Abstract WP324: Stroke Recognition Among Inpatient Staff at an Academic Medical Center

Background About 10% of all strokes occur in hospitalized patients. The goal of this work was to evaluate the knowledge of stroke signs and to determine predictors of that knowledge among inpatient staff at an academic medical center.

Methods Stroke education was the topic of a mandatory in-service for all adult inpatient medical, surgical, and ICU nursing unit clinical staff; including nurses, techs, and aides. The staff members anonymously completed an optional web-survey which included free text responses for stroke signs and symptoms, along with additional multiple choice questions regarding experience and training. The primary outcome was stroke knowledge which was defined as correct naming of 2 or more stroke warning signs or symptoms. Logistic regression was used to determine predictors of the primary outcome.

Results The survey was offered to 1,593 staff members and 875 (55%) completed the survey. Eighty-seven percent of inpatient staff members correctly identified 2 or more stroke warning signs or symptoms while 31% identified 3 stroke warning signs or symptoms. Individual level predictors of stroke knowledge are shown in the Table. Greater self-reported confidence in identifying stroke symptoms and higher ratings for the importance of rapid identification of stroke symptoms were associated with stroke knowledge. Clinical experience, educational experience, work location, and personal knowledge of a stroke patient were not associated with stroke knowledge.

Conclusion More than 80% of adult clinical inpatient staff members have knowledge of two or more stroke signs and symptoms. Future nursing education should emphasize the importance of rapid identification of stroke signs and symptoms and increasing confidence in knowledge of stroke symptoms.

Abstract WP389: Lack of Relationship Between Joint Commission Stroke Performance Measures and Functional Outcome in Ischemic Stroke

Background Performance measures are used to encourage quality improvement, but there is little data that show performance measures improve post-stroke functional outcome. We sought to determine if adherence to Joint Commission (JC) performance measures is associated with a better functional outcome after ischemic stroke.

Methods Ischemic stroke patients were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) project between Nov. 2008 and June 2011. Data were abstracted from the medical records for the following performance measures (using 2008 JC criteria): DVT prophylaxis at 48 hours, discharged on antithrombotic therapy, anticoagulation for patients with atrial fibrillation, thrombolytic therapy administered, antithrombotic by hospital day 2, discharged on cholesterol reducing medication, and assessed for rehabilitation. Adherence to quality measures was defined by a either a binary defect free score indicating receipt of all of the measures a patient was eligible for or an opportunity score indicating the proportion of eligible measures received. Functional outcome was ascertained by patient or proxy interview as a total ADL/IADL score at 90 days post-stroke, with higher scores indicating poorer function (range 22-88). Tobit regression was used to estimate the effects of adherence to quality measures on functional outcome with adjustment for age, gender, pre-stroke functional and cognitive status, ethnicity, stroke severity, medical comorbidities, education, and clustering of patients within hospital.

Results At total of 379 ischemic stroke patients were included. The median age was 68 and 52% of patients were women. 33.8% of patients had defect free care and the median opportunity score was 0.8 (IQR: 0.67-1). In the final multivariable models, defect free care (B -1.04, SE 2.24, p=0.66) and the opportunity score (B 1.80, SE 5.38, p=0.74) were not associated with functional outcome.

Conclusions In this population, meeting JC performance measures was not associated with improvement in post-stroke functional outcome. While process based measures are important and improve adherence to guideline recommended care, these measures may not lead to improved functional outcome, a measure that patients and families value.

Abstract WP34: Factors Associated with Reduced use of Stroke MRI: an Analysis of Practice Patterns

Background: Guidelines support the use of Magnetic Resonance Imaging (MRI) in the evaluation of acute stroke, however the perceived value of MRI information to providers in different clinical scenarios is not known. We aimed to identify patient characteristics associated with lower MRI use as means of identifying possible clinical scenarios where providers may perceive MRI to be less valuable.

Methods: Stroke hospitalizations (principal ICD-9-CM 433.x1, 434.x1, 436) were identified from the State Inpatient Databases (SID) from 2003-2009 for 12 states. MRI utilization was identified using revenue codes and ICD-9 procedure codes. Patient characteristics were abstracted from the hospitalization record. Multi-level logistic regression with a random hospital-level intercept was used to estimate the association between patient characteristics (demographics, vascular risk factors, stroke mimics, comorbidities, regional socioeconomic status) and MRI. Effect sizes were estimated using posterior probabilities with all covariates held at their means. Sensitivity analyses accounting for the distribution of MRI contraindications were performed.

Results: 670,309 hospitalizations were included in our sample; 51% of the population received MRI. From the model (area under ROC 0.82), age and potential cardioembolic source (atrial fibrillation, congestive heart failure, myocardial infarction) were associated with a lower probability of MRI utilization (table). The predicted probability of MRI in a 50 year old was 63.7% (95% CI 61.5%-65.9%) compared to 41.6% (39.4%-43.9%) in an 80 year-old. In sensitivity analysis, the association between cardioembolic sources and lower MRI use remained significant after accounting for extreme assumptions about the distribution of MRI contraindications.

Conclusions: In routine care, MRI may have less perceived value by providers in stroke patients who are older and have a potential cardioembolic source.

Abstract WP401: Influence of Hospital-Level Practices on Readmission after Ischemic Stroke

Introduction: The Center for Medicare and Medicaid Services intends to publicly report hospital-level readmission rates after ischemic stroke to enable comparisons of hospital quality. The influence of hospitals and hospital-level practices on readmission rates is unknown.

Methods: Adult subjects were entered into this cohort study when hospitalized for ischemic stroke (principal ICD-9-CM 433.x1, 434.x1, 436) in 6 states from 2003-2009 from the State Inpatient Databases. The primary outcome was any non-procedural readmission within 30 days. 26 hospital level practices of interest (utilization of diagnostic testing, procedures, ICU, tPA, and therapeutic modalities) were identified using a combination of ICD-9 procedure codes, diagnosis-related groups (DRGs) and Health Cost and Utilization Project utilization flags. Multilevel logistic regression was used to estimate the association between mean hospital-level practices and readmission after accounting for demographics, vascular risk factors, comorbidities, socioeconomic status and whether a practice was implemented in an individual patient.

Results: Hospitals accounted for 3.7% of the variance in the probability of readmission, intraclass correlation coefficient 0.037 (95% CI 0.031-0.043). Only three practices were associated with readmission: higher use of occupational therapy and acceptance of transfers were associated with lower readmission rates, while higher use of hospice was associated with higher readmission rates. (Table)

Conclusions: Hospitals are responsible for a small proportion of readmission variance. These findings suggest ways that readmission rates may be reduced and illustrate potential susceptibility of a publicly-reported readmission measure to manipulation.

An emergency department intervention to increase warfarin use for atrial fibrillation

BACKGROUND

Emergency department (ED) encounters represent lost opportunities to facilitate anticoagulation for stroke prevention in atrial fibrillation (AF). However, screening of warfarin eligibility in the ED may not be feasible. We evaluated whether a practical quality improvement initiative increased postdischarge warfarin use in ED patients with AF.

METHODS

This quasiexperimental study was conducted in a single academic health system. Eligible subjects were consecutive patients with AF identified by electrocardiogram during an ED evaluation who were discharged from the ED or the subsequent hospitalization off warfarin. The study consisted of data collection during 2 time periods: (1) preintervention (October 2009 to April 2010), serving as a baseline, and (2) intervention (June 2010 to December 2010). The intervention consisted of a mailing to the subjects and their primary care physicians. The primary outcome was the proportion of subjects taking warfarin 1 month after ED presentation. Differences between the proportion of preintervention and intervention subjects taking warfarin and warfarin or aspirin were compared with Chi-square tests.

RESULTS

At 1 month, 111 of 204 (55%) of the eligible preintervention and 90 of 160 (56%) of the eligible intervention group patients participated. There was no difference between the preintervention and intervention groups in the proportion of subjects taking warfarin at 1 month (12% v 9%; P = .54) or the proportion of subjects taking either aspirin or warfarin at 1 month (72% v 75%; P = .59).

CONCLUSIONS

This practical stroke prevention quality improvement initiative was not associated with an increase in warfarin use among ED patients with AF.

Use of BPPV processes in emergency department dizziness presentations: a population-based study

OBJECTIVE

A common cause of dizziness, benign paroxysmal positional vertigo (BPPV), is effectively diagnosed and cured with the Dix-Hallpike test (DHT) and the canalith repositioning maneuver (CRM). We aimed to describe the use of these processes in emergency departments (EDs), assess for trends in use over time, and determine provider level variability in use.

STUDY DESIGN

Prospective population-based surveillance study.

SETTING

Emergency departments in Nueces County, Texas, from January 15, 2008, to January 14, 2011.

SUBJECTS AND METHODS

Adult patients discharged from EDs with dizziness, vertigo, or imbalance documented at triage. Clinical information was abstracted from source documents. A hierarchical logistic regression model adjusting for patient and provider characteristics was used to estimate trends in DHT use and provider-level variability.

RESULTS

A total of 3522 visits for dizziness were identified. A DHT was documented in 137 visits (3.9%). A CRM was documented in 8 visits (0.2%). Among patients diagnosed with BPPV, a DHT was documented in only 21.8% (34 of 156) and a CRM in 3.9% (6 of 156). In the hierarchical model (c-statistic = 0.93), DHT was less likely to be used over time (odds ratio, 0.97; 95% confidence interval, 0.95-0.99), and the provider level explained 50% (intraclass correlation coefficient, 0.50) of the variance in the probability of DHT use.

CONCLUSION

Benign paroxysmal positional vertigo is seldom examined for and, when diagnosed, infrequently treated in this ED population. Use of the DHT is decreasing over time and varies substantially by provider. Implementation research focused on BPPV care may be an opportunity to optimize management in ED dizziness presentations.

The prevalence of spirituality, optimism, depression, and fatalism in a bi-ethnic stroke population

To provide insight into the reduced post-stroke all-cause mortality among Mexican Americans, we explored ethnic differences in the pre-stroke prevalence of (1) spirituality, (2) optimism, (3) depression, and (4) fatalism in a Mexican American and non-Hispanic white stroke population. The Brain Attack Surveillance in Corpus Christi (BASIC) project is a population-based stroke surveillance study in Nueces County, Texas. Seven hundred ten stroke patients were queried. For fatalism, optimism, and depression scales, unadjusted ethnic comparisons were made using linear regression models. Regression models were also used to explore how age and gender modify the ethnic associations after adjustment for education. For the categorical spirituality variables, ethnic comparisons were made using Fisher's exact tests. Mexican Americans reported significantly more spirituality than non-Hispanic whites. Among women, age modified the ethnic associations with pre-stroke depression and fatalism but not optimism. Mexican American women had more optimism than non-Hispanic white women. With age, Mexican American women had less depression and fatalism, while non-Hispanic white women had more fatalism and similar depression. Among men, after adjustment for education and age, there was no ethnic association with fatalism, depression, and optimism. Spirituality requires further study as a potential mediator of increased survival following stroke among Mexican Americans. Among women, evaluation of the role of optimism, depression, and fatalism as they relate to ethnic differences in post-stroke mortality should be explored.

A prescription for the Epley maneuver: www.youtube.com?

OBJECTIVES

Video-sharing Web sites are being used for information about common conditions including dizziness. The Epley maneuver (EM) is a simple and effective treatment for benign paroxysmal positional vertigo (BPPV) of the posterior canal. However, the maneuver is underused in routine care. In this study, we aimed to describe and analyze the available information about the EM on youtube.com.

METHODS

A YouTube search was performed on August 31, 2011, for videos that demonstrated the entire EM. Detailed data were abstracted from each video and corresponding Web site. Videos were rated on the accuracy of the maneuver by 2 authors, with differences resolved by adjudication. Comments posted by viewers were assessed for themes regarding video use.

RESULTS

Of the 3,319 videos identified, 33 demonstrated the EM. The total number of hits for all videos was 2,755,607. The video with the most hits (802,471) was produced by the American Academy of Neurology. Five of the videos accounted for 85% of all the hits. The maneuver demonstration was rated as accurate in 64% (21) of the videos. Themes derived from the 424 posted comments included patients self-treating with the maneuver after reviewing the videos, and providers using the videos as a prescribed treatment or for educational purposes.

CONCLUSION

Accurate video demonstration of the Epley maneuver is available and widely viewed on YouTube. Video-sharing media may be an important way to disseminate effective interventions such as the EM. The impact of video Web sites on outcomes and costs of care is not known and warrants future study.

Antihypertensive treatment prolongs tissue plasminogen activator door-to-treatment time: secondary analysis of the INSTINCT trial

BACKGROUND AND PURPOSE

Identifying modifiable tissue plasminogen activator treatment delays may improve stroke outcomes. We hypothesized that prethrombolytic antihypertensive treatment (AHT) may prolong door-to-treatment time (DTT).

METHODS

We performed an analysis of consecutive tissue plasminogen activator-treated patients at 24 randomly selected community hospitals in the Increasing Stroke Treatment through Interventional Behavior Change Tactics (INSTINCT) trial between 2007 and 2010. DTT among stroke patients who received prethrombolytic AHT were compared with those who did not receive prethrombolytic AHT. We then calculated a propensity score for the probability of receiving prethrombolytic AHT using logistic regression with demographics, stroke risk factors, home medications, stroke severity (National Institutes of Health Stroke Scale), onset-to-door time, admission glucose, pretreatment blood pressure, emergency medical service transport, and location at time of stroke as independent variables. A paired t test was performed to compare the DTT between the propensity-matched groups.

RESULTS

Of 534 tissue plasminogen activator-treated stroke patients analyzed, 95 received prethrombolytic AHT. In the unmatched cohort, patients who received prethrombolytic AHT had a longer DTT (mean increase, 9 minutes; 95% confidence interval, 2-16 minutes) than patients who did not. After propensity matching, patients who received prethrombolytic AHT had a longer DTT (mean increase, 10.4 minutes; 95% confidence interval, 1.9-18.8) than patients who did not receive prethrombolytic AHT.

CONCLUSIONS

Prethrombolytic AHT is associated with modest delays in DTT. This represents a potential target for quality-improvement initiatives. Further research evaluating optimum prethrombolytic hypertension management is warranted.

Validation of the 12-item stroke-specific quality of life scale in a biethnic stroke population

The 12-item Stroke-Specific Quality of Life Scale (SSQOL), a shortened version of the original SSQOL, was developed to be an efficient and valid outcome in stroke research. We aimed to assess the validity of this scale in a biethnic ischemic stroke population. Patients with validated ischemic stroke who completed the original 49-item SSQOL at 90 days poststroke were identified from a population-based study, the Brain Attack Surveillance in Corpus Christi Project. Cronbach's α was used to assess the internal consistency of the scales. Intraclass correlation coefficients and linear regression were used to assess agreement between the 2 scales. The study cohort comprised 45 patients with ischemic stroke, 56% female and 51% Mexican American, with a mean age of 66.0±11.3 years. The mean score for the 49-item scale was 3.33±0.84, compared with 3.31±0.95 for the 12-item scale. Internal consistency was 0.96 for the 49-item scale and 0.88 for the 12-item scale. The 2 scales were highly correlated (intraclass correlation coefficient, 0.98; R2=0.97). This study in patients with ischemic stroke from diverse racial/ethnic backgrounds found that the more efficient 12-item SSQOL is a valid alternative to the full 49-item SSQOL for the assessment of health-related quality of life.

A population-based analysis of ethnic differences in admission to the intensive care unit after stroke

BACKGROUND

Mexican-Americans (MAs) have shown lower post-stroke mortality compared to non-hispanic whites (NHWs). Limited evidence suggests race/ethnic differences exist in intensive care unit (ICU) admissions following stroke. Our objective was to investigate the association of ethnicity with admission to the ICU following stroke.

METHODS

Cases of intracerebral hemorrhage and acute ischemic stroke were prospectively ascertained as part of the Brain Attack Surveillance in Corpus Christi (BASIC) project for the period of January 2000 through December 2009. Logistic regression models fitted within the generalized additive model framework were used to test associations between ethnicity and ICU admission and potential confounders. An interaction term between age and ethnicity was investigated in the final model.

RESULTS

A total 1,464 cases were included in analysis. MAs were younger, more likely to have diabetes, and less likely to have atrial fibrillation, health insurance, or high school diploma than NHWs. On unadjusted analysis, there was a trend toward MAs being more likely to be admitted to ICU than NHWs (34.6 vs 30.3 %; OR = 1.22; 95 % CI 0.98-1.52; p = 0.08). However, on adjusted analysis, no overall association between MA ethnicity and ICU admission (OR = 1.13; 95 % CI 0.85-1.50) was found. When an interaction term for age and ethnicity was added to this model, there was only borderline evidence for effect modification by age of the ethnicity/ICU relationship (p = 0.16).

CONCLUSIONS

No overall association between ethnicity and ICU admission was observed in this community. ICU utilization alone does not likely explain ethnic differences in survival following stroke between MAs and NHWs.

Effect of insurance status on postacute care among working age stroke survivors

OBJECTIVE

Utilization of postacute care is associated with improved poststroke outcomes. However, more than 20% of American adults under age 65 are uninsured. We sought to determine whether insurance status is associated with utilization and intensity of institutional postacute care among working age stroke survivors.

METHODS

A retrospective cross-sectional study of ischemic stroke survivors under age 65 from the 2004-2006 Nationwide Inpatient Sample was conducted. Hierarchical logistic regression models controlling for patient and hospital-level factors were used. The primary outcome was utilization of any institutional postacute care (inpatient rehabilitation or skilled nursing facilities) following hospital admission for ischemic stroke. Intensity of rehabilitation was explored by comparing utilization of inpatient rehabilitation facilities and skilled nursing facilities.

RESULTS

Of the 33,917 working age stroke survivors, 19.3% were uninsured, 19.8% were Medicaid enrollees, and 22.8% were discharged to institutional postacute care. Compared to those privately insured, uninsured stroke survivors were less likely (adjusted odds ratio [AOR] 0.53, 95% confidence interval [CI] 0.47-0.59) while stroke survivors with Medicaid were more likely to utilize any institutional postacute care (AOR = 1.40, 95% CI 1.27-1.54). Among stroke survivors who utilized institutional postacute care, uninsured (AOR = 0.48, 95% CI 0.36-0.64) and Medicaid stroke survivors (AOR = 0.27, 95% CI 0.23-0.33) were less likely to utilize an inpatient rehabilitation facility than a skilled nursing facility compared to privately insured stroke survivors.

CONCLUSIONS

Insurance status among working age acute stroke survivors is independently associated with utilization and intensity of institutional postacute care. This may explain differences in poststroke outcomes among uninsured and Medicaid stroke survivors compared to the privately insured.

Stroke Health and Risk Education (SHARE): design, methods, and theoretical basis

BACKGROUND

Stroke is a disease with tremendous individual, family, and societal impact across all race/ethnic groups. Mexican Americans, the largest subgroup of Hispanic Americans, are at even higher risk of stroke than European Americans.

AIM

To test the effectiveness of a culturally sensitive, church-based, multi-component, motivational enhancement intervention for Mexican Americans and European Americans in reducing stroke risk factors.

METHODS

Participants enroll in family or friendship pairs, from the same Catholic church in the Corpus Christi Texas area, and are encouraged to change diet and physical activity behaviors and provide support for behavior change to their partners. Churches are randomized to either the intervention or control group. Goal enrollment for each of the 10 participating churches is 40 participant pairs. The intervention consists of self-help materials (including a motivational short film, cookbook/healthy eating guide, physical activity guide with pedometer, and photonovella), five motivational interviewing calls, two tailored newsletters, parish health promotion activities and environmental changes, and a peer support workshop where participants learn to provide autonomy supportive counseling to their partner. SHARE's three primary outcomes are self-reported sodium intake, fruit and vegetable intake, and level of physical activity. Participants complete questionnaires and have measurements at baseline, six months, and twelve months. Persistence testing is performed at 18 months in the intervention group. The trial is registered with clinicaltrials.gov (NCT01378780).

Abstract 32: Variation in Discharge Practices and Use of Life-Sustaining Procedures: Potential Pitfalls for Adjusted Mortality Quality Measures

Introduction: The Center for Medicare and Medicaid Services (CMS) is developing a risk-standardized stroke mortality measure intended for public comparison of hospital-level quality of care. We sought to determine the impact of discharge practices and use of life sustaining procedures on risk-standardized mortality. We could then address questions such as, how much does mortality differ between hospitals that routinely discharge patients to hospice and those that don’t?

Methods: We estimated risk standardized stroke inpatient mortality for all hospitals in the Nationwide Inpatient Sample (NIS) from 2008-9, using hierarchical logistic regression following a similar approach used for existing CMS mortality measures. Hospital-level adjusted stoke mortality was then categorized as below average, average or above average using standardized Hospital Compare methodology. We then developed individual and hospital level variables to characterize hospital-level practices of interest: discharge to long term acute care (LTAC), discharge to hospice and a life-sustaining procedure index which combined the rates of gastrostomy, tracheostomy, hemicraniectomy and ventriculostomy. These variables were added to the base model in a second hierarchical logistic regression model. This model was used to compare differences in risk-standardized mortality from hospitals grouped in the highest and lowest practice quintiles and to estimate the effects of the hospital practices on grades.

Results: A total of 186,689 stroke patients were identified. Median age was 72 (IQR 60-82) and 52% were female. Seventy six percent of strokes were ischemic, 19% were ICH and 5% were SAH. Of the 1,366 hospitals in the sample 1,210 received average, 73 below average and 83 above average grades for stroke mortality using the base model. Hospitals that more commonly discharged patients to hospice or LTAC or used more life-sustaining procedures had lower mortality. Mean risk standardized mortality was higher in the lowest quintile of hospice utilizing hospitals compared to the highest (11.4% vs. 10.0%, p < 0.01) and in the lowest quintile of LTAC utilizing hospitals compared to the highest (11.4% vs. 10.3%, p = 0.02). Similarly, mean risk standardized mortality was higher in the lowest quintile of hospital use of life-sustaining procedures compared to the highest (11.3% vs. 10.7%, p < 0.01). Accounting for changes in hospital-level practices resulted in significant hospital grade reassignment. Of the 73 initial below average grades, 19 (26%)were reclassified to average and of the 83 initial above average grades, 35 (42%) were reclassified to average. Overall, 6% were reclassified.

Conclusions: Variation in discharge practices and use of life-sustaining procedures alters hospital mortality rankings and distorts perceptions of comparative hospital quality. ns of comparative hospital quality.

Abstract 3092: Does Pre-existing Antiplatelet Treatment Influence Post-thrombolysis Intracranial Hemorrhage In Community Treated Ischemic Stroke Patients?

Background: Post-thrombolysis ICH is associated with poor outcomes. Previous investigations have attempted to determine the relationship between pre-existing anti-platelet (AP) use and the safety of intravenous thrombolysis, but have been limited by low event rates thus decreasing the precision of estimates. Our objective was to determine whether pre-existing AP therapy increases the risk of ICH following thrombolysis.

Methods: Consecutive cases of ED treated thrombolysis patients were identified using multiple methods, including active and passive surveillance. Retrospective data were collected from 4 hospitals from 1996-2005, and 24 distinct hospitals from 2007-2010 as part of a cluster randomized trial. The same chart abstraction tool was used during both time periods and data was subjected to numerous quality control checks. Hemorrhages were classified using a pre-specified methodology: ICH was defined as presence of hemorrhage in radiographic interpretations of follow up imaging (primary outcome). Symptomatic ICH (secondary outcome) was defined as radiographic ICH with associated clinical worsening. A multivariable logistic regression model was constructed to adjust for clinical factors previously identified to be related to post-thrombolysis ICH. The models included: pre-existing AP use, age*, NIHSS*, pre-treatment systolic blood pressure, onset to treatment interval, pre-treatment blood glucose*, tobacco use, presence of post-treatment protocol violations (*variable classified by quartile). As there were fewer SICH events, the multivariable model was constructed similarly, except that variables divided into quartiles in the primary analysis were dichotomized at the median.

Results: There were 830 patients included, with 47% having documented pre-existing AP treatment. The mean age was 69 years, the cohort was 53% male, and the median NIHSS was 12. The unadjusted proportion of patients with any ICH was 15.1% without AP and 19.3% with AP (difference 4.2% [95% CI: -1.2% - 9.6%]); for SICH this was 6.1% without AP and 9% with AP (difference 3.1% [95%CI: -1-6.7%]). No significant association between pre-existing AP treatment with radiographic or symptomatic ICH was observed ( table ).

Conclusions: We did not find that AP treatment was associated with post-thrombolysis ICH or SICH in this cohort of community treated patients. Pre-existing tobacco use, younger age, and lower severity were associated with lower odds of SICH. An association between AP therapy and SICH may still exist - further research with larger sample sizes is warranted in order to detect smaller effect sizes.

Abstract 2279: Ethnic Comparisons in Pre-Stroke Awareness and Treatment of Hypertension in Stroke Subjects: Modification by SES and Acculturation

Background and Objectives: Mexican Americans (MAs) have higher stroke incidence rates than non-Hispanic whites (NHWs). Ethnic differences in the pre-stroke treatment of risk factors could potentially explain this disparity and may be exacerbated by low socio-economic status or less acculturation. We assessed pre-stroke awareness and treatment of hypertension by ethnicity, education and English proficiency in a population-based stroke surveillance project.

Methods: Among 1,111 stroke subjects aged ≥45 years in the Brain Attack Surveillance in Corpus Christi (BASIC) project from 01/2000-06/2006, we examined pre-stroke hypertension prevalence (medical record documentation of hypertension diagnosis) at the time of the index stroke by ethnicity (MA vs. NHW). Among those with prevalent hypertension, we measured awareness (self-report of hypertension) and treatment (self-report of anti-hypertensive medication use). We first compared awareness and treatment of hypertension by ethnicity overall. We then compared ethnic differences in awareness and treatment of hypertension using 2 approaches: 1) after stratification by education (<high school vs. ≥high school); and 2) after dichotomizing MAs by self-reported language fluency. Limited English proficiency (EP) was defined as Spanish only (less accultured) and EP was defined as English only/bilingual (more accultured).We adjusted associations for age, gender, education, diabetes, coronary artery disease, and previous stroke using logistic regression.

Results: MAs (mean age 68.3 ± 12.1 years; n=566) were more likely than NHWs (mean age 74.4 ± 11.7 years; n=545) to report <high school education (71% vs. 23%; P<0.001). Thirty-two percent of MAs reported limited EP. Hypertension prevalence was 74% in both MAs and NHWs. There was a trend toward MAs having greater awareness than NHWs (89% vs. 85%; P=0.15) but similar treatment (89-90%) of hypertension. Among high school graduates, we found non-significant trends toward greater awareness but less treatment of hypertension in MAs compared with NHWs ( Figure 1 ). Compared with MAs with EP, NHWs and MAs with limited EP had less awareness of hypertension but similar treatment ( Figure 2 ). After adjustment for socio-demographics and co-morbidities, differences in hypertension awareness were no longer significant (NHWs: aOR, 0.96; 95%CI, 0.52-1.79; MAs with limited EP: aOR, 0.57; 95%CI, 0.27-1.19; MAs with EP: referent).

Conclusion: We found little evidence that differences in pre-stroke awareness and treatment of hypertension may explain ethnic disparities in stroke.

Abstract 2435: Validation of the 12-Item Stroke-Specific Quality of Life Scale in a Bi-ethnic Stroke Population

Background and Purpose: The 12-item Stroke-Specific Quality of Life Scale (SSQOL), a shortened version of the original SSQOL, was recently developed in a mixed cerebrovascular disorders population from the Netherlands. Lacking, however, are validation studies of the shortened version specifically in ischemic stroke patients alone and in those from other race-ethnic backgrounds. We aimed to assess the validity of this scale in a bi-ethnic ischemic stroke population.

Methods: From an on-going population-based study, the Brain Attack Surveillance in Corpus Christi (BASIC) Project, validated ischemic stroke patients who completed the 49-item SSQOL at 90 days post-stroke were identified. Cronbach’s alpha was used to assess internal consistency of the 49- and 12-item scales. An intraclass correlation coefficient (ICC) and linear regression model were used to assess agreement between the two scales and the variance of the 49-item SSQOL explained by the 12-item SSQOL subscale. The Bland-Altman “differences against the mean” plot was used to assess for bias in the 12-item scale across the range of scores.

Results: Of the 46 ischemic stroke patients, the mean age was 66.3 years (SD, 11.4). Fifty-four percent were female and 52% were Mexican American. The mean score of the 49-tem scale was 3.35 (SD, 0.85) compared with 3.34 (SD, 0.96) from the 12-item scale. Internal consistency was very high for both the 49-item scale (α = 0.96) and the 12-item scale (α = 0.88). More than 96% of the variance in the 49-item scale was explained by the 12-item scale (ICC, 0.98; R 2 , 0.97). The Bland Altman plot revealed that the 12-item scale scores were slightly higher than 49-item scores at high mean scores and slightly lower at low mean scores ( Figure ).

Conclusions: This study in ischemic stroke patients from diverse race-ethnic backgrounds found that the more efficient 12-item SSQOL is a valid alternative to the full scale for the assessment of health-related quality of life.

Figure.

Abstract 2719: The Impact of Insurance Status on Post-Acute Care among Working Age Stroke Survivors

Background and Purpose: Utilization of post-stroke rehabilitation is associated with improved functional outcomes. However, more than 20% of American adults under 65 are uninsured potentially leading to disparate utilization of post-acute care services. We sought to determine whether insurance status is associated with utilization and intensity of institutional post-acute care among working age stroke survivors.

Methods: A retrospective cross-sectional study of ischemic stroke survivors under the age of 65 (n=33,917) from the 2004-2006 Nationwide Inpatient Sample (NIS) was conducted. Stroke survivors were categorized based on their insurance status as:1) private insurance; 2) Medicaid; 3) no insurance. Using hierarchical logistic regression models, we explored the association of insurance status and utilization of any institutional post-acute care (inpatient rehabilitation facility (IRF) or skilled nurse facility (SNF)) versus home. We then explored the association of insurance status and intensity of rehabilitation (IRF vs SNF) among those who utilized any institutional post-acute care. All models were controlled for patient factors including age, gender, comorbidities, length of stay, thrombolysis and hospital level factors including size, location, teaching status, region of the country, annual stroke discharges, annual stroke mortality and hospital uninsured.

Results: Nineteen percent of the study population was uninsured while 20% were Medicaid enrollees. Median age of stroke survivors with private insurance was 56 (IQR 49-60) while that of the uninsured was 53 (IQR 47-59) and stroke survivors with Medicaid was 54 (IQR 47-60). Compared to those privately insured, uninsured stroke survivors were less likely to utilize any institutional post-acute care (adjusted OR=0.53, 95%CI 0.47-0.59). Conversely, stroke survivors with Medicaid were more likely to utilize any institutional post-acute care (adjusted OR=1.40, 95%CI 1.27-1.54) than privately insured stroke survivors. Among stroke survivors who utilized institutional post-acute care, uninsured (adjusted OR=0.48, 95%CI 0.36-0.64) and Medicaid stroke survivors (adjusted OR=0.27 95%CI 0.23-0.33) were less likely to utilize an IRF than a SNF compared to privately insured stroke survivors.

Conclusion: The results suggest differences in utilization and intensity of institutional post-acute care for working age stroke survivors based on their insurance status. These findings are interesting in light of the Patient Protection and Affordable Care Act which will result in millions of uninsured individuals transitioning to Medicaid. On one hand our results suggest that this healthcare reform will result in increased utilization of institutional post-acute care among stroke survivors but on the other hand our results suggest that this rehabilitation may be less intense than if they were privately insured.

Abstract 2722: Anti-hypertensive Treatment Prolongs tPA Door-to-treatment Time: Secondary Analysis Of The Increasing Stroke Treatment Through Interventional Behavior Change Tactics (INSTINCT) Trial

Background/Purpose: Increased time to tPA treatment is associated with worse outcomes. Thus, identifying modifiable treatment delays may improve stroke outcomes. We hypothesized that pre-thrombolytic anti-hypertensive treatment (AHT) may prolong door to treatment time (DTT).

Methods: Secondary data analysis of consecutive tPA-treated patients at 24 randomly selected Michigan community hospitals in the INSTINCT trial. DTT among stroke patients who received pre-thrombolytic AHT were compared to those that did not receive pre-thrombolytic AHT. We then calculated a propensity score for the probability of receiving pre-thrombolytic AHT using a logistic regression model with covariates including demographics, stroke risk factors, antiplatelet or beta blocker as home medication, stroke severity (NIHSS), onset to door time, admission glucose, pretreatment systolic and diastolic blood pressure, EMS usage and location at time of stroke. A paired t-test was then performed to compare the DTT between the propensity matched groups. A separate generalized estimating equations (GEE) approach was also used to estimate the differences between patients receiving pre-thrombolytic AHT and those that did not while accounting for within hospital clustering.

Results: A total of 557 patients were included in INSTINCT, however onset, arrival or treatment times were not able to be determined in 23, leaving 534 patients for this analysis. The unmatched cohort consisted of 95 stroke patients who received pre-thrombolytic AHT and 439 stroke patients who did not receive AHT from 2007-2010 ( table ). In the unmatched cohort, patients who received pre-thrombolytic AHT had a longer DTT (mean increase 9 minutes; 95% confidence interval (CI) 2-16 minutes) than patients who did not receive pre-thrombolytic AHT. After propensity matching (table), patients who received pre-thrombolytic AHT had a longer DTT (mean increase 10.4 minutes, 95% CI 1.9 - 18.8) than patients who did not receive pre-thrombolytic AHT. This effect persisted and its magnitude was not altered by accounting for clustering within hospitals.

Conclusion: Pre-thrombolytic AHT is associated with modest delays in DTT. This represents a feasible target for physician educational interventions and quality improvement initiatives. Further research evaluating optimum hypertension management pre-thrombolytic treatment is warranted.

Abstract 133: Protocol Deviations During and After IV Thrombolysis in Community Hospitals

Background and purpose Protocol deviations (PDs) before and immediately after IV thrombolysis for acute ischemic stroke are common. Patient and hospital factors associated with PDs are not well described. We aimed to determine which patient or hospital factors were associated with pre- and post-treatment PDs in a cohort of community treated thrombolysis patients.

Methods The INSTINCT (Increasing Stroke Treatment through Interventional Behavior Change Tactics) study was a multicenter, cluster-randomized controlled trial in 24 Michigan community hospitals evaluating the efficacy of a barrier assessment and educational intervention to increase appropriate tPA use. PDs were defined based on 2007 AHA guidelines with the addition of the 3-4.5 hour treatment window, for which the ECASS III criteria were applied. PDs were categorized as pre-treatment (Pre-PDs), post-treatment (Post-PDs) or both. Multi-level logistic regression models were fitted to determine whether patient and hospital variables were associated with Pre-PDs or Post-PDs. The models included all variables specified a priori to be potentially clinically relevant; Pre-PD was included as a covariate in the model for Post-PD.

Results During the study, 557 patients (mean age 70; 52% male; median NIHSS 12) were treated with IV tPA. PDs occurred in 233 (42%) patients: 26% had only Post-PDs, 7% had only Pre-PDs, and 9% had both. The most common PDs included failure to treat post-treatment hypertension (131, 24%), antiplatelet agent within 24 hours of treatment (61, 11%), pre-treatment blood pressure over 185/110 (39, 7%), anticoagulant agent within 24 hours of treatment (31, 6%), and treatment outside the time window (29, 5%). Symptomatic intracranial hemorrhage (SICH) was observed in 7.3% of patients with PDs and 6.5% of patients without any PD. In-hospital case fatality was 12% with and 10% without a PD. The differences in SICH and case fatality were not statistically significant. In the fully adjusted model, older age was significantly associated with Pre-PDs ( Table ). When Post-PDs were evaluated with adjustment for Pre-PDs, age was not associated with PDs; however, Pre-PDs were associated with Post-PDs.

Conclusion Older age was associated with increased odds of Pre-PDs in Michigan community hospitals. Pre-PDs were associated with Post-PDs. SICH and in-hospital case fatality were not associated with PDs; however, the low number of such events limited our ability to detect a difference. Stroke severity and hospital factors were not associated with PDs.

Sleep apnea risk among mexican american and non-Hispanic white stroke survivors

BACKGROUND AND PURPOSE

Sleep apnea is a modifiable independent stroke risk factor and is associated with poor stroke outcomes. Mexican Americans have a higher incidence of stroke than non-Hispanic whites. In a biethnic community, we sought to determine the frequency of screening, testing, and treatment of sleep apnea among stroke survivors and to compare self-perceived risk of sleep apnea with actual risk.

METHODS

A survey was mailed to ischemic stroke survivors in the Brain Attack Surveillance in Corpus Christi (BASIC) project. The survey included the validated sleep apnea screening tool, the Berlin questionnaire, and queried the frequency of sleep apnea screening by symptoms, formal sleep testing, and treatment. Self-perceived risk and actual high risk of sleep apnea were compared using McNemar's test.

RESULTS

Of the 193 respondents (49% response rate), 54% were Mexican American. Forty-eight percent of respondents had a high risk of sleep apnea based on the Berlin questionnaire, whereas only 19% thought they were likely to have sleep apnea (P<0.01). There was no difference in the proportion of respondents at high risk of sleep apnea between Mexican Americans and non-Hispanic whites (48% versus 51%, P=0.73). Less than 20% of respondents had undergone sleep apnea screening, testing, or treatment.

CONCLUSIONS

Stroke survivors perceive their risk of sleep apnea to be lower than their actual risk. Despite a significant proportion of both Mexican American and non-Hispanic white stroke survivors at high risk of sleep apnea, few undergo symptom screening, testing, or treatment. Both stroke survivors and physicians may benefit from educational interventions.

Fatalism, optimism, spirituality, depressive symptoms, and stroke outcome: a population-based analysis

BACKGROUND AND PURPOSE

We sought to describe the association of spirituality, optimism, fatalism, and depressive symptoms with initial stroke severity, stroke recurrence, and poststroke mortality.

METHODS

Stroke cases from June 2004 to December 2008 were ascertained in Nueces County, TX. Patients without aphasia were queried on their recall of depressive symptoms, fatalism, optimism, and nonorganizational spirituality before stroke using validated scales. The association between scales and stroke outcomes was studied using multiple linear regression with log-transformed National Institutes of Health Stroke Scale and Cox proportional hazards regression for recurrence and mortality.

RESULTS

Six hundred sixty-nine patients participated; 48.7% were women. In fully adjusted models, an increase in fatalism from the first to third quartile was associated with all-cause mortality (hazard ratio, 1.41; 95% CI, 1.06-1.88) and marginally associated with risk of recurrence (hazard ratio, 1.35; 95% CI, 0.97-1.88), but not stroke severity. Similarly, an increase in depressive symptoms was associated with increased mortality (hazard ratio, 1.32; 95% CI, 1.02-1.72), marginally associated with stroke recurrence (HR, 1.22; 95% CI, 0.93-1.62), and with a 9.0% increase in stroke severity (95% CI, 0.01-18.0). Depressive symptoms altered the fatalism-mortality association such that the association of fatalism and mortality was more pronounced for patients reporting no depressive symptoms. Neither spirituality nor optimism conferred a significant effect on stroke severity, recurrence, or mortality.

CONCLUSIONS

Among patients who have already had a stroke, self-described prestroke depressive symptoms and fatalism, but not optimism or spirituality, are associated with increased risk of stroke recurrence and mortality. Unconventional risk factors may explain some of the variability in stroke outcomes observed in populations and may be novel targets for intervention.

Acute care and long-term mortality among elderly patients with intracerebral hemorrhage who undergo chronic life-sustaining procedures

Little is known about patients with intracerebral hemorrhage (ICH) who undergo chronic life-sustaining procedures. We sought to explore variations in treatment, Medicare payments, and mortality among elderly patients with ICH who received a feeding tube, a tracheostomy, or neither chronic life-sustaining procedure. Medicare Provider Analysis and Review files from 2004 linked to Center for Medicaid and Medicare Services denominator files through January 2005 were analyzed. Patients over age 65 years with a primary diagnosis of ICH based on discharge code (ICD-9-CM 431) were divided into those who underwent tracheostomy, those who underwent feeding tube placement but not tracheostomy, and those who underwent neither procedure. Thirty-day and 1-year survival rates were estimated using Kaplan-Meier methods. Among the 32,210 patients studied, 6% underwent feeding tube placement, and 2.5% underwent tracheostomy. Compared with the patients who did not undergo a chronic life-sustaining procedure, those who underwent tracheostomy had a longer length of stay (median, 25 days vs 4 days; P < .01) and greater Medicare spending (median, $81,479 vs $6,008; P < .01) during their initial hospitalization. The 30-day and 1-year cumulative mortality risks were 47% and 59%, respectively, in patients who did not undergo a chronic life-sustaining procedure, 21% and 53% in patients who underwent feeding tube placement, and 19% and 65% in those who underwent tracheostomy (P < .01, log-rank test across the 3 groups). Our findings show high 1-year mortality among elderly patients with ICH, even in those who undergo chronic life-sustaining procedures. Medicare payments for patients who undergo tracheostomy are substantial. More information about functional outcomes is needed.

Community-based participatory research: a new approach to engaging community members to rapidly call 911 for stroke

BACKGROUND AND PURPOSE

Acute stroke treatments are underutilized primarily because of delayed hospital arrival. Using a community-based participatory research approach, we explored stroke self-efficacy, knowledge, and perceptions of stroke among a predominately African American population in Flint, Michigan.

METHODS

In March 2010, a survey was administered to youth and adults after religious services at 3 churches and during 1 church health day. The survey consisted of vignettes (12 stroke, 4 nonstroke) to assess knowledge of stroke warning signs and behavioral intent to call 911. The survey also assessed stroke self-efficacy, personal knowledge of someone who had experienced a stroke, personal history of stroke, and barriers to calling 911. Linear regression models explored the association of stroke self-efficacy with behavioral intent to call 911 among adults.

RESULTS

Two hundred forty-two adults and 90 youths completed the survey. Ninety-two percent of adults and 90% of youth respondents were African American. Responding to 12 stroke vignettes, adults would call 911 in 72% (SD, 0.26) of the vignettes, whereas youths would call 911 in 54% of vignettes (SD, 0.29; P<0.001). Adults correctly identified stroke in 51% (SD, 0.32) of the stroke vignettes and youth correctly identified stroke in 46% (SD, 0.28) of the stroke vignettes (P=0.28). Stroke self-efficacy predicted behavioral intent to call 911 (P=0.046).

CONCLUSIONS

In addition to knowledge of stroke warning signs, behavioral interventions to increase both stroke self-efficacy and behavioral intent may be useful for helping people make appropriate 911 calls for stroke. A community-based participatory research approach may be effective in reducing stroke disparities.

Guideline-Discordant Periprocedural Interruptions in Warfarin Therapy

Background—

Periprocedural interruptions in warfarin therapy increase thromboembolic risks to patients and are not indicated for all procedures. We sought to determine the frequency and guideline concordance of periprocedural warfarin interruptions to inform a future educational intervention.

Methods and Results—

In October and November of 2009, an anonymous postal survey was sent to all patients followed for more than 1 year by the University of Michigan Anticoagulation service. Patients were asked how many times in the prior year they were requested to interrupt warfarin therapy for a medical or dental procedure or test and the specific indication for the requested interruption in warfarin therapy. A total of 1686 of 2133 (79%) subjects responded. The mean age of respondents was 69 years (SD=14 years). The majority were men (56%) and white (93%). Atrial fibrillation was the most common indication for warfarin therapy (n=966, 57%). At least 1 request to interrupt warfarin therapy in the prior year was given by 819 of 1648 (50%) respondents, including 481 of the 947 (51%) respondents taking warfarin for atrial fibrillation. Forty-eight percent of requests to interrupt warfarin among all respondents and 50% of requests to interrupt warfarin among those taking warfarin, specifically for atrial fibrillation, were for indications not supported by guideline statements.

Conclusions—

Periprocedural requests to interrupt warfarin therapy are common and are often discordant with current guidelines. Educational interventions may decrease risk of periprocedural thromboembolic complications.

Poststroke fractures in a bi-ethnic community

BACKGROUND

Mexican Americans have increased risks of stroke and lower fractures compared with non-Hispanic whites, but little is known about poststroke fracture risk in Mexican Americans. The objective of this study was to describe poststroke fracture risk in a bi-ethnic population and to compare risk by ethnicity.

METHODS

In the Brain Attack Surveillance in Corpus Christi Project, strokes were identified through hospital surveillance (2000-2004) and validated by neurologists (n = 2389). Inpatient claims for fractures were ascertained (2000-2004) and cross-referenced with strokes. Survival free from fracture (any and hip) poststroke was estimated and compared by ethnicity. Cox regression was used to test the association of ethnicity and fracture risk adjusted for confounders. Interaction terms for ethnicity and age were considered.

RESULTS

The mean age was 71 years (SD, 13 yrs); 54% were Mexican American and 52% were women. The mean follow-up was 4 years. There were 105 fractures (33% of the hips). Survival free of any fracture and of hip fracture did not differ by ethnicity. Increasing age, female gender, intracerebral hemorrhage, and greater stroke severity were associated with risk of any fracture, but ethnicity was not. Ethnicity was associated with risk of hip fracture, but this association was modified by age (P = .02), where Mexican Americans were protected from hip fractures at younger but not older ages.

CONCLUSIONS

Stroke patients were at high risk for fractures, with a 10% risk at 5 years. Mexican Americans were protected from hip fractures at younger but not older ages. Both elderly Mexican Americans and non-Hispanic whites should be targeted for poststroke fracture prevention.

Mexican Americans with atrial fibrillation have more recurrent strokes than do non-Hispanic whites

BACKGROUND AND PURPOSE

Atrial fibrillation is a common cause of stroke with a known preventive treatment. We compared poststroke recurrence and survival in Mexican Americans (MAs) and non-Hispanic whites (NHWs) with atrial fibrillation in a population-based study.

METHODS

Using surveillance methods from the Brain Attack Surveillance in Corpus Christi Project, cases of ischemic stroke/transient ischemic attack with atrial fibrillation were prospectively identified from January 2000 to June 2008. Recurrent stroke and all-cause mortality were compared by ethnicity with survival analysis methods.

RESULTS

A total of 236 patients were available (88 MAs, 148 NHWs). MAs were younger than NHWs, with no ethnic differences in severity of the first stroke or proportion discharged on warfarin. MAs had a higher risk of stroke recurrence than did NHWs (Kaplan-Meier estimates of survival free of stroke recurrence risk at 28 days and 1 year were 0.99 and 0.85 in MAs and 0.98 and 0.96 in NHWs, respectively; P=0.01, log-rank test), which persisted despite adjustment for age and sex (hazard ratio=2.46; 95% CI, 1.19-5.11). Severity of the recurrent stroke was higher in MAs than in NHWs (P=0.02). There was no ethnic difference in survival after stroke in unadjusted analysis or after adjusting for demographic and clinical factors (hazard ratio=1.03; 95% CI, 0.63-1.67).

CONCLUSIONS

MAs with atrial fibrillation have a higher stroke recurrence risk and more severe recurrences than do NHWs but no difference in all-cause mortality. Aggressive stroke prevention measures focused on MAs are warranted.

Validity of proxies and correction for proxy use when evaluating social determinants of health in stroke patients

BACKGROUND AND PURPOSE

The purpose of this study was to evaluate stroke patient-proxy agreement with respect to social determinants of health, including depression, optimism, and spirituality, and to explore approaches to minimize proxy-introduced bias.

METHODS

Stroke patient-proxy pairs from the Brain Attack Surveillance in Corpus Christi Project were interviewed (n=34). Evaluation of agreement between patient-proxy pairs included calculation of intraclass correlation coefficients, linear regression models (ProxyResponse=alpha(0)+alpha(1)PatientResponse+delta, where alpha(0)=0 and alpha(1)=1 denotes no bias) and kappa statistics. Bias introduced by proxies was quantified with simulation studies. In the simulated data, we applied 4 approaches to estimate regression coefficients of stroke outcome social determinants of health associations when only proxy data were available for some patients: (1) substituting proxy responses in place of patient responses; (2) including an indicator variable for proxy use; (3) using regression calibration with external validation; and (4) internal validation.

RESULTS

Agreement was fair for depression (intraclass correlation coefficient, 0.41) and optimism (intraclass correlation coefficient, 0.48) and moderate for spirituality (kappa, 0.48 to 0.53). Responses of proxies were a biased measure of the patients' responses for depression, with alpha(0)=4.88 (CI, 2.24 to 7.52) and alpha(1)=0.39 (CI, 0.09 to 0.69), and for optimism, with alpha(0)=3.82 (CI, -1.04 to 8.69) and alpha(1)=0.81 (CI, 0.41 to 1.22). Regression calibration with internal validation was the most accurate method to correct for proxy-induced bias.

CONCLUSIONS

Fair/moderate patient-proxy agreement was observed for social determinants of health. Stroke researchers who plan to study social determinants of health may consider performing validation studies so corrections for proxy use can be made.