Determinants of extended door-to-needle time in acute ischemic stroke and its influence on in-hospital mortality: results of a nationwide Dutch clinical audit

Abstract Background Intravenous thrombolysis (IVT) plays a prominent role in the treatment of acute ischemic stroke (AIS). The sooner IVT is administered, the higher the odds of a good outcome. Therefore, registering the in-hospital time to treatment with IVT, i.e. the door-to-needle time (DNT), is a powerful way to measure quality improvement. The aim of this study was to identify determinants that are associated with extended DNT. Methods Patients receiving IVT in 2015 and 2016 registered in the Dutch Acute Stroke Audit were included. DNT and onset-to-door time (ODT) were dichotomized using the median (i.e. extended DNT) and the 90th percentile (i.e. severely extended DNT). Logistic regression was performed to identify determinants associated with (severely) extended DNT/ODT and its effect on in-hospital mortality. A linear model with natural spline was used to investigate the association between ODT and DNT. Results Included were 9518 IVT treated patients from 75 hospitals. Median DNT was 26 min (IQR 20–37). Determinants associated with a higher likelihood of extended DNT were female sex (OR 1.17, 95% CI 1.05–1.31) and admission during off-hours (OR 1.12, 95% CI 1.01–1.25). Short ODT correlated with longer DNT, whereas longer ODT correlated with shorter DNT. Young age (OR 1.38, 95% CI 1.07–1.76) and admission to a comprehensive stroke center (OR 1.26, 1.10–1.45) were associated with severely extended DNT, which was associated with in-hospital mortality (OR 1.54, 95%CI 1.19–1.98). Conclusions Even though DNT in the Netherlands is short compared to other countries, lowering the DNT may be achievable by focusing on specific subgroups.

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National trends in outcomes of ischemic stroke and prognostic influence of stroke center capability in Japan, 2010–2016

International Journal of Stroke ◽

10.1177/1747493019884526 ◽

2019 ◽

pp. 174749301988452 ◽

Cited By ~ 1

Author(s):

Akiko Kada ◽

Kuniaki Ogasawara ◽

Takanari Kitazono ◽

Kunihiro Nishimura ◽

Nobuyuki Sakai ◽

...

Keyword(s):

Ischemic Stroke ◽

Hospital Mortality ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Temporal Trends ◽

Stroke Severity ◽

Stroke Patients ◽

Poor Outcomes ◽

Comprehensive Stroke Center ◽

Stroke Center

Background Limited national-level information on temporal trends in comprehensive stroke center capabilities and their effects on acute ischemic stroke patients exists. Aims To examine trends in in-hospital outcomes of acute ischemic stroke patients and the prognostic influence of temporal changes in comprehensive stroke center capabilities in Japan. Methods This retrospective study used the J-ASPECT Diagnosis Procedure Combination database and identified 372,978 acute ischemic stroke patients hospitalized in 650 institutions between 2010 and 2016. Temporal trends in patient outcomes and recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy usage were examined. Facility comprehensive stroke center capabilities were assessed using a validated scoring system (comprehensive stroke center score: 1–25 points) in 2010 and 2014. The prognostic influence of temporal comprehensive stroke center score changes on in-hospital mortality and poor outcomes (modified Rankin Scale: 3–6) at discharge were examined using hierarchical logistic regression models. Results Over time, stroke severity at admission decreased, whereas median age, sex ratio, and comorbidities remained stable. The median comprehensive stroke center score increased from 16 to 17 points. After adjusting for age, sex, comorbidities, consciousness level, and facility comprehensive stroke center score, proportion of in-hospital mortality and poor outcomes at discharge decreased (from 7.6% to 5.0%, and from 48.7% to 43.1%, respectively). The preceding comprehensive stroke center score increase (in 2010–2014) was independently associated with reduced in-hospital mortality and poor outcomes, and increased rt-PA and mechanical thrombectomy use (odds ratio (95% confidence interval): 0.97 (0.95–0.99), 0.97 (0.95–0.998), 1.07 (1.04–1.10), and 1.21 (1.14–1.28), respectively). Conclusions This nationwide study revealed six-year trends in better patient outcomes and increased use of rt-PA and mechanical thrombectomy in acute ischemic stroke. In addition to lesser stroke severity, preceding improvement of comprehensive stroke center capabilities was an independent factor associated with such trends, suggesting importance of comprehensive stroke center capabilities as a prognostic indicator of acute stroke care.

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Abstract TP253: Ongoing Quality Improvement for Acute Ischemic Stroke at Comprehensive Stroke Center

Stroke ◽

10.1161/str.51.suppl_1.tp253 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Shimeng Liu ◽

Zhu Zhu ◽

Mohammad Shafie ◽

Hermelinda Abcede ◽

Jay Shah ◽

...

Keyword(s):

Quality Improvement ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Hospital Discharge ◽

Symptomatic Intracerebral Hemorrhage ◽

Significant Difference ◽

Time Periods ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Iv Tpa

Background: Ongoing quality improvement is essential for better outcomes and healthcare cost control. The aim of this study is to examine the progressive quality benchmarks for acute ischemic stroke (AIS) at an academic comprehensive stroke center (CSC). Methods: We retrospectively analyzed consecutive patients with AIS at University of California Irvine Medical Center from Jan 1 st , 2013 to Dec 31 th , 2018.Demographics and clinical data were collected from the Get-With-The-Guideline (GWTG) -Stroke registry and electronic medical records. Patients were stratified into 3 time periods according to their admission dates: 2013 to 2014; 2015 to 2016; and 2017 to 2018. Quality benchmarks for AIS, including door-to-needle (DTN) times, rates of receiving IV tPA and/or endovascular thrombectomy (EVT), rate of symptomatic intracerebral hemorrhage (sICH), and outcomes at hospital discharge were analyzed to identify trends of quality improvement in the last 6 years. Results: A total of 1369 patients were included in the study; 398 (29%) patients received acute reperfusion therapy, with 231 (17%) receiving IV tPA, 97 (7%) receiving both IV tPA and EVT, 70 (5%) receiving EVT only. There was no significant difference in baseline characteristics of the patients during the 3 time periods. IV tPA rates were 20% in 2013-2014, 30% in 2015-2016, and 22% in 2017-2018 ( p =0.0005). The EVT rates in 2017-2018 (15% vs. 9%; OR: 1.77; 95% CI: 1.16 - 2.68; p = 0.008) and 2015-2016 (14% vs. 9%; OR: 1.70; 95% CI: 1.11 - 2.59; p = 0.01) were significantly higher than in 2013-2014. There were significant ongoing improvements in median DTN times, with 57 minutes in 2013-2014, 45 minutes in 2015-2016, and 39 minutes in 2017-2018. Among patients receiving IV tPA, significantly more patients had favorable outcomes (mRS score 0-3) at hospital discharge in 2015-2016 (67% vs. 42%; OR: 2.80; 95% CI: 1.46 - 5.40; p =0.002) than in 2013-2014. Conclusions: We demonstrate ongoing improvement in rates of IV tPA and EVT as well as DTN times for IV tPA in patients with AIS.

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In-Hospital Stroke Care: A Six-Year Community-Based Primary Stroke Center Experience

The Neurohospitalist ◽

10.1177/19418744211007001 ◽

2021 ◽

pp. 194187442110070

Author(s):

Felix Ejike Chukwudelunzu ◽

Bart M Demaerschalk ◽

Leonardo Fugoso ◽

Emeka Amadi ◽

Donn Dexter ◽

...

Keyword(s):

Ischemic Stroke ◽

Hospital Mortality ◽

Statistical Significance ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Community Based ◽

Chi Square ◽

Stroke Team ◽

Primary Stroke Center ◽

Stroke Center

Background and purpose: In-hospital stroke-onset assessment and management present numerous challenges, especially in community hospitals. Comprehensive analysis of key stroke care metrics in community-based primary stroke centers is under-studied. Methods: Medical records were reviewed for patients admitted to a community hospital for non-cerebrovascular indications and for whom a stroke alert was activated between 2013 and 2019. Demographic, clinical, radiologic and laboratory information were collected for each incident stroke. Descriptive statistical analysis was employed. When applicable, Kruskal-Wallis and Chi-Square tests were used to compare median values and categorical data between pre-specified groups. Statistical significance was set at alpha = 0.05. Results: There were 192 patients with in-hospital stroke-alert activation; mean age (SD) was 71.0 years (15.0), 49.5% female. 51.6% (99/192) had in-hospital ischemic and hemorrhagic stroke. The most frequent mechanism of stroke was cardioembolism. Upon stroke activation, 45.8% had ischemic stroke while 40.1% had stroke mimics. Stroke team response time from activation was 26 minutes for all in-hospital activations. Intravenous thrombolysis was utilized in 8% of those with ischemic stroke; 3.4% were transferred for consideration of endovascular thrombectomy. In-hospital mortality was 17.7%, and the proportion of patients discharged to home was 34.4% for all activations. Conclusion: The in-hospital stroke mortality was high, and the proportions of patients who either received or were considered for acute intervention were low. Quality improvement targeting increased use of acute stroke intervention in eligible patients and reducing hospital mortality in this patient cohort is needed.

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Effect of “drip-and-ship” and “drip-and-drive” on endovascular treatment of acute ischemic stroke with large vessel occlusion: a single-center retrospective study

Acta Radiologica ◽

10.1177/02841851211006897 ◽

2021 ◽

pp. 028418512110068

Author(s):

Yu Hang ◽

Zhen Yu Jia ◽

Lin Bo Zhao ◽

Yue Zhou Cao ◽

Huang Huang ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Primary Stroke Center ◽

Secondary Endpoints ◽

Comprehensive Stroke Center ◽

Stroke Center

Background Patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) were usually transferred from a primary stroke center (PSC) to a comprehensive stroke center (CSC) for endovascular treatment (drip-and-ship [DS]), while driving the doctor from a CSC to a PSC to perform a procedure is an alternative strategy (drip-and-drive [DD]). Purpose To compare the efficacy and prognosis of the two strategies. Material and Methods From February 2017 to June 2019, 62 patients with LVO received endovascular treatment via the DS and DD models and were retrospectively analyzed from the stroke alliance based on our CSC. Primary endpoint was door-to-reperfusion (DTR) time. Secondary endpoints included puncture-to-recanalization (PTR) time, modified Thrombolysis in Cerebral Infarction (mTICI) rates at the end of the procedure, and modified Rankin Scale (mRS) at 90 days. Results Forty-one patients received the DS strategy and 21 patients received the DD strategy. The DTR time was significantly longer in the DS group compared to the DD group (315.5 ± 83.8 min vs. 248.6 ± 80.0 min; P < 0.05), and PTR time was shorter (77.2 ± 35.9 min vs. 113.7 ± 69.7 min; P = 0.033) compared with the DD group. Successful recanalization (mTICI 2b/3) was achieved in 89% (36/41) of patients in the DS group and 86% (18/21) in the DD group ( P = 1.000). Favorable functional outcomes (mRS 0–2) were observed in 49% (20/41) of patients in the DS group and 71% (15/21) in the DD group at 90 days ( P = 0.089). Conclusion Compared with the DS strategy, the DD strategy showed more effective and a trend of better clinical outcomes for AIS patients with LVO.

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Abstract P536: Impact of the Covid-19 Pandemic on the Volumes and Outcomes of Acute Ischemic Stroke and Myocardial Infarction

Stroke ◽

10.1161/str.52.suppl_1.p536 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Raul Nogueira ◽

Katherine Etter ◽

Thanh Nguyen ◽

Shelly Ikeme ◽

Michael R Frankel ◽

...

Keyword(s):

Myocardial Infarction ◽

Ischemic Stroke ◽

Length Of Stay ◽

Hospital Mortality ◽

Acute Ischemic Stroke ◽

Intravenous Thrombolysis ◽

Clinical Severity ◽

Hospital Length Of Stay ◽

Healthcare Database ◽

Hospitalization Costs

Introduction: The COVID-19 pandemic has wreaked havoc on the presentation, care and outcomes of patients with acute cerebrovascular and cardiovascular conditions. We sought to measure the national impact of COVID-19 on the care for acute ischemic stroke (AIS) and acute myocardial infarction (AMI). Methods: In this retrospective, observational study, we used the Premier Healthcare Database to evaluate the changes in the volume of care and hospital outcomes for AIS and AMI in relation to the pandemic. The pandemic months were defined from March 1, 2020- April 30, 2020 and compared to the same period in the year prior. Outcome measures were volumes of hospitalization and reperfusion treatment for AIS and AMI (including intravenous thrombolysis [IVT] and/or mechanical thrombectomy [MT] for AIS and percutaneous coronary interventions [PCI] for AMI) as well as in-hospital mortality, hospital length of stay (LOS) and hospitalization costs were compared across a 2-month period at the height of the pandemic versus the corresponding period in the prior year. Results: There were 95,453 AIS patients across 145 hospitals and 19,744 AMI patients across 126 hospitals. There was a significant nation-wide decline in the absolute number of hospitalizations for AIS (-38.94%;95%CI,-34.75% to -40.71%) and AMI (-38.90%;95%CI,-37.03% to -40.81%) as well as IVT (-30.32%;95%CI,-27.02% to -33.83%), MT (-23.54%;95%CI,-19.84% to -27.70%), and PCI (-35.05%;95%CI,-33.04% to -37.12%) during the first two months of the pandemic. This occurred across low-, mid-, and high-volume centers and in all geographic regions. Higher in-hospital mortality was observed in AIS patients (5.7% vs.4.2%, p=0.0037;OR 1.41,95%CI 1.1-1.8) but not AMI patients. A shift towards an increase in the proportion of admitted AIS and AMI patients receiving reperfusion therapies suggests a greater clinical severity among patients that were hospitalized for these conditions during the pandemic. A shorter length of stay (AIS: -17%, AMI: -20%), and decreased hospitalization costs (AIS: -12%, AMI: -19%) were observed. Conclusions: Our findings shed light on the combined health outcomes and economic impact the COVID-19 pandemic has had on acute stroke and cardiac emergency care.

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Nomogram to Predict Symptomatic Intracranial Hemorrhage after Intravenous Thrombolysis in Acute Ischemic Stroke in an Asian Population.

Current Neurovascular Research ◽

10.2174/1567202619666211223150907 ◽

2021 ◽

Vol 19 ◽

Author(s):

Xiaohua Xie ◽

Jie Yang ◽

Lijie Ren ◽

Shiyu Hu ◽

Wancheng Lian ◽

...

Keyword(s):

Logistic Regression ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intracranial Hemorrhage ◽

Calibration Curve ◽

Intravenous Thrombolysis ◽

Asian Population ◽

Individual Risk ◽

Clinical Effects ◽

Symptomatic Intracranial Hemorrhage

Background: Symptomatic intracranial hemorrhage (sICH) is a serious hemorrhagic complication after intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients. Most existing predictive scoring systems were derived from Western countries Objective: To develop a nomogram to predict the possibility of sICH after IVT in an Asian population. Methods: This retrospective cohort study included AIS patients treated with recombinant tissue plasminogen activator (rt-PA) in a tertiary hospital in Shenzhen, China, from January 2014 to December 2020. The end point was sICH within 36 hours of IVT treatment. Multivariable logistic regression was used to identify risk factors of sICH, and a predictive nomogram was developed. Area under the curve of receiver operating characteristic curves (AUC), calibration curve, and decision curve analyses were performed. The nomogram was validated by bootstrap resampling Results: Data on a total of 462 patients were collected, of whom 20 patients (4.3%) developed sICH. In the multivariate logistic regression model, the National Institute of Health stroke scale scores (NIHSS) (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.06–1.23, P < 0.001), onset to treatment time (OTT) (OR, 1.02; 95% CI, 1.01–1.03, P < 0.001), neutrophil to lymphocyte ratio (NLR) (OR, 1.22; 95% CI, 1.09–1.35, P < 0.001), and cardioembolism (OR, 3.74; 95% CI, 1.23–11.39, P = 0.020) were independent predictors for sICH and were used to construct a nomogram. Our nomogram exhibited favorable discrimination ability [AUC, 0.878; specificity, 87.35%; and sensitivity, 73.81%]. Bootstrapping for 500 repetitions was performed to further validate the nomogram. The AUC of the bootstrap model was 0.877 (95% CI: 0.823–0.922). The calibration curve exhibited good fit and calibration. The decision curve revealed good positive net benefits and clinical effects Conclusion: The nomogram consisted of the predictors NIHSS, OTT, NLR, and cardioembolism could be used as an auxiliary tool to predict the individual risk of sICH in Chinese AIS patients after IVT. Further external verification among more diverse patient populations is needed to demonstrate the accuracy of the model’s predictions.

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Abstract 5: Do Stroke Centers Reduce Mortality for Patients with Acute Ischemic Stroke? An Instrumental Variable Analysis

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.4.suppl_1.a5 ◽

2011 ◽

Vol 4 (suppl_1) ◽

Author(s):

Ying Xian ◽

Robert G Holloway ◽

Katia Noyes ◽

Manish N Shah ◽

Bruce Friedman

Keyword(s):

New York ◽

Ischemic Stroke ◽

Hospital Mortality ◽

Acute Ischemic Stroke ◽

New York State ◽

Selection Effect ◽

Stroke Care ◽

Instrumental Variable Analysis ◽

All Cause Mortality ◽

Stroke Center

Background: Although the establishment of stroke centers based on the Brain Attack Coalition recommendations has great potential to improve quality of stroke care, little is known about whether stroke centers improve health outcomes such as mortality. Methods: Using 2005-2006 New York State Statewide Planning and Research Cooperative System data, we identified 32,783 hospitalized patients age 18+ with a principal diagnosis of acute ischemic stroke (ICD-9 433.x1, 434.x1 and 436). We compared in-hospital mortality and up to one year all-cause mortality between New York State Designated Stroke Centers and non-stroke center hospitals. Because patients were not randomly assigned to hospitals, stroke centers might treat different types of patients than other hospitals (a selection effect). We used a “natural randomization” approach, instrumental variable analysis (differential distance was the instrument), to control for this selection effect. To determine whether the mortality difference was specific to stroke care, we repeated the analysis using a different group of patients with gastrointestinal (GI) hemorrhage (N=53,077). Results: Of the 32,783 stroke patients, nearly 50% (16,258) were admitted to stroke centers. Stroke centers had lower unadjusted in-hospital mortality and 30-, 90-, 180-, and 365-day all-cause mortality than non-stroke centers (7.0% vs. 7.8%, 10.0% vs. 12.6%, 14.6% vs. 17.5%, 18.0% vs. 21.0%, 22.4% vs. 26.2%, respectively). After adjusting for patient and hospital characteristics, comorbidities, and the patient selection effect, stroke centers were associated with significantly lower all-cause mortality. The adjusted differences were -2.6%, -2.7%, -1.8%, and -2.3% for 30-, 90-, 180- and 365-day mortality (all p<0.05). The adjusted difference in in-hospital mortality was -0.8% but was not statistically significant. In a specificity analysis of patients with GI hemorrhage, stroke centers had slightly higher mortality. Conclusions: Hospitals that are Designated Stroke Centers had lower mortality for acute ischemic stroke than non-stroke center hospitals. The mortality benefit was specific to stroke and was not observed for GI hemorrhage. Providing stroke centers nationwide has the potential to reduce mortality.

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Abstract TP21: Is Presence of Diabetes Mellitus a Key Prognostic Factor among Patients Receiving Endovascular Treatment for Acute Ischemic Stroke?

Stroke ◽

10.1161/str.48.suppl_1.tp21 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Seong-Joon Lee ◽

Yang-Ha Hwang ◽

Ji Man Hong ◽

Jin Wook Choi ◽

Dong-Hun Kang ◽

...

Keyword(s):

Diabetes Mellitus ◽

Logistic Regression ◽

Regression Analysis ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Logistic Regression Analysis ◽

Multiple Logistic Regression Analysis ◽

Univariate Analysis ◽

Intravenous Thrombolysis ◽

The Impact

Introduction: Given the recent positive endovascular therapy trials for acute ischemic stroke (AIS), this therapeutic strategy is now being increasingly incorporated into routine clinical practice. Identifying prognostic factors among AIS patients receiving endovascular revascularization treatments (ERT) in the real world could be important for clinicians and patients. While the impact of diabetes mellitus (DM) on IV thrombolytic outcomes after AIS has been extensively investigated, there is a paucity of data assessing effects of DM on ERT outcomes after AIS. We evaluated the impact of comorbid DM on ERT for AIS. Methods: From Jan 2011 to Feb 2016, patients with AIS who underwent ERT for cervicocephalic occlusions were consecutively enrolled into the Acute Stroke due to Intracranial Atherosclerotic occlusion and Neurointervention - Korean Retrospective (ASIAN KR) registry from 3 hospitals. Patients were excluded if onset to puncture time over 8 hours, in-hospital stroke, or unavailable 3-month mRS. DM was diagnosed if a patient had the history, or hemoglobin A1c on admission was over 6.5. Univariate analysis was performed to compare the characteristics between DM and non-DM population. Multiple logistic regression analysis was used to validate the effect of comorbid DM on 3 month outcomes. Results: Of 721 patients, 667 (93%) were finally included, with 233 DM patients and 434 non-DM patients. In the univariate analysis, comorbidity with hypertension (71.2% vs. 58.3%, p=0.001) and dyslipidemia (36.7% vs. 26.7%, p=0.012) were more frequent in the DM population. Periprocedural factors such as target vessels, intravenous thrombolysis, and final reperfusion grades did not differ. Good outcomes with mRS 0-2 were less frequent in the DM population (43.3% vs. 53.7%, p=0.011). In the logistic regression analysis adjusting age, male sex, initial NIHSS, premorbid mRS, hypertension history, atrial fibrillation, intravenous thrombolysis, onset to puncture time and successful reperfusion, DM was an independent predictor of poor outcomes (mRS 3-6; 1.933, 1.274-2.933, p=0.002). Conclusion: In patients receiving ERT for AIS due to cervicocephalic artery occlusions, the presence of DM as a comorbidity confers greater odds of a poor functional outcome.

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Abstract P188: Transfer Time From Spoke ER Arrival to CSC Arrival in a Hub-Spoke Transfer Model of Thrombolysis for Acute Ischemic Stroke

Stroke ◽

10.1161/str.52.suppl_1.p188 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Vivien H Lee ◽

Paul A Segerstrom ◽

Ciarán J Powers ◽

Sharon Heaton ◽

Shahid M Nimjee ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Univariate Analysis ◽

Transfer Model ◽

Transfer Time ◽

Intravenous Tissue Plasminogen Activator ◽

The Mean ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Er Status

Introduction: Acute ischemic stroke (AIS) patients who present to a spoke Emergency Room (ER) and require transfer to a comprehensive stroke center (CSC) hub face potential delays Methods: We performed a retrospective review of 269 suspected AIS patients who received intravenous tissue plasminogen activator (tPA) from July 2016 to October 2017 in our academic telestroke network. During this period, nearly all tPA patients were transferred to the CSC hub. Data was collected on patient demographics, National Institutes of Health Stroke Scale (NIHSS), door to needle time (DTN), and distance to CSC. ER-to-CSC was defined as the time from patient arrival at Spoke ER to arrival at CSC. Top volume ER status was assigned to the 4 Spoke ERs with the highest volume of tPA. Results: Among 269 AIS patients who received tPA at spoke ERs, the mean age was 65.4 years (range, 21 to 95), 49% were female, and 91.8% were white. The initial median NIHSS was 6 (range, 0 to 30) and the mean DTN was 73.1 minutes (range, 14 to 234). The mean distance from Spoke ER to CSC was 55.2 miles (range 5.8 to 125) and the mean ER-to-CSC was 2.6 hours (range 0.62 to 6.3) (Figure 1). In univariate analysis, the following factors were significantly associated with ER-to-CSC: distance (p < 0.0001), DTN (p < 0.0001), NIHSS (p 0.0007), and top volume ER status (p 0.0034). Patient sex, age, race, SBP, weight, initial NIHSS, daytime shift, and weekend status were not significantly associated with ER-to-CSC. Significant variables from the univariate analysis were included in multivariate linear regression model in which DTN (P < 0.0001), distance (P < 0.0001), and NIHSS (P 0.024) association with ER-to-CSC remained significant. Conclusions: In our series of AIS tPA patients transferred to CSC, the mean time from spoke ER arrival to CSC arrival was 2.6 hours. Factors associated with CSC arrival time include markers of ER performance (DTN), severity (NIHSS), and distance. Further study is warranted to improve transfer time in AIS.

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Abstract 16: Racial Disparities in Clinical Outcomes and Resource Utilization in Acute Ischemic Stroke Hospitalizations in the United States: Results from the 2012 National Inpatient Sample

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.8.suppl_2.16 ◽

2015 ◽

Vol 8 (suppl_2) ◽

Author(s):

Nilay Kumar ◽

Anand Venkatraman ◽

Neetika Garg

Keyword(s):

Logistic Regression ◽

Ischemic Stroke ◽

Length Of Stay ◽

Hospital Mortality ◽

Acute Ischemic Stroke ◽

Racial Minorities ◽

National Inpatient Sample ◽

The Us ◽

To Receive ◽

Total Charges

Background and objectives: There are limited data on racial differences in clinical and economic outcomes of acute ischemic stroke (AIS) hospitalizations in the US. We sought to ascertain the effect of race on AIS outcomes in a population based retrospective cohort study. Methods: We used the 2012 National Inpatient Sample (NIS), which is the largest database of inpatient stays in the US, to identify cases of AIS using ICD9-CM codes 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91 and 437.1 in patients >=18 years of age. Cases with missing data on race were excluded (5% of study sample). Primary outcome was in-hospital mortality. Secondary outcomes included proportion receiving endovascular mechanical thrombectomy (EMT) or thrombolysis, mean inflation adjusted charges and length of stay. Linear and logistic regression was used to test differences in continuous and categorical outcomes respectively. Survey techniques were used for all analyses. Results: There were 452, 330 hospitalizations for AIS in patients >=18 years in 2012. In univariate logistic regression using race as predictor, in-hospital mortality was significantly lower for Blacks (p<0.001), Hispanics (p=0.025) and Native Americans (p=0.047) compared to Whites. However, after adjusting for age, sex, Charlson comorbidity index, EMT and thrombolysis only blacks had a significantly lower mortality compared to whites (OR 0.74, 95% CI 0.66 - 0.82, p<0.001). Black patients were less likely to receive thrombolysis (OR 0.87, 95% CI 0.79 - 0.95; p=0.003) whereas Asian or Pacific Islanders were more likely to receive thrombolysis (OR 1.20, 95% CI 1.01 - 1.44; p=0.043) compared to whites. There was no difference in rates of EMT by race (p=0.18). Total charges and length of stay were significantly higher in racial minorities compared to whites (table). Conclusions: Blacks hospitalized for AIS have significantly lower in-hospital mortality compared to whites but are significantly less likely to receive thrombolysis compared to whites. Total charges and length of stay are significantly higher for racial minorities. Future studies should investigate mechanisms of this apparent protective effect of black race on in-hospital mortality in AIS.

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