Abstract P877: Race-Ethnic Disparities in Intracerebral Hemorrhage Outcomes

Introduction: Prior literature has reported differences in outcomes following stroke by race/ethnicity. While more attention has been focused on ischemic stroke, we sought to identify race/ethnic disparities in hospital outcomes at discharge following intracerebral hemorrhage (ICH). Methods: Data were obtained from the Florida Stroke Registry (FSR) consisting of stroke centers utilizing the Get With the Guidelines-Stroke (GWTG-S) tool. Pearson Chi-square and Kruskall-Wallis tests were used to compare descriptive statistics by race/ethnicity on 26,113 Florida cases with ICH discharged 2010-2018. Outcomes at discharge included in-hospital mortality, disposition, ambulation, modified Rankin Scale score & timing of initiation of comfort measures only (CMO). Generalized estimating equations logistic models accounted for age, sex, insurance, smoking, hypertension, diabetes, dyslipidemia, prior anti-coagulant/platelet use, history of stroke/TIA, admission NIHSS, ICH score, arrival mode, hospital size, teaching status & years in GWTG-S. Results: 65% were non-Hispanic White (NHW), 20% non-Hispanic Black (NHB) and 15% Hispanic. NHB were younger at ICH onset (median 60, IQR 52-71; NHW: 71, 58-81; Hispanic: 69, 52-80; p < 0.0001), had higher risk of hypertension (HTN; 74%; NHW: 66%; Hispanic: 64%; p < 0.0001), diabetes (29%; NHW: 20%; Hispanic: 27%; p < 0.0001), smoking (14%; NHW: 12%; Hispanic: 9%; p < 0.0001) and chronic renal insufficiency (8%; NHW: 4%; Hispanic: 4% ; p < 0.0001). NHW had higher risk of dyslipidemia (35%; NHB: 21%; Hispanic: 27%; p < 0.0001), atrial fibrillation/flutter (20%; NHB: 6%; Hispanic: 10%; p < 0.0001) and a higher use of prior anticoagulants (13%; NHB: 6%, Hispanic: 8%, p < 0.0001). NHB had lower odds of in-hospital mortality (adjusted OR=0.77, 95% CI=[0.61-0.96]) and CMO on days 0/1 (0.63, 0.45-0.87) compared to NHW. Conclusions: Differences in risk factor profiles, such as higher rates of HTN in NHB and greater use of anticoagulants among NHW, raises the possibility of tailoring preventive and acute care responses to ICH by race/ethnicity. Moreover, despite observing persistently lower odds of mortality and CMO among NHB after adjustment, more data are needed to identify the unobserved effects leading to these disparities.

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Abstract P436: Outcomes in Intracerebral Hemorrhage Patients Presenting With Impaired Level of Consciousness

Stroke ◽

10.1161/str.52.suppl_1.p436 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Ayham Alkhachroum ◽

Antonio Bustillo ◽

Negar Asdaghi ◽

Erika T Marulanda-londono ◽

Carolina M Gutierrez ◽

...

Keyword(s):

Length Of Stay ◽

Intracerebral Hemorrhage ◽

Hospital Mortality ◽

Early Recovery ◽

Hospital Size ◽

Stroke Registry ◽

Level Of Consciousness ◽

Chi Squared ◽

Ich Score ◽

Gcs Score

Background: Impaired level of consciousness (LOC) on presentation after intracerebral hemorrhage (ICH) may affect outcomes and the decision to withdraw life-sustaining treatment (WLST). We aim to investigate the outcomes and trends after ICH by the LOC status on presentation. Methods: We studied 37,613 cases with ICH in the Florida Stroke Registry from 2010-2019. Pearson chi-squared and Kruskall-Wallis tests were used to compare descriptive statistics. A multivariable-logistic regression with GEE accounted for basic demographics, comorbidities, ICH severity, hospital size and teaching status. Results: At stroke presentation, 12,272 (33%) cases had impaired LOC (mean age 72, 49% women, 61 white%, 20% Black, 14% Hispanic). Compared to cases with preserved LOC, LOC case were older (72 vs. 70 years old), more women (49% vs. 45%), more likely to have aphasia (38% vs. 16%), had lower GCS score (9 vs. 15), had greater ICH score (3 vs. 1), greater WLST rates (41% vs. 18%), and had greater in-hospital mortality rates (32% vs. 12%). In our adjusted model, no association was found between impaired LOC and in-hospital mortality, or length of stay. Those with preserved LOC were more likely discharged home/rehab (OR 0.4, 95%CI 0.2-0.9, p=0.03) and more likely to ambulate independently (OR 1.6, 95%CI 1.1-2.4, p=0.02). Trend analysis (2010-2019) showed decreased mortality, increased length of stay, and increased rates of discharge to home/rehab in all, regardless of the LOC status. Conclusion: In this large multi-center registry, a third of ICH cases presents with impaired LOC. Although LOC was not associated with significantly more in-hospital morality, LOC was associated with had higher rates of WLST and more disability at discharge. Future efforts should focus on biomarkers of LOC that detect early recovery and reduced disability in ICH patients with impaired LOC.

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Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired Consciousness

Stroke ◽

10.1161/strokeaha.121.035233 ◽

2021 ◽

Author(s):

Ayham Alkhachroum ◽

Antonio J. Bustillo ◽

Negar Asdaghi ◽

Erika Marulanda-Londono ◽

Carolina M. Gutierrez ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Hospital Mortality ◽

Odds Ratio ◽

Mediation Effect ◽

Hospital Length Of Stay ◽

Do Not Resuscitate ◽

Hospital Size ◽

Stroke Registry ◽

Discharge Disposition ◽

Life Sustaining Treatment

Background and Purpose: Impaired level of consciousness (LOC) on presentation at hospital admission in patients with intracerebral hemorrhage (ICH) may affect outcomes and the decision to withhold or withdraw life-sustaining treatment (WOLST). Methods: Patients with ICH were included across 121 Florida hospitals participating in the Florida Stroke Registry from 2010 to 2019. We studied the effect of LOC on presentation on in-hospital mortality (primary outcome), WOLST, ambulation status on discharge, hospital length of stay, and discharge disposition. Results: Among 37 613 cases with ICH (mean age 71, 46% women, 61% White, 20% Black, 15% Hispanic), 12 272 (33%) had impaired LOC at onset. Compared with cases with preserved LOC, patients with impaired LOC were older (72 versus 70 years), more women (49% versus 45%), more likely to have aphasia (38% versus 16%), had greater ICH score (3 versus 1), greater risk of WOLST (41% versus 18%), and had an increased in-hospital mortality (32% versus 12%). In the multivariable-logistic regression with generalized estimating equations accounting for basic demographics, comorbidities, ICH severity, hospital size and teaching status, impaired LOC was associated with greater mortality (odds ratio, 3.7 [95% CI, 3.1–4.3], P <0.0001) and less likely discharged home or to rehab (odds ratio, 0.3 [95% CI, 0.3–0.4], P <0.0001). WOLST significantly mediated the effect of impaired LOC on mortality (mediation effect, 190 [95% CI, 152–229], P <0.0001). Early WOLST (<2 days) occurred among 51% of patients. A reduction in early WOLST was observed in patients with impaired LOC after the 2015 American Heart Association/American Stroke Association ICH guidelines recommending aggressive treatment and against early do-not-resuscitate. Conclusions: In this large multicenter stroke registry, a third of ICH cases presented with impaired LOC. Impaired LOC was associated with greater in-hospital mortality and worse disposition at discharge, largely influenced by early decision to withhold or WOLST.

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Abstract TP455: Race-Ethnic Disparities in Subarachnoid Hemorrhage Outcomes

Stroke ◽

10.1161/str.51.suppl_1.tp455 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Antonio Bustillo ◽

Kefeng Wang ◽

Hannah Gardener ◽

Carolina M Gutierrez ◽

Nicole Sur ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Hospital Mortality ◽

Ethnic Disparities ◽

Descriptive Statistics ◽

Stroke Registry ◽

Logistic Regression Models ◽

Chi Squared ◽

Race Ethnicity ◽

Artery Disease ◽

Demographic Subgroups

Introduction: Identification of race/ethnic disparities in stroke outcomes is essential in achieving equity of patient care across demographic subgroups. We sought to identify disparities by race/ethnicity in patient outcomes following subarachnoid hemorrhage (SAH). Methods: Records obtained from the Florida Stroke Registry (FSR), a multi-hospital Get With the Guidelines (GWTG)-Stroke data collaborative, were used to compare descriptive statistics and outcomes by race/ethnicity. Pearson chi-squared and Kruskall-Wallis tests were used to compare descriptive statistics by race/ethnicity. Outcomes included in-hospital mortality, discharge location, ambulation at discharge, modified Rankin Scale (mRS) score at discharge, and receiving comfort measures only. Logistic regression models with generalized estimating equations accounted for age, insurance, smoking, hypertension, diabetes, dyslipidemia, atrial fibrillation/flutter, coronary artery disease, peripheral vascular disease, prior stroke/TIA, carotid stenosis, prior anticoagulation or antiplatelet use, prior ambulatory status, arrival mode, admission NIHSS, Florida region, number of beds, years in GWTG, and teaching hospital status. Results: The sample consisted of 10, 559 records with SAH discharged between 2010-2018; 63% were non-Hispanic White (NHW), 19.4% non-Hispanic Black (NHB), and 17.6% Hispanic. NHB were younger at onset (median age=54, IQR=45-65; NHW: 62, 53-73; Hispanic: 58, 48-71; p < 0.0001) and had the highest rate of hypertension (62%; NHW: 50%, Hispanic: 51%; p < 0.001), while NHW had the highest rate of smoking (24%; NHB: 20%; Hispanic: 17%; p < 0.0001). NHB had lower odds of in-hospital mortality compared to NHW (adjusted OR 0.8, 95% CI 0.68-0.94), but were less likely to have been discharged home/rehab (0.83, 0.73-0.94), to ambulate independently at discharge (0.71, 0.60-0.84), and to have a discharge mRS score of 0-2 (0.67, 0.49-0.92). Conclusions: While NHB have lowered odds of dying in-hospital from SAH, survivors have worse functional outcomes. These race/ethnic disparities highlight the need for further research into the causes of these differences and to refine approaches to improve acute care of SAH.

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172 Sleep Disparities in Preschool-Aged Children

SLEEP ◽

10.1093/sleep/zsab072.171 ◽

2021 ◽

Vol 44 (Supplement_2) ◽

pp. A70-A70

Author(s):

Jennifer Holmes ◽

Olivia Hanron ◽

Rebecca Spencer

Keyword(s):

Sleep Duration ◽

Ethnic Disparities ◽

Data Race ◽

Older Children ◽

Hispanic Children ◽

Sleep Habits ◽

Chi Square ◽

White Children ◽

Race Ethnicity ◽

And Gender

Abstract Introduction Sleep is known to be associated with socioeconomic status (SES) in older children and adults with those from lower SES households often experiencing poorer sleep quality. Whether this disparity exists in early childhood is relatively unknown, despite being an important age marked by sleep transitions and the establishment of lifelong sleep habits. Furthermore, it is a critical period for cognitive development and learning, which are supported by sleep. Here, we explore associations between sleep and SES in a preschool population. We hypothesized that children from lower SES households would exhibit shorter overnight sleep, longer and more frequent naps, and shorter 24-hr sleep. Additionally, we considered racial and ethnic disparities in sleep which can be confounded with SES in some samples. Methods Child (n=441; M age=51.9mo; 45.4% female) sleep was measured objectively using actigraph watches, worn for 3-16 days (M=9.5 days). Caregivers reported child demographics and household data. Race/ethnicity of our sample was 72% White, 10.2% Black, 17.8% other or more than one race, and 28.4% identified as Hispanic. 20.1% of our sample was categorized as low SES. Effects of SES and race/ethnicity on continuous sleep measures were assessed using multiple regression models, with age and gender as covariates. Nap habituality was assessed using chi-square tests. Results Lower SES was associated with shorter nighttime sleep duration, longer nap duration, and shorter 24-hr sleep duration (p’s<.001). Children from lower SES households were also more likely to nap habitually (p=.04) as were Hispanic children (p<.001). Hispanic children also tended to have longer nap bouts (p=.002). Hispanic and Black children on average had shorter overnight sleep durations than White children (p’s<.04), but their 24-hr sleep did not differ. Conclusion SES-related sleep disparities were present in this preschool population, with lower SES children exhibiting poorer sleep. When controlling for SES, Hispanic children tended to sleep less overnight which was compensated for by longer, more frequent naps. This underscores the necessity of naps for some children to achieve adequate sleep. Future directions will explore the relationship between parenting factors and sleep, such as bedtime routines and parent knowledge surrounding child sleep needs. Support (if any) NIH R01 HL111695

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Abstract 19854: A National Perspective of Weekend- Effect on Mortality and Adverse Outcomes in Patients with Intracerebral Hemorrhage

Circulation ◽

10.1161/circ.130.suppl_2.19854 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Achint Patel ◽

Girish Nadkarni ◽

Neil Patel ◽

Sopan Lahewala ◽

Sudharani Busani ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Hospital Mortality ◽

Adverse Outcome ◽

Adverse Outcomes ◽

Weekend Effect ◽

Categorical Variables ◽

Multilevel Regression ◽

Chi Square ◽

Co Morbidity ◽

Morbidity Index

Introduction: Management of intracerebral hemorrhage (ICH) requires urgent diagnostic and therapeutic procedures, which may not be uniformly available throughout the week. We attempt to define a "weekend effect" for ICH, which has not yet been fully established in this patient population. Hypothesis: We aimed to evaluate whether outcomes differ with respect to the day of admission in patients admitted with ICH. Methods: We reviewed the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample (NIS) database from 2000 to 2011 for ICH using ICD 9-CM codes. NIS represents 20% of all US hospital pts and weighted numbers represent national estimates.We defined primary outcome as mortality and adverse outcome(composite of in-hospital mortality & discharge other than home). We utilized chi-square test for univariable analysis for categorical variables and generated hierarchical multilevel regression models to determine independent predictors of mortality and adverse outcome. Results: We included 161017 patients (weighted n=788641) with ICH, out of which 42996(weighted n= 210592) were admitted on weekend. After adjusting for confounders (demographics, Deyo’s modification of charlson’s co-morbidity index, admission type (elective or emergent), hospital region, hospital teaching status, hospital ICH volume and primary payer), the weekend admissions were still associated with 10 % higher mortality (OR 1.10, 95% CI 1.07-1.16, P=0.001) and 20% higher adverse outcome (OR 1.12, 95% CI 1.09-1.16, p=0.001). Conclusions: Thus, admission for ICH on the weekend was a significant and independent predictor of increased in hospital mortality and adverse outcomes as compared to weekday admission. The reasons for this are likely manifold and warrant further investigation both from a quantitative and qualitative standpoint.

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Abstract P397: Outcomes in Acute Ischemic Stroke Patients Presenting With Impaired Level of Consciousness

Stroke ◽

10.1161/str.52.suppl_1.p397 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Ayham Alkhachroum ◽

Antonio Bustillo ◽

Negar Asdaghi ◽

Erika T Marulanda-londono ◽

Carolina M Gutierrez ◽

...

Keyword(s):

Ischemic Stroke ◽

Length Of Stay ◽

Hospital Mortality ◽

Acute Ischemic Stroke ◽

Stroke Severity ◽

Stroke Patients ◽

Early Recovery ◽

Hospital Size ◽

Stroke Registry ◽

Level Of Consciousness

Background: Impaired level of consciousness (LOC) on presentation after acute ischemic stroke (AIS) may affect outcomes and the decision to withdraw life-sustaining treatment (WLST). We aim to investigate the outcomes and their trends after AISby the LOC on stroke presentation. Methods: We studied 238,989 cases with AIS in the Florida Stroke Registry from 2010-2019. Pearson chi-squared and Kruskall-Wallis tests were used to compare descriptive statistics. A multivariable-logistic regression with GEE accounted for basic demographics, comorbidities, stroke severity, location, hospital size and teaching status. Results: At stroke presentation, 32,861 (14%) cases had impaired LOC (mean age 77, 54% women, 60 white%, 19% Black, 16% Hispanic). Compared to cases with preserved LOC, impaired cases were older (77 vs. 72 years old), more women (54% vs. 48%), had more comorbidities, greater stroke severity on NIHSS ≥ 5 (49% vs. 27%), higher WLST rates (3% vs. 0.6%), and greater in-hospital mortality rates (9% vs. 3%). In our adjusted model however, no significant association was found between impaired LOC and in-hospital mortality, or length of stay. Those with preserved LOC were more likely discharged home/rehab (OR 0.7, 95%CI 0.6-0.8, p<0.0001) and more likely to ambulate independently (OR 0.7, 95%CI 0.6-0.9, p=0.001). Trend analysis (2010-2019) showed decreased mortality, increased length of stay, and increased rates of discharge to home/rehab in all irrespective of LOC status. Conclusion: In this large multicenter registry, AIS cases presenting with impaired LOC had more severe strokes at presentation. Although LOC was not associated with significantly worse in-hospital morality, it was associated with higher rates of WLST and more disability among survivors. Future efforts should focus on biomarkers of LOC that discriminates the potential for early recovery and reduced disability in acute stroke patients with impaired LOC.

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Abstract P265: Identifying Factors Associated With Early Transfer Death of Stroke Patients Can Improve Transfer Criteria

Stroke ◽

10.1161/str.52.suppl_1.p265 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Randi R Toumbs ◽

Thanh Dao ◽

Liang Zhu ◽

Sean I Savitz

Keyword(s):

Hospital Mortality ◽

High Mortality ◽

Financial Burden ◽

Early Death ◽

University Hospital ◽

Stroke Patients ◽

Chi Square ◽

Exact Test ◽

Chi Square Test ◽

Ich Score

Introduction: Mortality is an important performance metric monitored by CMS, US News and World Report, and Vizient UHC. Large academic medical centers have high mortality given higher severity of disease and volume. We analyzed mortality of stroke patients transferred to our university hospital from community EDs. Transferring patients who die within 48 hours raises questions about resources, financial burden, and unrealistic expectations from families. We analyzed our transfer early death (TED) population to improve identification of patients who likely do not benefit from transfer out of a community hospital. Methods: Patients with DRG codes for ischemic and hemorrhagic strokes admitted from July 2018-June 2020 were identified. Transfer patients were isolated and grouped as outside hospital (OSH) or intra-system transfers. Data were analyzed for overall hospital mortality and TED mortalities and characteristics. Demographic and clinic variables were compared between intra-system and outside transfers by chi-square test, Fisher’s exact test, t test or Wilcoxon rank sum test. Results: The total stroke mortality rate was 13% with 276 deaths out of 2,145 patients. There were 171 early deaths out of 276 deaths (62%). There were a total of 923 transfer patients in the 2-year period; 76 were TED (8%) and TED accounted for 27% of all in-hospital mortality at our center. Median age of TED was 67, median NIHSS was 27, 39% were >70, and 80% were ICH with a median ICH score 4. The mean volume of ICH was 68mL (SD=55.2). There were no significant associations between age, sex and ethnicity with TED compared with patients who survived beyond 48 hrs. Among TED, 31 (41%) were from within our health system and 45 (59%) were OHS transfers. There were no significant differences among stroke type, severity (GCS, NIHSS, ICH score, MRS), or demographics between intra-system and OSH transfers. Conclusions: TED patients are more likely to have severe ICH where medical care may be futile. Strategies are needed to work with community hospitals to establish goals of care and implement approaches to provide end-of-life services at these facilities. Identification and implementation of such strategies may also reduce intra-system transfers of patients with high mortality.

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24-Hour ICH Score Is a Better Predictor of Outcome than Admission ICH Score

ISRN Stroke ◽

10.1155/2013/605286 ◽

2013 ◽

Vol 2013 ◽

pp. 1-4 ◽

Cited By ~ 5

Author(s):

Aimee M. Aysenne ◽

Karen C. Albright ◽

Tiffany Mathias ◽

Tiffany R. Chang ◽

Amelia K. Boehme ◽

...

Keyword(s):

Computed Tomography ◽

Glasgow Coma Scale ◽

Intracerebral Hemorrhage ◽

Independent Predictor ◽

Significant Independent Predictor ◽

Stroke Registry ◽

Expected Outcome ◽

Ich Score ◽

Head Computed Tomography

Background. The ICH score is a validated tool for predicting 30-day morbidity and mortality in patients with intracerebral hemorrhage. Aims and/or Hypothesis. The aim of this study is to determine if the ICH score calculated 24 hours after admission is a better predictor of mortality than the ICH score calculated on admission. Methods. Patients presenting to our center with ICH from 7/08–12/10 were retrospectively identified from our prospective stroke registry. ICH scores were calculated based on initial Glasgow coma scale (GCS) and emergent head computed tomography (CT) on initial presentation and were recalculated after 24 hours. Results. A total of 91 patients out of 121 had complete data for admission and 24-hour ICH score. The ICH score changed in 38% from baseline to 24 hours. After adjusting for age, NIHSS on admission, and glucose, ICH score at 24 hours was a significant, independent predictor of mortality (OR = 2.71, 95% CI 1–19–6.20, and ), but ICH score on admission was not (OR = 2.14, 95% CI 0.88–5.24, and ). Conclusion. Early determination of the ICH score may incorrectly estimate the severity and expected outcome after ICH. Calculations of the ICH score 24 hours after admission will better predict early outcomes.

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Prognostic Value of ICH Score and ICH-GS Score in Chinese Intracerebral Hemorrhage Patients: Analysis From the China National Stroke Registry (CNSR)

PLoS ONE ◽

10.1371/journal.pone.0077421 ◽

2013 ◽

Vol 8 (10) ◽

pp. e77421 ◽

Cited By ~ 15

Author(s):

Wenjuan Wang ◽

Jingjing Lu ◽

Chunxue Wang ◽

Yilong Wang ◽

Hao Li ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Prognostic Value ◽

Stroke Registry ◽

Ich Score

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Lack of racial and ethnic-based differences in acute care delivery in intracerebral hemorrhage

International Journal of Emergency Medicine ◽

10.1186/s12245-021-00329-w ◽

2021 ◽

Vol 14 (1) ◽

Author(s):

Chun Mei Su ◽

Andrew Warren ◽

Cassie Kraus ◽

Wendy Macias-Konstantopoulos ◽

Kori S. Zachrison ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Acute Care ◽

English Language ◽

Care Delivery ◽

Tertiary Care ◽

Multivariable Analysis ◽

Ethnic Disparities ◽

Scan Time ◽

Care Processes ◽

Race Ethnicity

Abstract Background and aim Early diagnosis and treatment of intracerebral hemorrhage (ICH) is thought to be critical for improving outcomes. We examined whether racial or ethnic disparities exist in acute care processes in the first hours after ICH. Methods We performed a retrospective review of a prospectively collected cohort of consecutive patients with spontaneous primary ICH presenting to a single urban tertiary care center. Acute care processes studied included time to computerized tomography (CT) scan, time from CT to inpatient bed request, and time from bed request to hospital admission. Clinical outcomes included mortality, Glasgow Outcome Scale, and modified Rankin Scale. Results Four hundred fifty-nine patients presented with ICH between 2006 and 2018 and met inclusion criteria (55% male; 75% non-Hispanic White [NHW]; mean age of 73). In minutes, median time to CT was 43 (interquartile range [IQR] 28, 83), time to bed request was 62 (IQR 33, 114), and time to admission was 142 (IQR 95, 232). In a multivariable analysis controlling for demographic factors, clinical factors, and disease severity, race/ethnicity had no effect on acute care processes. English language, however, was independently associated with slower times to CT (β = 30.7 min, 95% CI 9.9 to 51.4, p = 0.004) and to bed request (β = 32.8 min, 95% CI 5.5 to 60.0, p = 0.02). Race/ethnicity and English language were not independently associated with worse outcome. Conclusions We found no evidence of racial/ethnic disparities in acute care processes or outcomes in ICH. English as first language, however, was associated with slower care processes.

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