therapy: Mechanical Thrombectomy as a Standard of Care

2015 ◽  
Vol 83 (6) ◽  
pp. 953-956 ◽  
Author(s):  
Keith G. DeSousa ◽  
Matthew B. Potts ◽  
Eytan Raz ◽  
Erez Nossek ◽  
Howard A. Riina
Keyword(s):  
Acute Stroke ◽  
Turning Point ◽  
Mechanical Thrombectomy ◽  
Standard Of Care ◽  
Stroke Therapy ◽  
Acute Stroke Therapy

scholarly journals Effect of Prior Aspirin Use on Stroke Severity in the Trial of Org 10172 in Acute Stroke Treatment (TOAST)

Stroke ◽  
2001 ◽  
Vol 32 (12) ◽  
pp. 2836-2840 ◽  
Author(s):  
Janet L. Wilterdink ◽  
Birgitte Bendixen ◽  
Harold P. Adams ◽  
Robert F. Woolson ◽  
William R. Clarke ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Stroke Severity ◽  
Stroke Treatment ◽  
Acute Stroke Treatment

Abstract W P48: Marked Regional Variation in Acute Stroke Treatment in Medicare Beneficiaries

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
James F Burke ◽  
Lesli E Skolarus ◽  
Eric E Adelman ◽  
Phillip A Scott ◽  
William J Meurer
Keyword(s):  
Population Density ◽  
Acute Stroke ◽  
Census Data ◽  
Combined Therapy ◽  
Local Health ◽  
Median Income ◽  
Medicare Beneficiaries ◽  
Stroke Treatment ◽  
Acute Stroke Treatment ◽  
Iv Tpa

Objective: Regionalization of stroke care has occurred sporadically across the U.S, so determining realistic goal treatment rates for individual regions or the nation as a whole is challenging. Studies of a single hospital or region vary widely in estimates of eligibility for acute therapy and may have limited generalizability or biases. We hypothesized that the proportion of U.S. Medicare beneficiaries receiving acute stroke therapy varies by region. Treatment rates in high performing regions may represent realistic national goals and inform policy to increase treatment rates. Methods: All Medicare beneficiaries with a principal diagnosis of ischemic stroke (ICD-9 433.x1, 434.x1, 436) admitted through the emergency department were identified using MEDPAR files from 2007-2010. Receipt of IV tPA (DRG 559, MS-DRG 61-63, ICD-9 procedure code 99.10) or IA thrombolysis (CPT code 37184-6, 37201, 75896 via linked Medicare Carrier files) was determined. Patients were assigned to one of 3,436 Hospital Service Areas (HSA; local health care markets for hospital care) by zip code. Regional acute stroke treatment rates were calculated and the lowest and highest quintiles were compared. Multi-level logistic regression was used to adjust for individual demographics as well as regional population density, education, median income, and unemployment using linked census data. Model-based adjusted regional acute stroke treatment rates were estimated. Results: Of 916,232 stroke admissions 3.6% received IV tPA only and 0.6% received IA or combined therapy. Unadjusted treatment rates by region ranged from 0.8% (minimum) to 14.8% (maximum). Regional rates ranged from 1.7% (quintile 1) to 5.4% (quintile 5). Regions with higher education, population density and income had higher treatment rates (p <= 0.001). After adjustment, regional differences were attenuated slightly _ 1.9% (quintile 1) to 5.1% (quintile 5). Conclusions: Marked variation exists in acute stroke treatment rates by region, even after adjusting for patient and regional characteristics, supporting the perception that a major opportunity exists to improve acute stroke treatment within many HSAs.

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