Alcohol withdrawal is associated with poorer outcome in acute ischemic stroke

ObjectiveTo determine the association between alcohol abuse (AA) and alcohol withdrawal (AW) with acute ischemic stroke (AIS) outcomes.MethodsAll adult AIS admissions in the United States from 2004 to 2014 were identified from the National Inpatient Sample (weighted n = 4,438,968). Multivariable-adjusted models were used to evaluate the association of AW with in-hospital medical complications, mortality, cost, and length of stay in patients with AIS.ResultsOf the AA admissions, 10.6% of patients, representing 0.4% of all AIS, developed AW. The prevalence of AA and AW in AIS increased by 45.2% and 40.0%, respectively, over time (p for trend <0.001). Patients with AA were predominantly men (80.2%), white (65.9%), and in the 40- to 59-year (44.6%) and 60- to 79-year (45.6%) age groups. After multivariable adjustment, AIS admissions with AW had >50% increased odds of urinary tract infection, pneumonia, sepsis, gastrointestinal bleeding, deep venous thrombosis, and acute renal failure compared to those without AW. Patients with AW were also 32% more likely to die during their AIS hospitalization compared to those without AW (odds ratio 1.32, 95% confidence interval 1.11–1.58). AW was associated with ≈15-day increase in length of stay and ≈$5,000 increase in hospitalization cost (p < 0.001).ConclusionAW is associated with increased cost, longer hospitalizations, and higher odds of medical complications and in-hospital mortality after AIS. Proactive surveillance and management of AW may be important in improving outcomes in these patients.

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Abstract WMP50: Age-Specific Female-Male Disparities in Endovascular Thrombectomy Use for Acute Ischemic Stroke in the United States

Stroke ◽

10.1161/str.51.suppl_1.wmp50 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Hamidreza Saber ◽

Amytis Towfighi ◽

David S Liebeskind ◽

Jeffrey L Saver

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Age Groups ◽

Reperfusion Therapy ◽

The United States ◽

National Inpatient Sample ◽

Endovascular Thrombectomy ◽

Age Related ◽

The Us ◽

Age And Sex

Introduction: Studies have suggested sex-related and age-related variations in frequency of reperfusion therapy, but have been limited by constrained geographic scope, data from before the modern thrombectomy era, and incomplete exploration of sex-related differences in discrete age ranges. We therefore analyzed sex-, age-, and sex-age interaction in the frequency of endovascular thrombectomy (EVT) for acute ischemic stroke in the US National Inpatient Sample. Methods: In the National Inpatient Sample , we identified all adult ischemic stroke EVT hospitalizations from 2010-2016, using ICD-9-CM and ICD-10-CM codes. Patient age was categorized as: <50y, 50-59y, 60-69y, 70-79y and ≥80ys. Rates of use of EVT were assessed standardized to the 2010 US Census population. Results: Among 50,573 EVT hospitalizations, 50.1% were female. The number of EVTs increased from 4091 in 2010 to 12,875 in 2016. Over the entire 7y time period, a sex-age interaction was noted: 49% in <50y; 37% in 50-59y; 35% in 60-69y; 53% in 70-79y; and 66% in ≥80y. This sex-age interaction was present as well for EVT rates per 100,000 individuals in the population, with the total ratio of female to male rate of EVT per 100,000: 0.93 for in <50y; 0.52 in 50-59y; 0.58 in 60-69y; 0.91 in 70-79y; and 1.1 in ≥80y. EVT utilization rates increased substantially over time in both men and women in all age groups. However, the ratio of women to men per 100,000 receiving EVT changed for only one age range, decreasing among <50y from 0.98 in 2010 to 0.79 in 2016 (P<0.05). Conclusion: While half of all endovascular thrombectomies in the US are performed in women, there are major age-related sex-specific variations in EVT rates, with rates of EVT much lower among women than men in 50-70 age group. Determinants of these age-specific female-male disparities in EVT treatment merit detailed investigation. Figure: Age- and sex-specific female to male thrombectomy utilization rates.

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Abstract WP212: Trends in Acute Ischemic Stroke Hospitalizations by Age Groups, Length of Stay, Mortality and Hospital Costs in the United States From 2000-2014

Stroke ◽

10.1161/str.50.suppl_1.wp212 ◽

2019 ◽

Vol 50 (Suppl_1) ◽

Author(s):

Prashanth Rawla ◽

Anantha Vellipuram ◽

Rakesh Khatri ◽

Alberto Maud ◽

Gustavo J Rodriguez ◽

...

Keyword(s):

United States ◽

Ischemic Stroke ◽

Length Of Stay ◽

Acute Ischemic Stroke ◽

Hospital Costs ◽

Age Groups ◽

The United States

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Abstract 45: Thrombolytic Treatment for In-Hospital Ischemic Strokes in United States

Stroke ◽

10.1161/str.44.suppl_1.a45 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Tenbit Emiru ◽

Malik M Adil ◽

Adnan I Qureshi

Keyword(s):

United States ◽

Ischemic Stroke ◽

Length Of Stay ◽

Hospital Mortality ◽

Acute Ischemic Stroke ◽

Clinical Characteristics ◽

The United States ◽

Treated Group ◽

Hospital Charges ◽

Thrombolytic Treatment

BACKGROUND: Despite the recent emphasis on protocols for emergent triage and treatment of in-hospital acute ischemic stroke, there is little data on rates and outcomes of patients receiving thrombolytics for in-hospital ischemic strokes. OBJECTIVE: To determine the rates of in-hospital ischemic stroke treated with thrombolytics and to compare outcomes with patients treated with thrombolytics on admission. DESIGN/METHODS: We analyzed a seven-year data (2002-2009) from the National Inpatient Survey (NIS), a nationally representative inpatient database in the United States. We identified patients who had in-hospital ischemic strokes (defined by thrombolytic treatment after one day of hospitalization) and those who received thrombolytics on the admission day. We compared demographics, baseline clinical characteristics, in hospital complications, length of stay, hospitalization charges, and discharge disposition, between the two patient groups. RESULT: A total of 18036 (21.5%) and 65912 (78.5%) patients received thrombolytics for in-hospital and on admission acute ischemic stroke, respectively. In hospital complications such as pneumonia (5.0% vs. 3.4%, p=0.0006), deep venous thrombosis (1.9% vs. 0.6%, p<0.0001) and pulmonary embolism (0.8% vs. 0.4%, p=0.01) were significantly higher in the in-hospital group compared to on admission thrombolytic treated group. Hospital length of stay and mean hospital charges were not different between the two groups. Patients who had in-hospital strokes had had higher rates of in hospital mortality (12.1% vs. 10.6%, p=0.02). In a multivariate analysis, in-hospital thrombolytic treated group had higher in-hospital mortality after adjustment for age, gender and baseline clinical characteristics (odds ratio 0.84, 95% confidence interval 0.74-0.95, p=0.008). CONCLUSION/RELEVANCE: In current practice, one out of every five acute ischemic stroke patients treated with thrombolytics is receiving treatment for in-hospital strokes. The higher mortality and complicated hospitalization in such patients needs to be recognized.

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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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Abstract WMP94: Temporal Trends in Racial, Age, and Sex-Specific Utilization of Decompressive Hemicraniectomy Among Acute Ischemic Stroke Patients in the United States

Stroke ◽

10.1161/str.51.suppl_1.wmp94 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Sai P Polineni ◽

Fadar O Otite ◽

Seemant Chaturvedi

Keyword(s):

United States ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Temporal Trends ◽

Age Groups ◽

The United States ◽

Decompressive Hemicraniectomy ◽

Study Results ◽

Over Time ◽

Age And Sex

Background: The aim of this study is to evaluate current trends in racial, age, and sex-specific utilization of decompressive hemicraniectomy (HC) in acute ischemic stroke (AIS) patients in the United States over the last decade. Methods: All adult patients with a diagnosis of AIS were identified from the 2004-2015 Nationwide Inpatient Sample (weighted N=4,792,428) using International Classification of Diseases Ninth revision (ICD-9) codes. Proportion of patients undergoing HC in various age, race, and sex groups were ascertained using ICD-9 procedural codes. Temporal trends were mapped by year in order to track changes in utilization over time. Analysis of utilization disparities and trends within age, sex, and race subgroups was conducted via multivariate logistic regression. Results: Of all eligible AIS patients from 2004-2015, 0.25% underwent HC (.08 in 2004 to .46 in 2015). Increased utilization over time was seen in both men (.13 to .57) and women (.08 to .54), with women showing comparable odds of utilization to men [OR: 0.95 (95% CI: .87-1.04, p=0.27)]. Similarly, increased utilization trends were seen in all age groups (Figure 1) with the highest rates in the 18-39 subgroup (1.41%). Compared to trends in this younger subgroup (.43 to 2.12), patients aged 60-79 experienced a similar overall increase but at lower utilization rates (.06 to .37). Compared to white patients in multivariate models, blacks did not show significant differences in odds of HC [1.09 (.96-1.24, p=0.20)], while patients from Hispanic [1.25 (1.03-1.51, p=0.02)] and other [1.26 (1.04-1.52, p=0.02)] race-ethnic groups showed increased odds. Conclusions: From 2004-2015, hemicraniectomy rates have seen substantial increases in all age, sex, and race groups. The increasing rates of hemicraniectomies among those over age 60 suggest that there has been at least partial acceptance of DESTINY 2 study results.

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Abstract WP181: Timing of Percutaneous Endoscopic Gastrostomy (PEG) for Acute Ischemic Stroke Inpatients in the United States

Stroke ◽

10.1161/str.48.suppl_1.wp181 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

George P Albert ◽

Benjamin P George ◽

Adam G Kelly ◽

David Y Hwang ◽

Robert G Holloway

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Percutaneous Endoscopic Gastrostomy ◽

Oldest Old ◽

Age Groups ◽

The United States ◽

Nasogastric Feeding ◽

Adult Age ◽

Endoscopic Gastrostomy ◽

To Receive

Background and Purpose: Stroke guidelines recommend time-limited trials of nasogastric feeding prior to placement of percutaneous endoscopic gastrostomy (PEG) tubes. We sought to describe timing of PEG placement and identify factors associated with early PEG for acute ischemic stroke. Methods: We designed a retrospective observational study to examine time to PEG for ischemic stroke admissions in the Nationwide Inpatient Sample, 2001-2011. We defined early PEG placement as 1-7 days from admission. Using multivariable regression analysis, we identified the effects of patient and hospital characteristics on time to PEG. Results: We identified 34,623 admissions receiving a PEG from 2001-2011, 53% of which received the PEG early. Among hospitals placing ≥10 PEG tubes, median time to PEG for individual hospitals ranged from 3 days to over 3 weeks (interquartile range: 6-8.5 days). Older adult age groups were associated with early PEG placement (≥85 years vs. 18-54 years: Adjusted Odds Ratio [AOR] 1.68, 95% CI 1.50-1.87). Those receiving a PEG tube and tracheostomy were less likely to receive the PEG early (vs. no tracheostomy; AOR 0.27, 95% CI 0.24-0.29), and these patients were more often younger compared to PEG only recipients ( Figure ). Those admitted to high volume hospitals were more likely to receive their PEG early (≥350 vs. <150 hospitalizations; AOR 1.26, 95% CI 1.17-1.35). Conclusions: More than half of PEG recipients received their surgical feeding tube within 7 days of admission. The oldest old, who may be the most likely to benefit from time-limited trials of nasogastric feeding, were most likely to receive a PEG early.

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Abstract WP7: Impact of Stent-Retrievers on Real World Stroke Outcomes Utilizing the National Inpatient Sample

Stroke ◽

10.1161/str.48.suppl_1.wp7 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Anit K Behera ◽

Eric Adjei Boakye ◽

Eric Armbrecht ◽

Amer Alshekhlee ◽

Randall Edgell

Keyword(s):

Ischemic Stroke ◽

Length Of Stay ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Real World ◽

First Generation ◽

National Inpatient Sample ◽

Period 2 ◽

Time Period ◽

Stent Retrievers

Introduction: In 2015, mechanical thrombectomy (MT) with stent-retrievers became a standard of care treatment for acute ischemic stroke (AIS). Data on the impact of stent-retrievers on clinical outcomes in non-trial settings is limited. This study examines the association between the transition from first generation devices to stent-retrievers and clinical outcomes in a large inpatient sample. Methods: We used data from the 2010 - 2013 National Inpatient Sample for patients (n=3553) with a diagnosis of AIS using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9 CM) diagnosis codes who underwent MT using ICD-9-CM procedure code of 39.74. Patients in the 2010-2011 time period (Period 1) were categorized as first generation device patients and patients in the 2012-2013 time period (Period 2) were categorized as second generation device patients. Outcomes were in-hospital mortality (alive/dead), discharge disposition (favorable/unfavorable), and length of stay (normal/prolonged). Weighted binary logistic regression models adjusting for patient and hospital level factors were developed. Results: The number of procedures increases from 679 in 2010 to 1128 in 2013. In Period 1, 1443 patients were treated with MT and in Period 2, 2110 patients were treated with MT. In the adjusted model, compared to patients in Period 1, patients in Period 2 were 31% less likely to be deceased (aOR = 0.69; 95% CI = 0.58-0.83) and 22% less likely to be discharged to an unfavorable location (aOR = 0.78; 95% CI = 0.64-0.95). There was no statistically significant association between treatment period and length of stay (aOR = 0.95; 95% CI = 0.82-1.10). Conclusion: Patients that had an MT performed during the stent-retrievers years were less likely to expire and be discharged to an unfavorable location than patients in the first generation device years. This confirms the past literature on the beneficial effects of a second generation of stent-retrievers in the treatment of acute ischemic stroke in a real world setting.

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Abstract 183: Trends in Hospitalizations and Cost Associated with Acute Ischemic Stroke by Age, United States 2003-2012

Stroke ◽

10.1161/str.47.suppl_1.183 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Xin Tong ◽

Mary G George ◽

Cathleen Gillespie ◽

Robert K Merritt

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Disease Burden ◽

Hospital Costs ◽

Age Groups ◽

National Inpatient Sample ◽

Principal Diagnosis ◽

Time Intervals ◽

Hospitalization Rates ◽

Study Population

Introduction: Stroke mortality has decreased from 4 th to 5 th leading cause of death in the U.S. However, it is still a leading cause of disability and the disease burden associated with stroke by age is not well known. Methods: The study population consisted of 2003-2012 adult hospitalizations from the National Inpatient Sample of the Healthcare Cost and Utilization Project. Acute ischemic stroke (AIS) hospitalizations were identified by the principal diagnosis ICD-9-CM code. We estimated national acute ischemic stroke hospitalization rates and associated inflation-adjusted hospital costs across five consecutive 2-year time intervals (2003-04 through 2011-12), stratified by six age groups: 18-34 years, 35-44 years, 45-54 years, 55-64 years, 65-74 years, and ≥75 years. Results: The hospitalization rates per 100,000 persons with a principal diagnosis of AIS increased significantly among persons aged 18 to 54 years, but decreased significantly among those aged≥65 years. The largest increase was observed among ages 35-44 years. The average per-hospitalization cost increased 7%-19% across all 6 age groups after adjusting for inflation and the estimated total national cost increased 18% for AIS from 2003-04 to 2011-12. The estimated total cost for AIS hospitalization reached $12.55 billion in 2011-12. Conclusions: While AIS hospitalizations among ages ≥65 declined from 2003 to 2012, the hospitalization rates increased significantly among ages 18-54. The estimated hospital costs increased across all age groups during the study period, indicating the rising economic burden of stroke in the health care system.

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Cardiovascular outcomes of concurrent TAVR and PCI compared to TAVR alone using the U.S. national inpatient sample: 2011–2014

European Heart Journal ◽

10.1093/ehjci/ehaa946.2557 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M Byer ◽

D Celli ◽

B Zarrabian ◽

R Colombo

Keyword(s):

Cardiac Arrest ◽

Ischemic Stroke ◽

Length Of Stay ◽

Hospital Mortality ◽

Cardiogenic Shock ◽

Hospital Admission ◽

Clinical Decision Making ◽

The United States ◽

Cardiovascular Outcomes ◽

National Inpatient Sample

Abstract Introduction The high concurrent prevalence of coronary artery disease (CAD) in patients with severe aortic stenosis (AS) inevitably forces experts to face a pressing decision whether to revascularize and replace the aortic valve at the same time. While current recommendations support combined transaortic valve replacement (TAVR) and percutaneous coronary intervention (PCI) for treatment of ostial/proximal lesions, or in unstable patients, less clear indications exist for patients not fulfilling this pattern. The population undergoing concomitant TAVR and PCI can be clinically challenging and thus it is important to further characterize prognosis and major cardiovascular outcomes in this cohort. Purpose To assess the likelihood of major cardiovascular events in patients undergoing TAVR with PCI during the same hospital admission compared to those with TAVR only. As well as to have a better understanding of the risks and possible benefits of a combined procedure and thus aid in clinical decision-making. Methods This study used the National Inpatient Sample (NIS) of patients undergoing a TAVR from 2011 to 2014. The NIS is a stratified systematic random sample of 20% hospital admissions in the United States. Internal Classification of Diseases Ninth Revision-Clinical Modification procedure codes were used to identify all patients that underwent a PCI and/or TAVR during the same admission. Patients aged greater than 50 years were included. Outcomes of interest included all-cause in-hospital mortality, new TIA/ischemic stroke, cardiogenic shock, cardiac arrest, hemopericardium, and length of stay. Multivariate logistic regression was used to adjust for patient and procedural confounders. Results Among the 33,652 patients who underwent TAVR between 2011 and 2014, 1,179 underwent a PCI during the same hospital admission. The adjusted odds of all-cause in-hospital mortality was 3.05 (95% CI 1.95–4.75) in those with a TAVR+PCI compared to TAVR only. The adjusted odds of cardiac arrest and cardiogenic shock was 2.50 (95% CI: 1.48–4.22) and 4.85 (95% CI 3.05–7.7), respectively. Furthermore, the odds of a new TIA/ischemic stroke during the same admission was 0.86 (95% CI 0.35–2.07) and odds of hemopericardium was 3.13 (95% CI: 0.71–13.70). Conclusion Concomitant PCI and TAVR during the same hospitalization was associated with higher all-cause in-hospital mortality, increased length of stay, cardiogenic shock, and cardiac arrest but does not appear to increase the likelihood of stroke/TIA. While this suggest worse outcomes in the cohort undergoing both procedures, the initial indications for these patients to receive a PCI might predispose them to these outcomes. Funding Acknowledgement Type of funding source: None

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Abstract WP182: Trends in Acute Ischemic Stroke Hospitalizations and Risk Factors Among Young Adults: 12 Years of Nationally Representative Data

Stroke ◽

10.1161/str.48.suppl_1.wp182 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Urvish K Patel ◽

Priti Poojary ◽

Vishal Jani ◽

Mandip S Dhamoon

Keyword(s):

Risk Factors ◽

Older Adults ◽

Young Adults ◽

Ischemic Stroke ◽

Length Of Stay ◽

Acute Ischemic Stroke ◽

Stroke Risk ◽

Behavioral Risk Factors ◽

Behavioral Risk ◽

Stroke Risk Factors

Background: There is limited recent population-based data of trends in acute ischemic stroke (AIS) hospitalization rates among young adults (YA). Rising prevalence of stroke risk factors may increase stroke rates in YA. We hypothesized that 1) stroke hospitalizations and mortality among YA are increasing over time (2000-2011), 2) besides traditional stroke risk factors, non-traditional factors are associated with stroke in YA, 3) stroke hospitalization among YA is associated with higher mortality, length of stay (LOS), and cost. Methods: In the Nationwide Inpatient Sample database (years 2000-2011), adult hospitalizations for AIS and concurrent diagnoses were identified by ICD-9-CM codes; the analytic cohort constituted all AIS hospitalizations. We performed weighted analysis using chi-square, t-test, and Jonckheere trend test. Multivariable survey regression models evaluated interactions between age group (18-45 vs. >45 years) and traditional and non-traditional risk factors, with outcomes including mortality, LOS, and cost. Models were adjusted for race, sex, Charlson’s Comorbidity Index, primary payer, location and teaching status of hospital, and admission day. Results: Among 5220960 AIS hospitalizations, 231858 (4.4%) were YA. On trend analysis, proportion of YA amongst AIS increased from 3.6% in 2000 to 4.7% in 2011 (p<0.0001) but mortality in YA decreased from 3.7% in 2000 to 2.6% in 2011, compared to 7.1% in 2000 to 4.6% in 2011 (p<0.0001) among older adults. Non-traditional, especially behavioral, risk factors were more common among YA, and LOS and cost were higher (Table). Conclusion: There was a trend for higher proportion of YA among AIS hospitalizations, though there was a decreasing mortality trend over 10 years. Behavioral risk factors were more common among YA, and there was an increased length of stay and cost. AIS in YA may require different preventive approaches compared to AIS among older adults.

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