scholarly journals Editorial: Workforce needs for endovascular acute ischemic stroke therapy: myth or reality?

2014 ◽  
Vol 36 (1) ◽  
pp. E8 ◽  
Author(s):  
Harry Cloft
Keyword(s):  
United States ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
The United States ◽  
Stroke Therapy ◽  
Adequate Supply ◽  
Intraarterial Therapy ◽  
Workforce Needs ◽  
Future Demand

The acute ischemic strokes amenable to intraarterial therapy probably number no more than 20,000 per year in the United States. The future demand for intraarterial reperfusion techniques may change, but the fraction of patients who require intraarterial thrombolysis is currently rather low, and the number of neurointerventionists is adequate. Each hospital caring for patients with acute stroke will need to determine its own demand for intraarterial therapy and employ an adequate supply of qualified neurointerventionists available to meet demand. Comprehensive stroke centers are now being designated and hopefully will foster a rational, regionalized approach to the delivery of endovascular therapies for stroke.

Abstract 196: Thrombolytic Treatment using Drip and Ship Treatment Paradigm among Acute Ischemic Stroke Patients in the United States: Outcomes and impact on regional thrombolytic utilization and referral patterns

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Wondwossen G Tekle ◽  
Saqib A Chaudhry ◽  
Habib Qaiser ◽  
Ameer E Hassan ◽  
Gustavo J Rodriguez ◽  
...  
Keyword(s):  
United States ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
The United States ◽  
Thrombolytic Treatment ◽  
Stroke Patients ◽  
Referral Patterns ◽  
Hospital Outcomes ◽  
Treatment Paradigm

Background: While single center and regional estimates of thrombolytic administration using drip and ship treatment paradigm are available, patient outcomes, thrombolytic utilization, cost, and referral patterns has not been assessed in United States. Objective: To provide national estimates of patients treated with thrombolytics using drip and ship paradigm and determine the impact of drip and ship treatment on regional thrombolytic utilization, treatment cost, and referral patterns of acute stroke patients in a large cohort. Methods: We determined the proportion of patients treated with drip and ship paradigm among all acute ischemic stroke patients treated with thrombolytic treatment and obtained comparative in-hospital outcomes from the Nationwide Inpatient Survey (NIS) data files from October 2008 to December 2009. All the in-hospital outcomes were analyzed after adjusting for potential confounders using multivariate analysis. Thrombolytic utilization, hospitalization cost, and patterns of referral related to drip and ship treatment of acute stroke were estimated. Results: Of the 26,814 ischemic stroke patients who received thrombolytic treatment, 5144 (19%) were treated using drip and ship paradigm. Seventy nine percent of all the drip and ship treated patients were referred to urban teaching hospitals for further care, and 7% of them received follow up endovascular treatment at the referral facility. States with higher proportion of patients treated using the drip and ship paradigm had higher rates of thrombolytic utilization (3.1% vs. 2.4%, p<0.001). After adjusting for age, gender, presence of hypertension, diabetes mellitus, renal failure, and hospital teaching status, outcomes of patients treated with drip and ship paradigm was similar to those who received thrombolytic and stayed in the same facility: self care (odds ratio [OR], 1.055, 95% confidence interval [CI], 0.910-1.224, p=0.4779); death(OR , 0.821 95% CI, 0.619- 1.088, p=0.1688); and nursing home discharge (OR, 1.023, 95% CI, 0.880- 1.189, p=0.7659) at discharge. Drip and ship paradigm was associated with shorter hospital stay (mean [days, SE] 5.9± 0.18 vs. 7.4 ± 0.15, p<0.001), and lower cost of hospitalization (mean total charges [$, SE) 57,000 ± 3,324 vs. 83,000 ± 3,367, p<0.001). Conclusions: One out of every five patients who received thromboytic treatment in United States is currently treated using drip and ship paradigm with comparable adjusted rates of favorable outcomes. There was a higher rates of thrombolytic utilization in States where drip and ship was more commonly implemented.

Achieving More Rapid Door-to-Needle Times and Improved Outcomes in Acute Ischemic Stroke in a Nationwide Quality Improvement Intervention

Stroke ◽  
2021 ◽  
Author(s):  
Ying Xian ◽  
Haolin Xu ◽  
Eric E. Smith ◽  
Jeffrey L. Saver ◽  
Mathew J. Reeves ◽  
...  
Keyword(s):  
United States ◽  
Quality Improvement ◽  
Ischemic Stroke ◽  
Thrombolytic Therapy ◽  
Phase I ◽  
Acute Ischemic Stroke ◽  
Symptom Onset ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
The United States

Background and Purpose: The benefits of tPA (tissue-type plasminogen activator) in acute ischemic stroke are time-dependent. However, delivery of thrombolytic therapy rapidly after hospital arrival was initially occurring infrequently in hospitals in the United States, discrepant with national guidelines. Methods: We evaluated door-to-needle (DTN) times and clinical outcomes among patients with acute ischemic stroke receiving tPA before and after initiation of 2 successive nationwide quality improvement initiatives: Target: Stroke Phase I (2010–2013) and Target: Stroke Phase II (2014–2018) from 913 Get With The Guidelines-Stroke hospitals in the United States between April 2003 and September 2018. Results: Among 154 221 patients receiving tPA within 3 hours of stroke symptom onset (median age 72 years, 50.1% female), median DTN times decreased from 78 minutes (interquartile range, 60–98) preintervention, to 66 minutes (51–87) during Phase I, and 50 minutes (37–66) during Phase II ( P <0.001). Proportions of patients with DTN ≤60 minutes increased from 26.4% to 42.7% to 68.6% ( P <0.001). Proportions of patients with DTN ≤45 minutes increased from 10.1% to 17.7% to 41.4% ( P <0.001). By the end of the second intervention, 75.4% and 51.7% patients achieved 60-minute and 45-minute DTN goals. Compared with the preintervention period, hospitals during the second intervention period (2014–2018) achieved higher rates of tPA use (11.7% versus 5.6%; adjusted odds ratio, 2.43 [95% CI, 2.31–2.56]), lower in-hospital mortality (6.0% versus 10.0%; adjusted odds ratio, 0.69 [0.64–0.73]), fewer bleeding complication (3.4% versus 5.5%; adjusted odds ratio, 0.68 [0.62–0.74]), and higher rates of discharge to home (49.6% versus 35.7%; adjusted odds ratio, 1.43 [1.38–1.50]). Similar findings were found in sensitivity analyses of 185 501 patients receiving tPA within 4.5 hours of symptom onset. Conclusions: A nationwide quality improvement program for acute ischemic stroke was associated with substantial improvement in the timeliness of thrombolytic therapy start, increased thrombolytic treatment, and improved clinical outcomes.

Abstract 504: Regional Variations of Ischemic Stroke in The United States

2017 ◽  
Vol 37 (suppl_1) ◽  
Author(s):  
Prateeth Pati ◽  
Adnan Khalif ◽  
Balaji Shanmugam
Keyword(s):  
United States ◽  
Ischemic Stroke ◽  
Seasonal Variation ◽  
Acute Ischemic Stroke ◽  
Geographic Distribution ◽  
The United States ◽  
Categorical Variables ◽  
The South ◽  
Admission Rates ◽  
Chi Square Analysis

Geographic Distribution of Acute Ischemic Stroke admissions in the United States Background: The geographic distribution of acute ischemic stroke in the United States has not been evaluated, unlike the association shown with acute MI by Patel et al., (International Journal of Cardiology, 2014, 172.3). Our study looked at the geographic distribution and seasonal variation of acute ischemic stroke using the National Inpatient Sample (NIS) from 2011 - 2013. Methods: Adult admissions with a primary diagnosis of acute ischemic stroke were extracted from the NIS database using the ICD 9 code 434.91 from 2011 - 2013. Admission information included hospital region (West, South, Mid-Atlantic and Northwest) and seasonal admission rates (Winter=December-February, Spring=March-May, Summer=June-August, Fall=September-November). A Chi square analysis was used to analyze differences in categorical variables (we assumed a normal distribution of 25% per region). Results: A total of 120714 admissions were identified (weighted = 603361). There were more cases of acute ischemic stroke in the South (41.52 percent of admissions) compared to the mid Atlantic (21.4), Northwest (17.98) or West (19.08) with a p value < 0.0001. Each year between 2011 to 2013 showed a higher rate of admissions for acute ischemic stroke in the South. Taking the years into summation showed no statistically significant difference in seasonal variation in any of the regions. Conclusion: Our study shows a higher number of admissions for acute ischemic stroke in the South, but failed to show any seasonal differences. However, there are several studies that suggest a preponderance of admissions for acute myocardial infarction during the winter season, Spencer et al., (Journal of the American College of Cardiology, 1998, 31.2.) Further studies are needed to identify why there is a significant regional difference in the admission rates for acute ischemic stroke.

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

Stroke ◽  
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.

Abstract TP77: Race/Ethnic Disparity Trends in tPA Administration in the United States

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Michelle P Lin ◽  
Steven Cen ◽  
Amytis Towfighi ◽  
May Kim-Tenser ◽  
William Mack ◽  
...  
Keyword(s):  
United States ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Rate Ratio ◽  
The United States ◽  
Racial Groups ◽  
Primary Analysis ◽  
Targeted Interventions ◽  
Yearly Change ◽  
Administration Rate

Introduction: Prior studies have shown racial disparities in tPA use for acute ischemic stroke. With the implementation of nationwide quality improvement measures, we sought to describe the temporal change in racial disparity in tPA administration. Hypothesis: Disparity in tPA administration improved across all racial groups in the past decade Methods: Data were obtained from all US states that contributed to the Nationwide Inpatient Sample. All patients (N=5,932,175) admitted to hospitals between 2000 and 2010 with a discharge diagnosis of ischemic stroke (ICD9 codes) were included. Primary analysis was the proportion of patients who received tPA administration stratified by race (white, black, Hispanic, Asian) temporally. Survey-weighted Poisson regression was used to estimate the rate ratio and compare the trend for yearly change between race categories. Results: Of the patients with ischemic stroke, 55.4% were white, black 11.89%, Hispanic 5.32%, Asian 1.89%, others 1.77%, missing race 23.31%. tPA administration rate increased from 2000 to 2010 regardless of race. In 2000, tPA administration rate was 0.96%, 0.40%, 0.73%, 0.59% in white, black, Hispanic, Asian, respectively. In 2010, tPA administration rate was 4.0%, 2.14%, 2.09%, 2.13% respectively. The relative change was the greatest in black with rate ratio of 6.7 (5.95-7.54), compared to other racial groups, Asian 5.36 (4.23-6.78), Hispanic 3.93 (3.42-4.51), and white 3.88 (3.74-4.03). Conclusions: Over the last decade, the rate of tPA administration for acute ischemic stroke in the United States have increased for every racial group. There is a lasting but improved disparity in tPA administration in non-white race. Targeted interventions designed to increase treatment and close disparity gap focusing on culturally tailored education and communications to address barriers need to be further explored.

Abstract WMP94: Readmission Within 30 days After Acute Ischemic Stroke, United States 2013

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Xin Tong ◽  
Mary G George ◽  
Sallyann M Coleman King ◽  
Cathleen Gillespie ◽  
Robert Merritt
Keyword(s):  
United States ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Readmission Rate ◽  
Hospital Readmissions ◽  
The United States ◽  
Artery Occlusion ◽  
Principal Diagnosis ◽  
Readmission Rates ◽  
The Cost

Introduction: Hospital readmissions contribute significantly to the cost of medical care and reflect the burden of disease. Limited data have been reported on national hospital readmission after acute ischemic stroke. Methods: Among 2013 adult hospitalizations from the National Inpatient Sample of the Healthcare Cost and Utilization Project (HCUP) Nationwide Readmissions Database (NRD), we identified acute ischemic stroke (AIS) hospitalizations using principal diagnosis ICD-9-CM codes. We provided national estimates of AIS non-elective readmission rates within 30 days. Results: In 2013, there were a total of 489,813 adult index AIS admissions in the United States. The readmission rate within 30 days for a new AIS as the principal diagnosis was 2.1% of index AIS admissions, and was 10.2% of all readmissions. The readmission rate for all non-elective reasons increased with age, with the lowest readmission rate (8.9%) among ages 18-44, and the highest (11.7%).among ages 85+. The readmission rate was higher among patients with public insurance (11.1%) as compared to private (7.4%) or others (7.9%). Recurrent AIS (20.2%) was the most common reason for readmission, including unspecified cerebral artery occlusion with infarction (ICD9-CM=434.91, 13.0%) and cerebral embolism with infarction (ICD9-CM=434.11, 3.1%). In addition, infections were among the most common causes (Septicemia 5.7%, UTI 2.7%, and pneumonia 2.2%) and TIA (2.4%). Conclusions: The findings have important implications for identifying groups and conditions at high-risk for readmission. The large number of recurrent AIS within 30 days of index AIS highlights the need for improved patient follow-up and secondary prevention treatment.

Abstract 187: Temporal Trends in Sex and Age Disparities in Acute Ischemic Stroke Treatment and Outcomes in the United States From 2004 to 2014

Stroke ◽  
2018 ◽  
Vol 49 (Suppl_1) ◽  
Author(s):  
Vasu Saini ◽  
Fadar O Otite ◽  
Priyank Khandelwal ◽  
Dileep R Yavagal ◽  
Seemant Chaturvedi ◽  
...  
Keyword(s):  
United States ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Temporal Trends ◽  
The United States ◽  
Stroke Treatment ◽  
Age Disparities
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