1
|
Metcalf D, Zhang D. Racial and ethnic disparities in the usage and outcomes of ischemic stroke treatment in the United States. J Stroke Cerebrovasc Dis 2023; 32:107393. [PMID: 37797411 PMCID: PMC10841526 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 09/12/2023] [Accepted: 09/25/2023] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVES This study explores racial and ethnic differences in 1) receiving tissue plasminogen activator (tPA) and endovascular thrombectomy (EVT) as treatment for ischemic stroke and 2) outcomes and quality of care after use of tPA or EVT in the US. MATERIALS AND METHODS An observational analysis of 89,035 ischemic stroke patients from the 2019 National Inpatient Sample was conducted. We performed weighted logistic regressions between race and ethnicity and 1) tPA and EVT utilization and 2) in-hospital mortality. We also performed a weighted Poisson regression between race and ethnicity and length of stay (LOS) after tPA or EVT. RESULTS Non-Hispanic (NH) Black patients had significantly lower odds of receiving tPA (Adjusted odds ratio [AOR] = 0.85, 95 % Confidence Internal [C.I.]: 0.80-0.91) and EVT (AOR = 0.75, 95 % CI: 0.70-0.82) than NH White patients. Minority populations (including but not limited to NH Black, Hispanic, Pacific Islander, Native American, and Asian) had significantly longer hospital LOS after treatment with tPA or EVT. We did not find a significant difference between race/ethnicity and in-hospital mortality post-tPA or EVT. CONCLUSIONS While we failed to find a difference in in-hospital mortality, racial and ethnic disparities are still evident in the decreased usage of tPA and EVT and longer LOSs for racial and ethnic minority patients. This study calls for interventions to expand the utilization of tPA and EVT and advance quality of care post-tPA or EVT in order to improve stroke care for minority patients.
Collapse
Affiliation(s)
- Delaney Metcalf
- Medical College of Georgia and Augusta University/ University of Georgia Medical Partnership, Athens, GA 30605, United States.
| | - Donglan Zhang
- Center for Population Health and Health Services, Research Department of Foundations of Medicine, NYU Grossman Long Island School of Medicine, Mineola, NY 11501, United States
| |
Collapse
|
2
|
Ho W, Fawcett AP. Outcomes in patients with acute stroke treated at a comprehensive stroke center using telemedicine versus in-person assessments. J Telemed Telecare 2023:1357633X231169115. [PMID: 37125439 DOI: 10.1177/1357633x231169115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
INTRODUCTION Telemedicine has been shown to be a safe and effective modality to assess and treat patients with acute stroke who present to a community hospital. There are no previous reports on using telemedicine to treat patients with acute stroke who present to a comprehensive stroke center. We report here the outcomes of patients with acute stroke treated in 2021 at our comprehensive stroke center using telemedicine versus an in-person assessment. METHODS Patients with acute ischemic stroke who were treated after either a telemedicine or in-person assessment at our hospital in 2021 were identified by a retrospective chart review. The primary outcomes collected were door-to-needle (DTN) time for alteplase (tPA) administration, door-to-puncture (DTP) time for endovascular thrombectomy, symptomatic intracranial hemorrhage (sICH) rates and 3-month mortality. RESULTS There were 302 patients with acute stroke treated at our hospital in 2021. Of these, 18.2% (n = 55/302) were treated using telemedicine. There were no differences in any of the outcomes between patients treated using telemedicine versus an in-person assessment: DTN (35.5 min (n = 42) vs 33 min (n = 182), p < 0.76), DTP (86.5 min (n = 30) vs 85 min (n = 134), p < 0.97), sICH (0% (n = 0/55) vs 1.6% (n = 4/245, p < 0.59) or 3-month mortality (20.6% (n = 7/34) vs 22.1% (n = 40/181), p < 0.29). DISCUSSION To the best of our knowledge, this is the first study to report on outcomes for acute stroke patients treated using telemedicine at a comprehensive stroke center. In this study, there were no differences in outcomes between patients treated using telemedicine versus an in-person assessment.
Collapse
Affiliation(s)
- Wilson Ho
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Adrian P Fawcett
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Trillium Health Partners, Mississauga, Ontario, Canada
| |
Collapse
|
3
|
Farooqui M, Ikram A, Suriya S, Qeadan F, Bzdyra P, Quadri SA, Zafar A. Patterns of Care in Patients with Basilar Artery Occlusion (BAO): A Population-Based Study. Life (Basel) 2023; 13:life13030829. [PMID: 36983984 PMCID: PMC10053211 DOI: 10.3390/life13030829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/06/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Basilar artery occlusion (BAO) is associated with high morbidity and mortality. Endovascular therapy (EVT) has been shown to be beneficial in acute BAO patients. This retrospective observational study used the National Inpatient Sample (NIS) database to identify BAO patients using the International Classification of Diseases (ICD). Multivariable models were used to evaluate the association of risk factors, comorbidities, length of stay (LOS) in hospital, total cost, disposition, and transfer status. A total of 1120 (447 females, 39.95%) patients were identified, with a higher proportion of White individuals (66.8% vs. 57.6%), atrial fibrillation (31.5% vs. 17.2%; p < 0.0001), and peripheral vascular disease (21.2% vs. 13.7%; p = 0.009). A lower proportion of individuals with diabetes mellitus (32.1% vs. 39.5%; p = 0.05) was found in the EVT group. Majority of the patients (924/1120, 82.5%) were treated at the urban teaching facility, which also performed most of the EVT procedures (164, 89.13%), followed by non-academic urban (166, 14.8%) and rural (30, 2.7%) hospitals. Most patients (19/30, 63%) admitted to rural hospitals were transferred to other facilities. Urban academic hospitals also had the highest median LOS (8.9 days), cost of hospitalization (USD 117,261), and disposition to home (32.6%). This study observed distinct patterns and geographical disparities in the acute treatment of BAO patients. There is a need for national- and state-level strategies to improve access to stroke care.
Collapse
Affiliation(s)
- Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Asad Ikram
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Sajid Suriya
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque, NM 87106, USA
| | - Fares Qeadan
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT 84112, USA
| | - Piotr Bzdyra
- Department of Neurology, St. Bernardine Medical Center, San Bernadino, CA 92404, USA
| | - Syed A Quadri
- Department of Neurology, University of Cincinnati, Cincinnati, OH 45221, USA
| | - Atif Zafar
- Department of Neurology, St. Michael Hospital, University of Toronto, Toronto, ON M5B 1W8, Canada
| |
Collapse
|
4
|
Peters GA, Ordoobadi AJ, Panchal AR, Cash RE. Differences in Out-of-Hospital Cardiac Arrest Management and Outcomes across Urban, Suburban, and Rural Settings. PREHOSP EMERG CARE 2023; 27:162-169. [PMID: 34913821 DOI: 10.1080/10903127.2021.2018076] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Rural prehospital care settings are underrepresented in the out-of-hospital cardiac arrest (OHCA) literature. This study aimed to describe treatment patterns and the odds of a favorable patient outcome (e.g., return of spontaneous circulation (ROSC) or being presumptively alive at the end of the incident) among rural OHCA patients in the U.S. METHODS Using the 2018 National Emergency Medical Services Informational System (NEMSIS) dataset, we analyzed OHCA incidents where an emergency medical services (EMS) unit provided cardiopulmonary resuscitation (CPR) and either terminated the resuscitation or completed transport. We excluded traumatic injuries, pediatric patients, and incidents with response time >60 minutes. The primary outcome was ROSC at any time during the EMS incident. The secondary outcome was a binary end-of-event indicator previously described for use in NEMSIS to estimate longer-term outcomes. Multivariable logistic regression was performed for each outcome measure comparing rural, suburban, and urban settings while controlling for key factors. RESULTS A total of 64,489 OHCA incidents were included, with 5,601 (8.9%) in rural settings. Among the full sample of OHCA incidents, ROSC was achieved in 20,578 (33.6%) cases, including 29.2% in rural settings and 34.1% in urban or suburban settings (p < 0.001). Advanced life support units responded to 95.3% of all calls, and a greater proportion of rural OHCA incidents were managed by basic life support units (7.4% vs. 4.2%, p < 0.001). Rural OHCA incidents had longer response times (7.5 vs. 5.9 minutes, p < 0.001), and rural patients were less likely to receive epinephrine (69.3% vs. 73.3%, p < 0.001). Further, EMS clinicians in rural areas were more likely to use mechanical CPR (29.5% vs. 27.6%, p < 0.01) and were less likely to perform advanced airway management (48.5% vs. 54.2%, p < 0.001). Rural patients had lower odds of achieving ROSC than urban patients after controlling for other factors (OR 0.81, 95% CI: 0.75-0.87). Rural patients also had lower odds of having a positive end-of-event outcome (i.e., presumptively alive) after controlling for other factors (OR 0.86, 95% CI: 0.79-0.93). CONCLUSION In this national sample of EMS-treated OHCAs, rural patients had lower odds of a favorable outcome (e.g., ROSC or presumptively alive) compared to those in urban settings.
Collapse
Affiliation(s)
- Gregory A Peters
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Ashish R Panchal
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio.,National Registry of Emergency Medical Technicians, Columbus, Ohio
| | - Rebecca E Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
5
|
Ovenden CD, Hewitt J, Kovoor J, Gupta A, Edwards S, Abou-Hamden A, Kleinig T. Time to hospital presentation following intracerebral haemorrhage: Proportion of patients presenting within eight hours and factors associated with delayed presentation. J Stroke Cerebrovasc Dis 2022; 31:106758. [PMID: 36137452 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 08/21/2022] [Accepted: 09/04/2022] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Prolonged time to diagnosis of primary intracerebral haemorrhage (ICH) can result in delays in obtaining appropriate blood pressure control, reversal of coagulopathy or surgical intervention in select cases. We sought to characterise the time to diagnosis in a cohort of patients with ICH and identify factors associated with delayed diagnosis. METHODOLOGY The stroke database of our hospital was retrospectively reviewed to identify patients presenting to our hospitals emergency department with ICH over two years (January 2017-December 2018.) Data collected included demographics (age and sex), comorbidities, anticoagulation status, clinical scores (NIHSS, GCS, ICH score), and imaging (anatomical site, haematoma size). Time from symptom onset to diagnosis and hospital presentation were recorded. Factors associated with diagnosis >8 h post ictus were assessed using a univariate and then multivariable analysis. RESULTS 235 patients were identified with 125 males (53%) and a median age of 76 (range 40-98). For the 200 patients that initially presented to our hospital, median time to presentation was 179 min (IQR 77-584 min), and median time from ictus to imaging diagnosis was 268 min (IQR 114-717 min). 139 (70%) presented within 8 h of symptom onset, and 129 (65%) patients had imaging of the brain performed within 8 h of symptom onset. Factors associated with presentation >8 h post symptom onset included wake up stroke (OR 5.31, 95% confidence interval (CI) 2.36-11.96, p < 0.0001) and age (OR 1.04, 95% CI 1.01-1.08, p = 0.01). Patients with hemiplegia were less likely to present >8 h following ictus (OR 0.41, 95% CI 0.21-0.84, p = 0.01). CONCLUSIONS The majority of patients with ICH presented within 8 h of ictus. Cases of delayed diagnosis involved patients who had not incurred hemiplegia.
Collapse
Affiliation(s)
- Christopher Dillon Ovenden
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.
| | - Joseph Hewitt
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joshua Kovoor
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Aashray Gupta
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Suzanne Edwards
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Amal Abou-Hamden
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Timothy Kleinig
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia; Stroke Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| |
Collapse
|
6
|
Kobashi Y, Cheam S, Hayashi Y, Tsubokura M, Ly V, Noun C, Kozuma T, Nit B, Okawada M. Regional Differences in Admission Rates of Emergency Patients Who Visited a Private General Hospital in the Capital City of Cambodia: A Three-Year Observational Study. Int J Health Policy Manag 2022; 11:1425-1431. [PMID: 34060276 PMCID: PMC9808335 DOI: 10.34172/ijhpm.2021.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 04/14/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Regional disparity is an imperative component of health disparity. In particular, providing emergency care that is equally available in rural areas is an essential part of reducing the urban-rural disparity. The objective of this study was to examine the worsening admission rate among Cambodian emergency patients in a rural area and determine their background characteristics that cause this decline. METHODS To investigate the disparity among patients who visited Sunrise Japan Hospital (SJH), a major general private hospital in the capital, patient data from November 2016 to September 2019 were obtained from the electronic reception patient database. The primary outcome was defined as the proportion of admission patients as an indicator of illness severity. The patients' addresses were classified into 4 areas based on distance from the capital. RESULTS A total of 6167 patients who visited the emergency department at SJH between January 2017 and September 2019 were included in the analysis. The proportion of patients who needed to be hospitalized or transferred increased with the distance from the capital. The proportion of patients who finished consultation decreased with the distance from the capital (P<.01: Chi-square test). The results of the logistic regression analysis showed that the admission rate in rural areas was significantly higher only among males as compared to that of the capital in multivariate analyses adjusted for age, time, and season. CONCLUSION The admission rate of emergency patients who visited a private general hospital in Cambodia's capital city increased with distance from the capital city. To improve regional disparity among emergency patients, further research is necessary to identify the issues among emergency patients, especially those who are vulnerable.
Collapse
Affiliation(s)
- Yurie Kobashi
- Department of General Internal Medicine, Sunrise Japan Hospital Phnom Penh, Phnom Penh, Cambodia
| | - Sophathya Cheam
- Department of Pediatrics, Sunrise Japan Hospital Phnom Penh, Phnom Penh, Cambodia
| | - Yoshifumi Hayashi
- Department of Neurosurgery, Sunrise Japan Hospital Phnom Penh, Phnom Penh, Cambodia
- Department of Neurosurgery, Kitahara International Hospital, Tokyo, Japan
| | - Masaharu Tsubokura
- Department of Internal Medicine, Soma Central Hospital, Fukushima, Japan
| | - Veyleang Ly
- Department of General Internal Medicine, Sunrise Japan Hospital Phnom Penh, Phnom Penh, Cambodia
| | - Chanmakara Noun
- Department of General Internal Medicine, Sunrise Japan Hospital Phnom Penh, Phnom Penh, Cambodia
| | - Takehiro Kozuma
- Department of General Internal Medicine, Sunrise Japan Hospital Phnom Penh, Phnom Penh, Cambodia
| | - Buntongyi Nit
- Department of Medicine, University of Puthisastra, Phnom Penh, Cambodia
| | - Manabu Okawada
- Department of Pediatrics, Sunrise Japan Hospital Phnom Penh, Phnom Penh, Cambodia
| |
Collapse
|
7
|
Young M, Peterson AH. Neuroethics across the Disorders of Consciousness Care Continuum. Semin Neurol 2022; 42:375-392. [PMID: 35738293 DOI: 10.1055/a-1883-0701] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
8
|
O’Connell GC, Walsh KB, Smothers CG, Ruksakulpiwat S, Armentrout BL, Winkelman C, Milling TJ, Warach SJ, Barr TL. Use of deep artificial neural networks to identify stroke during triage via subtle changes in circulating cell counts. BMC Neurol 2022; 22:206. [PMID: 35659609 PMCID: PMC9164330 DOI: 10.1186/s12883-022-02726-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 05/17/2022] [Indexed: 11/10/2022] Open
Abstract
Background The development of tools that could help emergency department clinicians recognize stroke during triage could reduce treatment delays and improve patient outcomes. Growing evidence suggests that stroke is associated with several changes in circulating cell counts. The aim of this study was to determine whether machine-learning can be used to identify stroke in the emergency department using data available from a routine complete blood count with differential. Methods Red blood cell, platelet, neutrophil, lymphocyte, monocyte, eosinophil, and basophil counts were assessed in admission blood samples collected from 160 stroke patients and 116 stroke mimics recruited from three geographically distinct clinical sites, and an ensemble artificial neural network model was developed and tested for its ability to discriminate between groups. Results Several modest but statistically significant differences were observed in cell counts between stroke patients and stroke mimics. The counts of no single cell population alone were adequate to discriminate between groups with high levels of accuracy; however, combined classification using the neural network model resulted in a dramatic and statistically significant improvement in diagnostic performance according to receiver-operating characteristic analysis. Furthermore, the neural network model displayed superior performance as a triage decision making tool compared to symptom-based tools such as the Cincinnati Prehospital Stroke Scale (CPSS) and the National Institutes of Health Stroke Scale (NIHSS) when assessed using decision curve analysis. Conclusions Our results suggest that algorithmic analysis of commonly collected hematology data using machine-learning could potentially be used to help emergency department clinicians make better-informed triage decisions in situations where advanced imaging techniques or neurological expertise are not immediately available, or even to electronically flag patients in which stroke should be considered as a diagnosis as part of an automated stroke alert system.
Collapse
|
9
|
Menlibayeva K, Babi A, Makhambetov Y, Akshulakov S. Challenges in Neurosurgery During the COVID-19 Pandemic: The Experience of Kazakhstan. World Neurosurg 2022; 161:e376-e383. [PMID: 35144030 PMCID: PMC8820954 DOI: 10.1016/j.wneu.2022.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The practice of neurosurgery has been profoundly affected by the coronavirus disease 2019 (COVID-19) pandemic in Kazakhstan. Many elective surgeries were postponed or canceled, which resulted in difficulties in hospitalization. In the present study, we aimed to describe the effects of COVID-19 on neurosurgical practice and to determine whether a discrepancy was present in the effects between metropolises and regional cities in Kazakhstan. METHODS We performed an electronic internet-based survey among Kazakhstan's neurosurgeons using the virtual snowball sampling method. The invitation link to complete the questionnaire was sent to neurosurgeons through personal and corporate electronic mail and social networks. The data were analyzed using Excel and Stata. RESULTS A total of 43 neurosurgeons completed the survey. The distribution of regional and urban respondents was almost equal. The male neurosurgeons outnumbered the female neurosurgeons (93.02% vs. 6.98%). A decrease in consultations (65.34% ± 28.24%) and surgeries (56.55% ± 26.34%) had been observed by all neurosurgeons, regardless of city type. However, the proportion of neurosurgeons who had attended online educational courses during the pandemic was significantly higher (P = 0.001) for the surgeons from major cities (68.18%) compared with the surgeons from smaller cities (19.05%). The regional neurosurgeons tended to perform urgent surgeries on COVID-19-positive patients 3 times more often than had the metropolitan neurosurgeons (P < 0.001). CONCLUSIONS The true effect of the pandemic remains unknown for Kazakhstan. A discrepancy between the metropolitan and regional cities was found in the present study. Efforts are required and relevant guidelines must be developed to ensure that the neurosurgical treatment of various conditions continues to be available during health emergencies and that the disparities are addressed.
Collapse
Affiliation(s)
- Karashash Menlibayeva
- Hospital Management Department, National Center for Neurosurgery, Nur-Sultan, Kazakhstan.
| | - Aisha Babi
- Hospital Management Department, National Center for Neurosurgery, Nur-Sultan, Kazakhstan; Department of Biomedical Sciences, School of Medicine, Nazarbayev University, Nur-Sultan, Kazakhstan
| | - Yerbol Makhambetov
- Department of Vascular and Functional Neurosurgery, National Center for Neurosurgery, Nur-Sultan, Kazakhstan
| | - Serik Akshulakov
- Department of Vascular and Functional Neurosurgery, National Center for Neurosurgery, Nur-Sultan, Kazakhstan
| |
Collapse
|
10
|
Richard JV, Mehrotra A, Schwamm LH, Wilcock AD, Uscher‐Pines L, Majersik JJ, Zachrison KS. Improving Population Access to Stroke Expertise Via Telestroke: Hospitals to Target and the Potential Clinical Benefit. J Am Heart Assoc 2022; 11:e025559. [PMID: 35435016 PMCID: PMC9238444 DOI: 10.1161/jaha.122.025559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
| | - Ateev Mehrotra
- Harvard Medical School Boston MA
- Beth Israel Deaconess Medical Center Boston MA
| | - Lee H. Schwamm
- Harvard Medical School Boston MA
- Massachusetts General Hospital Boston MA
| | | | | | | | - Kori S. Zachrison
- Harvard Medical School Boston MA
- Massachusetts General Hospital Boston MA
| |
Collapse
|
11
|
Hunter MD, Kulick ER, Miller E, Willey J, Boehme AK, Branas C, Elkind MSV. Rural-Urban Differences in Diagnosed Cervical Artery Dissection in New York State. Cerebrovasc Dis 2022; 51:506-510. [PMID: 35034032 PMCID: PMC9256775 DOI: 10.1159/000521204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/19/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Cervical artery dissection (CeAD) is a leading cause of stroke in young adults. Incidence estimates may be limited by under- or overdiagnosis. OBJECTIVE We aimed to investigate if CeAD diagnosis would be higher in urban centers compared to rural regions of New York State (NYS). METHODS For this ecological study, administrative codes were used to identify CeAD discharges in the NYS Statewide Planning and Research Cooperative System (SPARCS) from 2009 to 2014. Rural Urban Commuting Area (RUCA) codes were taken from the US Department of Agriculture and included the classifications metropolitan, micropolitan, small town, and rural. Negative binomial models were used to calculate effect estimates and 95% confidence limits (eβ; 95% CL) for the association between RUCA classification and the number of dissections per ZIP code. Models were further adjusted by population. RESULTS Population information was obtained from the US Census Bureau on 1,797 NYS ZIP codes (70.7% of NYS ZIP codes), 826 of which had at least 1 CeAD-related discharge from 2009 to 2014. Nonrural ZIP codes were more likely to report more CeAD cases relative to rural areas even after adjusting for population (metropolitan effect = eβ 5.00; 95% CI: 3.75-6.66; micropolitan effect 3.02; 95% CI: 2.16-4.23; small town effect 2.34; 95% CI: 1.58-3.47). CONCLUSIONS CeAD diagnosis correlates with population density as defined by rural-urban status. Our results could be due to underdiagnosis in rural areas or overdiagnosis with increasing urbanicity.
Collapse
Affiliation(s)
- Madeleine Dulany Hunter
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Erin R. Kulick
- Department of Epidemiology and Biostatsistics, College of Public Health, Temple University, Philadelphia PA
| | - Eliza Miller
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Joshua Willey
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Amelia K. Boehme
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Charles Branas
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Mitchell S. V. Elkind
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| |
Collapse
|
12
|
Newly-identified blood biomarkers of neurological damage are correlated with infarct volume in patients with acute ischemic stroke. J Clin Neurosci 2021; 94:107-113. [PMID: 34863423 DOI: 10.1016/j.jocn.2021.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 08/26/2021] [Accepted: 10/11/2021] [Indexed: 11/22/2022]
Abstract
Our group recently performed a genome-wide informatic analysis that highlighted eight brain-enriched proteins with strong potential to serve as blood biomarkers of neurological injury (GFAP, MBP, β-synuclein, OPALIN, MT-3, SNAP-25, KIF5A, MOBP), including six that have yet to be widely investigated. In this study, our aim was to determine whether the circulating levels of these proteins could be used to approximate the extent of neural tissue damage in ischemic stroke. To address this aim, blood was collected from 43 ischemic stroke patients immediately upon hospital admission. The serum levels of the eight candidate proteins were measured via ELISA, infarct volume was assessed via manual tracing of neuroradiological images, and correlational analysis was performed to examine potential associative relationships. The serum levels of all eight proteins exhibited positive correlations with infarct volume, however the strongest associations were observed in a subset of four proteins known to originate from neurons specifically (MT-3, SNAP-25, KIF5A, β-synuclein). Combining the serum levels of these neuron-originating proteins using principal components analysis produced a single composite value that was more strongly correlated with infarct volume than the levels of any single protein considered in isolation (r = 0.48, p < 0.001). Measures of these proteins could potentially be used to provide a minimally invasive approximation of lesion size when advanced imaging techniques are not available, or when imaging results are inconclusive.
Collapse
|
13
|
Helwig SA, Ragoschke-Schumm A, Schwindling L, Kettner M, Roumia S, Kulikovski J, Keller I, Manitz M, Martens D, Grün D, Walter S, Lesmeister M, Ewen K, Brand J, Fousse M, Kauffmann J, Zimmer VC, Mathur S, Bertsch T, Guldner J, Magull-Seltenreich A, Binder A, Spüntrup E, Chatzikonstantinou A, Adam O, Kronfeld K, Liu Y, Ruckes C, Schumacher H, Grunwald IQ, Yilmaz U, Schlechtriemen T, Reith W, Fassbender K. Prehospital Stroke Management Optimized by Use of Clinical Scoring vs Mobile Stroke Unit for Triage of Patients With Stroke: A Randomized Clinical Trial. JAMA Neurol 2021; 76:1484-1492. [PMID: 31479116 DOI: 10.1001/jamaneurol.2019.2829] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Transferring patients with large-vessel occlusion (LVO) or intracranial hemorrhage (ICH) to hospitals not providing interventional treatment options is an unresolved medical problem. Objective To determine how optimized prehospital management (OPM) based on use of the Los Angeles Motor Scale (LAMS) compares with management in a Mobile Stroke Unit (MSU) in accurately triaging patients to the appropriate hospital with (comprehensive stroke center [CSC]) or without (primary stroke center [PSC]) interventional treatment. Design, Setting, and Participants In this randomized multicenter trial with 3-month follow-up, patients were assigned week-wise to one of the pathways between June 15, 2015, and November 15, 2017, in 2 regions of Saarland, Germany; 708 of 824 suspected stroke patients did not meet inclusion criteria, resulting in a study population of 116 adult patients. Interventions Patients received either OPM based on a standard operating procedure that included the use of the LAMS (cut point ≥4) or management in an MSU (an ambulance with vascular imaging, point-of-care laboratory, and telecommunication capabilities). Main Outcomes and Measures The primary end point was the proportion of patients accurately triaged to either CSCs (LVO, ICH) or PSCs (others). Results A predefined interim analysis was performed after 116 patients of the planned 232 patients had been enrolled. Of these, 53 were included in the OPM group (67.9% women; mean [SD] age, 74 [11] years) and 63 in the MSU group (57.1% women; mean [SD] age, 75 [11] years). The primary end point, an accurate triage decision, was reached for 37 of 53 patients (69.8%) in the OPM group and for 63 of 63 patients (100%) in the MSU group (difference, 30.2%; 95% CI, 17.8%-42.5%; P < .001). Whereas 7 of 17 OPM patients (41.2%) with LVO or ICH required secondary transfers from a PSC to a CSC, none of the 11 MSU patients (0%) required such transfers (difference, 41.2%; 95% CI, 17.8%-64.6%; P = .02). The LAMS at a cut point of 4 or higher led to an accurate diagnosis of LVO or ICH for 13 of 17 patients (76.5%; 6 triaged to a CSC) and of LVO selectively for 7 of 9 patients (77.8%; 2 triaged to a CSC). Stroke management metrics were better in the MSU group, although patient outcomes were not significantly different. Conclusions and Relevance Whereas prehospital management optimized by LAMS allows accurate triage decisions for approximately 70% of patients, MSU-based management enables accurate triage decisions for 100%. Depending on the specific health care environment considered, both approaches are potentially valuable in triaging stroke patients. Trial Registration ClinicalTrials.gov identifier: NCT02465346.
Collapse
Affiliation(s)
- Stefan A Helwig
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | | | - Lenka Schwindling
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Michael Kettner
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany.,Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany
| | - Safwan Roumia
- Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany
| | - Johann Kulikovski
- Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany
| | - Isabel Keller
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Matthias Manitz
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Daniel Martens
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Daniel Grün
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Silke Walter
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Martin Lesmeister
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Kira Ewen
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Jannik Brand
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Mathias Fousse
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Jil Kauffmann
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Valerie C Zimmer
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Shrey Mathur
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Jürgen Guldner
- Department of Neurology, Knappschaftsklinikum Saar, Püttlingen, Germany
| | | | - Andreas Binder
- Department of Neurology, Klinikum Saarbrücken, Saarbrücken, Germany
| | - Elmar Spüntrup
- Department of Radiology, Klinikum Saarbrücken, Saarbrücken, Germany
| | | | - Oliver Adam
- Medizinische Klinik, Kreiskrankenhaus St Ingbert, St Ingbert, Germany
| | - Kai Kronfeld
- Interdisciplinary Centre for Clinical Trials (IZKS), Mainz, Germany
| | - Yang Liu
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Christian Ruckes
- Interdisciplinary Centre for Clinical Trials (IZKS), Mainz, Germany
| | | | - Iris Q Grunwald
- Department of Neuroscience, Faculty of Medical Science, Postgraduate Medical Institute, Anglia Ruskin University, Chelmsford, Southend University Hospital, Southend-on-Sea, United Kingdom
| | - Umut Yilmaz
- Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany
| | - Thomas Schlechtriemen
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany.,Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany.,Zweckverband für Rettungsdienst und Feuerwehralarmierung, Saar, Germany
| | - Wolfgang Reith
- Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany
| | - Klaus Fassbender
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| |
Collapse
|
14
|
Yu CY, Blaine T, Panagos PD, Kansagra AP. Demographic Disparities in Proximity to Certified Stroke Care in the United States. Stroke 2021; 52:2571-2579. [PMID: 34107732 DOI: 10.1161/strokeaha.121.034493] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
[Figure: see text].
Collapse
Affiliation(s)
- Cathy Y Yu
- Washington University School of Medicine (C.Y.Y.)
| | - Timothy Blaine
- Mallinckrodt Institute of Radiology (T.B., A.P.K.), Washington University School of Medicine, St. Louis, MO
| | - Peter D Panagos
- Department of Emergency Medicine (P.D.P.), Washington University School of Medicine, St. Louis, MO.,Department of Neurology (P.D.P., A.P.K.), Washington University School of Medicine, St. Louis, MO
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology (T.B., A.P.K.), Washington University School of Medicine, St. Louis, MO.,Department of Neurology (P.D.P., A.P.K.), Washington University School of Medicine, St. Louis, MO.,Department of Neurological Surgery (A.P.K.), Washington University School of Medicine, St. Louis, MO
| |
Collapse
|
15
|
Geographic Access to Stroke Care Services in Rural Communities in Ontario, Canada. Can J Neurol Sci 2021; 47:301-308. [PMID: 31918777 DOI: 10.1017/cjn.2020.9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Optimal stroke care requires access to resources such as neuroimaging, acute revascularization, rehabilitation, and stroke prevention services, which may not be available in rural areas. We aimed to determine geographic access to stroke care for residents of rural communities in the province of Ontario, Canada. METHODS We used the Ontario Road Network File database linked with the 2016 Ontario Acute Stroke Care Resource Inventory to estimate the proportion of people in rural communities, defined as those with a population size <10,000, who were within 30, 60, and 240 minutes of travel time by car from stroke care services, including brain imaging, thrombolysis treatment centers, stroke units, stroke prevention clinics, inpatient rehabilitation facilities, and endovascular treatment centers. RESULTS Of the 1,496,262 people residing in rural communities, the majority resided within 60 minutes of driving time to a center with computed tomography (85%), thrombolysis (81%), a stroke unit (68%), a stroke prevention clinic (74%), or inpatient rehabilitation (77.0%), but a much lower proportion (32%) were within 60 minutes of driving time to a center capable of providing endovascular thrombectomy (EVT). CONCLUSIONS Most rural Ontario residents have appropriate geographic access to stroke services, with the exception of EVT. This information may be useful for jurisdictions seeking to optimize the regional organization of stroke care services.
Collapse
|
16
|
Fassbender K, Merzou F, Lesmeister M, Walter S, Grunwald IQ, Ragoschke-Schumm A, Bertsch T, Grotta J. Impact of mobile stroke units. J Neurol Neurosurg Psychiatry 2021; 92:jnnp-2020-324005. [PMID: 34035130 PMCID: PMC8292607 DOI: 10.1136/jnnp-2020-324005] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/01/2021] [Accepted: 04/07/2021] [Indexed: 12/26/2022]
Abstract
Since its first introduction in clinical practice in 2008, the concept of mobile stroke unit enabling prehospital stroke treatment has rapidly expanded worldwide. This review summarises current knowledge in this young field of stroke research, discussing topics such as benefits in reduction of delay before treatment, vascular imaging-based triage of patients with large-vessel occlusion in the field, differential blood pressure management or prehospital antagonisation of anticoagulants. However, before mobile stroke units can become routine, several questions remain to be answered. Current research, therefore, focuses on safety, long-term medical benefit, best setting and cost-efficiency as crucial determinants for the sustainability of this novel strategy of acute stroke management.
Collapse
Affiliation(s)
- Klaus Fassbender
- Department of Neurology, Saarland University Medical Center, Homburg, Saarland, Germany
| | - Fatma Merzou
- Department of Neurology, Saarland University Medical Center, Homburg, Saarland, Germany
| | - Martin Lesmeister
- Department of Neurology, Saarland University Medical Center, Homburg, Saarland, Germany
| | - Silke Walter
- Department of Neurology, Saarland University Medical Center, Homburg, Saarland, Germany
| | - Iris Quasar Grunwald
- Department of Neuroscience, Medical School, Anglia Ruskin University, Chelmsford, UK
- Division of Imaging Science and Technology, School of Medicine, University of Dundee, Dundee, UK
| | | | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Paracelsus Private Medical University-Nuremberg Campus, Nuremberg, Bayern, Germany
| | - James Grotta
- Department of Neurology, Memorial Hermann Hospital, Houston, Texas, USA
| |
Collapse
|
17
|
Luchowski P, Szmygin M, Wojczal J, Prus K, Sojka M, Luchowska E, Rejdak K. Stroke patients from rural areas have lower chances for long-term good clinical outcome after mechanical thrombectomy. Clin Neurol Neurosurg 2021; 206:106687. [PMID: 34015697 DOI: 10.1016/j.clineuro.2021.106687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study evaluated 3-months clinical outcome after mechanical thrombectomy (MT) in stroke patients transferred to a comprehensive stroke center (CSC) from a rural and urban areas in a Lubelskie province, the third largest province in Poland. MATERIALS AND METHODS Acute stroke patients with a premorbid modified Rankin scale (mRS) score 0-2 who were admitted within 6 h after stroke onset and treated with MT between 2016 and 2020 were retrospectively analyzed. Patients from rural and urban areas transported directly to CSC were compared regarding the onset-to-groin time, reperfusion rate, symptomatic intracranial hemorrhage (sICH) and favourable clinical outcome (modified Rankin Scale score 0-2) 3-months after MT. RESULTS A total of 398 patients were analyzed: 179 from rural areas (RA) and 219 from urban areas (UA). There was no significant difference in baseline neurological deficit expressed in The National Institutes of Health Stroke Scale (median 18.4 for RA patients versus 18.1 for UA patients, p = 0.70). Time from stroke onset to groin puncture was significantly shorter in the UA patients (median 197.3 min versus 219.6 min, p = 0.004). There was a significant difference in 3 months favourable clinical outcome between these two groups (31.3% of RA patients versus 42.5% of UA patients, p = 0.021) and full recovery rates (5.6% of RA patients versus 15.0% of UA patients, p = 0.002). The rate of sICH and 3-months mortality was similar in both groups (7.3% of RA patients versus 8.7% of UA patients, p = 0.61% and 21.8% of RA group vs. 22.4% of UA group, p = 0.88, respectively). CONCLUSION Stroke patients from RA undergoing thrombectomy had worse functional outcome compared to UA patients. Since the benefit of MT is time dependent, urban-rural differences in stroke outcome probably result from the longer time from stroke onset to reperfusion treatment in RA patients.
Collapse
Affiliation(s)
- Piotr Luchowski
- Department of Neurology, Medical University of Lublin, Poland.
| | - Maciej Szmygin
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, Poland
| | - Joanna Wojczal
- Department of Neurology, Medical University of Lublin, Poland
| | - Katarzyna Prus
- Department of Neurology, Medical University of Lublin, Poland
| | - Michał Sojka
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, Poland
| | - Elżbieta Luchowska
- Department of Laboratory Diagnostics, Medical University of Lublin, Poland
| | - Konrad Rejdak
- Department of Neurology, Medical University of Lublin, Poland
| |
Collapse
|
18
|
Bulmer T, Volders D, Kamal N. Analysis of Thrombolysis Process for Acute Ischemic Stroke in Urban and Rural Hospitals in Nova Scotia Canada. Front Neurol 2021; 12:645228. [PMID: 33790851 PMCID: PMC8005571 DOI: 10.3389/fneur.2021.645228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/12/2021] [Indexed: 11/27/2022] Open
Abstract
Background: Stroke is a devastating disease, but it is treatable with alteplase or tissue plasminogen activator (tPA). The effectiveness of tPA is highly time-dependent, meaning rapid treatment is critical. Fast treatment with tPA has been reported in many urban hospitals, but hospitals in rural locations struggle to reduce treatment times. This qualitative study examines current thrombolysis processes in one urban and two rural hospitals in Nova Scotia, Canada, by mapping and comparing the treatment process in these settings for acute ischemic stroke (AIS) patients, and by analyzing the healthcare professionals views on various treatment topics. Methods: Structured interviews were conducted with healthcare professionals involved in stroke treatment across the three sites. The interviews focused on the various activities in the thrombolysis treatment at each site. Additionally, participants were asked about the following 10 topics: comfort treating acute ischemic stroke patients; perceptions about tPA; appropriate tPA treatment window; stroke patient priority; tPA availability; patient consent; urban-rural treatment differences; efficiency of their treatment process; treatment delays; and suggested process improvements. Results were analyzed using the Framework Method, as well as through the development of process maps. Results: Twenty three healthcare professionals were interviewed at 2 rural hospitals and 1 urban hospital. Acute ischemic stroke patients are triaged as the highest or urgent priority at each included site. Physicians are more hesitant to treat with tPA in rural settings. A total of 11 urban-rural treatment differences were noted by the rural sites. Additionally, 11 patient-related and 29 system treatment delays were described. A process map was developed for each site, representing the arrival by ambulance and by private vehicle pathways. Conclusions: Guidelines and clear protocols are critical in reducing treatment times and ensuring consistent access to treatment. The majority of treatment delays encountered are system delays, which can be appropriately planned for to reduce delays within the care pathway. There is a general consensus that there is an urban-rural treatment gap for acute ischemic stroke patients in Nova Scotia, and that continuing education is key in rural hospitals to improve Emergency Department (ED) physician comfort with treating patients with tPA.
Collapse
Affiliation(s)
- Tessa Bulmer
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - David Volders
- Interventional & Diagnostic Neuroradiology, QEII Health Sciences Centre, Nova Scotia Health, Halifax, NS, Canada.,Department of Radiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| |
Collapse
|
19
|
Holcombe A, Mohr N, Farooqui M, Dandapat S, Dai B, Zevallos CB, Quispe-Orozco D, Siddiqui F, Ortega-Gutierrez S. Patterns of Care and Clinical Outcomes in Patients with Cerebral Sinus Venous Thrombosis. J Stroke Cerebrovasc Dis 2020; 29:105313. [PMID: 32992183 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/04/2020] [Accepted: 09/07/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVES To explore the association between rurality, transfer patterns and level of care with clinical outcomes of CVST patients in a rural Midwestern state. MATERIALS AND METHODS CVST patients admitted to the hospitals between 2005 and 2014 were identified by inpatient diagnosis codes from statewide administrative claims dataset. Records were linked across interhospital transfers using probabilistic linkage. Rurality was defined by Rural-Urban Commuting Areas using the 2-category approximation. Driving distances were estimated using GoogleMaps Application Programming Interface. Hospital stroke certification was defined by the Joint Commission. Severity of CVST was estimated by cost of care corrected for inflation and cost-to-charge ratios. Outcome was discharge disposition and total length of stay (LOS). Wilcoxon rank-sum, Chi-square, Fisher's exact tests and linear and logistic regressions were used. RESULTS 168 CVST patients were identified (79.8% female; median age = 32, IQR = 24.0-45.5). Median LOS was four days (IQR = 2-7) and patients traveled a median of 8.1 miles (IQR = 2.5-28.5) to the first hospital; 42% of patients were transferred to a second hospital, 5% to a third. More than half (58.3%) bypassed the nearest hospital. 86% visit a primary or comprehensive stroke center (CSC) during their acute care. Rurality was not significantly associated with LOS or discharge disposition after adjusting for age, sex and cost of care. Patients in CSC demonstrated greater likelihood of being discharged home compared to at a primary stroke center after adjusting for age and disease severity (p = 0.008). CONCLUSIONS While rurality was not significantly associated with LOS or disposition outcome, care at a CSC increases likelihood of being discharge home.
Collapse
Affiliation(s)
- Andrea Holcombe
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Nicholas Mohr
- Department of Emergency Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Sudeepta Dandapat
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Biyue Dai
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Cynthia B Zevallos
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Darko Quispe-Orozco
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Fazeel Siddiqui
- Department of Neuroscience, Metro Health, University of Michigan, Wyoming, MI, United States
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery, and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States.
| |
Collapse
|
20
|
Lee MK, Yih Y, Griffin PM. Quantifying the Impact of Acute Stroke System of Care Transfer Protocols on Patient Outcomes. Med Decis Making 2020; 40:873-884. [PMID: 33000686 DOI: 10.1177/0272989x20946694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We quantify the impact of implementing a stroke system of care requiring transport of individuals believed to have stroke to a primary stroke center, in rural and urban settings, based on time from symptom recognition to treatment, probability of receiving treatment within 3 hours of stroke onset, and probability of overcrowding. We use Indiana as an example. METHODS We used discrete-event simulation to estimate outcomes for 2 scenarios: stroke system of care with enabling technology (mobile stroke unit, stroke team expansion) and stroke system of care with no enabling technology, as compared with the status quo. We considered patient flow from symptom recognition to treatment. Patient locations and stroke events were generated for the 92 Indiana counties in Indiana, subdivided into 1009 locations. We considered time from emergency medical service (EMS) arrival at onset to treatment, probability of tissue plasminogen activator administered within 3 h of onset, and percentage of patients admitted beyond the occupancy level at the comprehensive stroke center. RESULTS Results varied by urbanicity. Under no enabling technology, having a stroke system of care improved outcomes for individuals in urban and suburban settings. However, in rural settings, the implementation of stroke system of care guidelines decreased the average rate of treatment within 3 h of stroke onset and increased the EMS arrival to treatment times compared with sending the individual to the closest provider. Enabling technologies improved outcomes regardless of setting. DISCUSSION Geographic disparities tend to increase the number of transfers, decrease the rate of treatment within 3 h of onset, and increase transit time. This could be overcome through federal and state initiatives to reduce quality gaps in stroke care in rural settings and promote care with dedicated stroke wards.
Collapse
Affiliation(s)
- Min K Lee
- School of Industrial Engineering, Purdue University, West Lafayette, IN, USA
| | - Yuehwern Yih
- School of Industrial Engineering, Purdue University, West Lafayette, IN, USA.,Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, IN, USA
| | - Paul M Griffin
- School of Industrial Engineering, Purdue University, West Lafayette, IN, USA.,Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, IN, USA
| |
Collapse
|
21
|
Mekonnen B, Wang G, Rajbhandari-Thapa J, Shi L, Thapa K, Zhang Z, Zhang D. Weekend Effect on in-Hospital Mortality for Ischemic and Hemorrhagic Stroke in US Rural and Urban Hospitals. J Stroke Cerebrovasc Dis 2020; 29:105106. [PMID: 32912515 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/23/2020] [Accepted: 06/26/2020] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Previous studies have reported a "weekend effect" on stroke mortality, whereby stroke patients admitted during weekends have a higher risk of in-hospital death than those admitted during weekdays. AIMS We aimed to investigate whether patients with different types of stroke admitted during weekends have a higher risk of in-hospital mortality in rural and urban hospitals in the US. METHODS We used data from the 2016 National Inpatient Sample and used logistic regression to assess in-hospital mortality for weekday and weekend admissions among stroke patients aged 18 and older by stroke type (ischemic or hemorrhagic) and rural or urban status. RESULTS Crude stroke mortality was higher in weekend admissions (p <0.001). After adjusting for confounding variables, in-hospital mortality among hemorrhagic stroke patients was significantly greater (22.0%) for weekend admissions compared to weekday admissions (20.2%, p = 0.009). Among rural hospitals, the in-hospital mortality among hemorrhagic stroke patients was also greater among weekend admissions (36.9%) compared to weekday admissions (25.7%, p = 0.040). Among urban hospitals, the mortality of hemorrhagic stroke patients was 21.1% for weekend and 19.6% for weekday admissions (p = 0.026). No weekend effect was found among ischemic stroke patients admitted to rural or urban hospitals. CONCLUSIONS Our results help to understand mortality differences in hemorrhagic stroke for weekend vs. weekday admissions in urban and rural hospitals. Factors such as density of care providers, stroke centers, and patient level risky behaviors associated with the weekend effect on hemorrhagic stroke mortality need further investigation to improve stroke care services and reduce weekend effect on hemorrhagic stroke mortality.
Collapse
Affiliation(s)
- Birook Mekonnen
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, United States.
| | - Guijing Wang
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA 30341, United States.
| | - Janani Rajbhandari-Thapa
- Department of Health Policy and Management, College of Public Health, University of Georgia, 100 Foster Road, 205D Wright Hall, Athens, GA 30602, United States.
| | - Lu Shi
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States.
| | - Kiran Thapa
- Department of Health Policy and Management, College of Public Health, University of Georgia, 100 Foster Road, 205D Wright Hall, Athens, GA 30602, United States.
| | - Zheng Zhang
- Department of Neurology, Wenzhou Medical University, Zhejiang, China.
| | - Donglan Zhang
- Department of Health Policy and Management, College of Public Health, University of Georgia, 100 Foster Road, 205D Wright Hall, Athens, GA 30602, United States.
| |
Collapse
|
22
|
Almallouhi E, Al Kasab S, Nahhas M, Harvey JB, Caudill J, Turner N, Debenham E, Giurgiutiu DV, Leira EC, Switzer JA, Holmstedt CA. Outcomes of interfacility helicopter transportation in acute stroke care. Neurol Clin Pract 2020; 10:422-427. [PMID: 33299670 DOI: 10.1212/cpj.0000000000000737] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 08/19/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate the long-term functional outcome of interhospital transfer of patients with stroke with suspected large vessel occlusion (LVO) using Helicopter Emergency Medical Services (HEMS). METHODS Records of consecutive patients evaluated through 2 telestroke networks and transferred to thrombectomy-capable stroke centers between March 2017 and March 2018 were reviewed. Inverse probability of treatment weighting (IPTW) using the propensity score was performed to address confounding factors. Multivariate logistic regression analysis with IPTW was used to determine whether HEMS were associated with good long-term functional outcome (modified Rankin scale score ≤ 2). RESULTS A total of 199 patients were included; median age was 67 years (interquartile range [IQR] 55-79 years), 90 (45.2%) were female, 120 (60.3%) were white, and 100 (50.3%) were transferred by HEMS. No significant differences between the 2 groups were found in mean age, sex, race, IV tissue plasminogen activator (tPA) receipt, and thrombectomy receipt. The median baseline NIH Stroke Scale score was 14 (IQR 9-18) in the helicopter group vs 11 (IQR 6-18) for patients transferred by ground (p = 0.039). The median transportation time was 60 minutes (IQR 49-70 minutes) by HEMS and 84 minutes (IQR 25-102 minutes) by ground (p < 0.001). After weighting baseline characteristics, the use of HEMS was associated with higher odds of good long-term outcome (OR 4.738, 95% CI 2.15-10.444, p < 0.001) controlling for transportation time, door-in-door-out time, and thrombectomy and tPA receipt. The magnitude of the HEMS effect was larger in thrombectomy patients who had successful recanalization (OR 1.758, 95% CI 1.178-2.512, p = 0.027). CONCLUSIONS HEMS use was associated with better long-term functional outcome in patients with suspected LVO, independently of transportation time.
Collapse
Affiliation(s)
- Eyad Almallouhi
- Department of Neurology (EA, NT, ED, CAH), Medical University of South Carolina, Charleston; Departments of Neurology, Epidemiology and Neurosurgery (SAK, ECL), University of Iowa Carver College of Medicine; Department of Neurology (MN, JC, D-VG, JAS), Augusta University, GA; and Department of Healthcare Leadership and Management (JBH), College of Health Professions, Medical University of South Carolina, Charleston
| | - Sami Al Kasab
- Department of Neurology (EA, NT, ED, CAH), Medical University of South Carolina, Charleston; Departments of Neurology, Epidemiology and Neurosurgery (SAK, ECL), University of Iowa Carver College of Medicine; Department of Neurology (MN, JC, D-VG, JAS), Augusta University, GA; and Department of Healthcare Leadership and Management (JBH), College of Health Professions, Medical University of South Carolina, Charleston
| | - Michael Nahhas
- Department of Neurology (EA, NT, ED, CAH), Medical University of South Carolina, Charleston; Departments of Neurology, Epidemiology and Neurosurgery (SAK, ECL), University of Iowa Carver College of Medicine; Department of Neurology (MN, JC, D-VG, JAS), Augusta University, GA; and Department of Healthcare Leadership and Management (JBH), College of Health Professions, Medical University of South Carolina, Charleston
| | - Jillian B Harvey
- Department of Neurology (EA, NT, ED, CAH), Medical University of South Carolina, Charleston; Departments of Neurology, Epidemiology and Neurosurgery (SAK, ECL), University of Iowa Carver College of Medicine; Department of Neurology (MN, JC, D-VG, JAS), Augusta University, GA; and Department of Healthcare Leadership and Management (JBH), College of Health Professions, Medical University of South Carolina, Charleston
| | - Juanita Caudill
- Department of Neurology (EA, NT, ED, CAH), Medical University of South Carolina, Charleston; Departments of Neurology, Epidemiology and Neurosurgery (SAK, ECL), University of Iowa Carver College of Medicine; Department of Neurology (MN, JC, D-VG, JAS), Augusta University, GA; and Department of Healthcare Leadership and Management (JBH), College of Health Professions, Medical University of South Carolina, Charleston
| | - Nancy Turner
- Department of Neurology (EA, NT, ED, CAH), Medical University of South Carolina, Charleston; Departments of Neurology, Epidemiology and Neurosurgery (SAK, ECL), University of Iowa Carver College of Medicine; Department of Neurology (MN, JC, D-VG, JAS), Augusta University, GA; and Department of Healthcare Leadership and Management (JBH), College of Health Professions, Medical University of South Carolina, Charleston
| | - Ellen Debenham
- Department of Neurology (EA, NT, ED, CAH), Medical University of South Carolina, Charleston; Departments of Neurology, Epidemiology and Neurosurgery (SAK, ECL), University of Iowa Carver College of Medicine; Department of Neurology (MN, JC, D-VG, JAS), Augusta University, GA; and Department of Healthcare Leadership and Management (JBH), College of Health Professions, Medical University of South Carolina, Charleston
| | - Dan-Victor Giurgiutiu
- Department of Neurology (EA, NT, ED, CAH), Medical University of South Carolina, Charleston; Departments of Neurology, Epidemiology and Neurosurgery (SAK, ECL), University of Iowa Carver College of Medicine; Department of Neurology (MN, JC, D-VG, JAS), Augusta University, GA; and Department of Healthcare Leadership and Management (JBH), College of Health Professions, Medical University of South Carolina, Charleston
| | - Enrique C Leira
- Department of Neurology (EA, NT, ED, CAH), Medical University of South Carolina, Charleston; Departments of Neurology, Epidemiology and Neurosurgery (SAK, ECL), University of Iowa Carver College of Medicine; Department of Neurology (MN, JC, D-VG, JAS), Augusta University, GA; and Department of Healthcare Leadership and Management (JBH), College of Health Professions, Medical University of South Carolina, Charleston
| | - Jeffrey A Switzer
- Department of Neurology (EA, NT, ED, CAH), Medical University of South Carolina, Charleston; Departments of Neurology, Epidemiology and Neurosurgery (SAK, ECL), University of Iowa Carver College of Medicine; Department of Neurology (MN, JC, D-VG, JAS), Augusta University, GA; and Department of Healthcare Leadership and Management (JBH), College of Health Professions, Medical University of South Carolina, Charleston
| | - Christine A Holmstedt
- Department of Neurology (EA, NT, ED, CAH), Medical University of South Carolina, Charleston; Departments of Neurology, Epidemiology and Neurosurgery (SAK, ECL), University of Iowa Carver College of Medicine; Department of Neurology (MN, JC, D-VG, JAS), Augusta University, GA; and Department of Healthcare Leadership and Management (JBH), College of Health Professions, Medical University of South Carolina, Charleston
| |
Collapse
|
23
|
Zhang D, Son H, Shen Y, Chen Z, Rajbhandari-Thapa J, Li Y, Eom H, Bu D, Mu L, Li G, Pagán JA. Assessment of Changes in Rural and Urban Primary Care Workforce in the United States From 2009 to 2017. JAMA Netw Open 2020; 3:e2022914. [PMID: 33112401 PMCID: PMC7593812 DOI: 10.1001/jamanetworkopen.2020.22914] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Access to primary care clinicians, including primary care physicians and nonphysician clinicians (nurse practitioners and physician assistants) is necessary to improving population health. However, rural-urban trends in primary care access in the US are not well studied. OBJECTIVE To assess the rural-urban trends in the primary care workforce from 2009 to 2017 across all counties in the US. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study of US counties, county rural-urban status was defined according to the national rural-urban classification scheme for counties used by the National Center for Health Statistics at the Centers for Disease Control and Prevention. Trends in the county-level distribution of primary care clinicians from 2009 to 2017 were examined. Data were analyzed from November 12, 2019, to February 10, 2020. MAIN OUTCOMES AND MEASURES Density of primary care clinicians measured as the number of primary care physicians, nurse practitioners, and physician assistants per 3500 population in each county. The average annual percentage change (APC) of the means of the density of primary care clinicians over time was calculated, and generalized estimating equations were used to adjust for county-level sociodemographic variables obtained from the American Community Survey. RESULTS The study included data from 3143 US counties (1167 [37%] urban and 1976 [63%] rural). The number of primary care clinicians per 3500 people increased significantly in rural counties (2009 median density: 2.04; interquartile range [IQR], 1.43-2.76; and 2017 median density: 2.29; IQR, 1.57-3.23; P < .001) and urban counties (2009 median density: 2.26; IQR. 1.52-3.23; and 2017 median density: 2.66; IQR, 1.72-4.02; P < .001). The APC of the mean density of primary care physicians in rural counties was 1.70% (95% CI, 0.84%-2.57%), nurse practitioners was 8.37% (95% CI, 7.11%-9.63%), and physician assistants was 5.14% (95% CI, 3.91%-6.37%); the APC of the mean density of primary care physicians in urban counties was 2.40% (95% CI, 1.19%-3.61%), nurse practitioners was 8.64% (95% CI, 7.72%-9.55%), and physician assistants was 6.42% (95% CI, 5.34%-7.50%). Results from the generalized estimating equations model showed that the density of primary care clinicians in urban counties increased faster than in rural counties (β = 0.04; 95% CI, 0.03 to 0.05; P < .001). CONCLUSIONS AND RELEVANCE Although the density of primary care clinicians increased in both rural and urban counties during the 2009-2017 period, the increase was more pronounced in urban than in rural counties. Closing rural-urban gaps in access to primary care clinicians may require increasingly intensive efforts targeting rural areas.
Collapse
Affiliation(s)
- Donglan Zhang
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens
| | - Heejung Son
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens
- Department of Epidemiology & Biostatistics, College of Public Health, University of Georgia, Athens
| | - Ye Shen
- Department of Epidemiology & Biostatistics, College of Public Health, University of Georgia, Athens
| | - Zhuo Chen
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens
| | - Janani Rajbhandari-Thapa
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens
| | - Yan Li
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Heesun Eom
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Daniel Bu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lan Mu
- Department of Geography, University of Georgia, Athens
| | - Gang Li
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - José A. Pagán
- Department of Public Health Policy and Management, School of Global Public Health, New York University, New York
| |
Collapse
|
24
|
Georgakakos PK, Swanson MB, Ahmed A, Mohr NM. Rural Stroke Patients Have Higher Mortality: An Improvement Opportunity for Rural Emergency Medical Services Systems. J Rural Health 2020; 38:217-227. [PMID: 32757239 DOI: 10.1111/jrh.12502] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE Early recognition and prompt prehospital care is a cornerstone of acute stroke treatment. Residents of rural areas have worse access to stroke services than urban residents. The purpose of this study was to (1) describe US trends in rural-urban stroke mortality and (2) identify possible factors associated with rural-urban stroke case-fatality disparities. METHODS This study was a nationwide retrospective cohort study of stroke admissions. The primary exposure was rurality of patient's residence. The primary outcome was death during hospital encounter. The secondary outcome was discharge to a care facility or home healthcare. Univariable and multivariable logistic regressions estimated the odds of mortality by subject rurality among stroke subjects. FINDINGS Rural stroke subjects had higher mortality than nonrural counterparts (18.6% rural vs 16.9% nonrural). After adjustment for patient and hospital factors, patient rurality was associated with increased odds of mortality (aOR = 1.11; 95% CI: 1.06-1.15; P < .001). For the secondary outcome of discharge to home, rural stroke subjects were less likely to be discharged to a care facility than nonrural stroke visits (aOR 0.94; 95% CI: 0.91-0.97; P < .001). Results were similar after adjusting for thrombolytics administration and transfer status. CONCLUSIONS Rural stroke patients have higher mortality than their urban counterparts likely due to their increased burden of chronic disease, lower health literacy, and reduced access to prompt prehospital care. There may be an opportunity for emergency medical services systems to assist in increasing stroke awareness for both patients and clinicians and to establish response patterns to expedite emergency care.
Collapse
Affiliation(s)
- Peter K Georgakakos
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Morgan B Swanson
- University of Iowa Carver College of Medicine, Iowa City, Iowa.,Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
| | - Azeemuddin Ahmed
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa.,Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa.,Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa
| |
Collapse
|
25
|
Wilcock AD, Zachrison KS, Schwamm LH, Uscher-Pines L, Zubizarreta JR, Mehrotra A. Trends Among Rural and Urban Medicare Beneficiaries in Care Delivery and Outcomes for Acute Stroke and Transient Ischemic Attacks, 2008-2017. JAMA Neurol 2020; 77:863-871. [PMID: 32364573 PMCID: PMC7358912 DOI: 10.1001/jamaneurol.2020.0770] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/21/2020] [Indexed: 12/20/2022]
Abstract
Importance Over the last decade or so, there have been substantial investments in the development of stroke systems of care to improve access and quality of care in rural communities. Whether these have narrowed rural-urban disparities in care is unclear. Objective To describe trends among rural and urban patients with acute ischemic stroke or transient ischemic attack in the type of health care centers to which patients were admitted, what care was provided, and the outcomes patients experienced. Design, Setting, and Participants This descriptive observational study included 100% claims for beneficiaries of traditional fee-for-service Medicare from 2008 through 2017. All rural and urban areas in the US were included, defined by whether a beneficiary's residential zip code was in a metropolitan or nonmetropolitan area. All admissions in the US among patients with traditional Medicare who had a transient ischemic attack or acute stroke (N = 4.01 million) were eligible to be included in this study. Admissions for beneficiaries with end-stage kidney disease (n = 85 927 [2.14%]), beneficiaries with unidentified Rural-Urban Commuting Area codes (n = 12 797 [0.32%]), and beneficiaries not continuously enrolled in traditional Medicare in the 12 months before and 3 months after their admission (n = 442 963 [11.0%]) were excluded. Exposures Residence in an urban or rural area; admission to a hospital with a transient ischemic attack or acute stroke. Main Outcomes and Measures Discharge from a certified stroke center, receiving a neurology consultation during admission, treatment with alteplase, days institutionalized, and 90-day mortality. Results The final sample included 3.47 million admissions from 2008 through 2017. In this sample, 2.01 million patients (58.0%) were female, and the mean (SD) age was 78.6 (10.5) years. In 2008, 24 681 patients (25.2%) and 161 217 patients (60.6%) in rural and urban areas, respectively, were cared for at a certified stroke center (disparity, -35.4%). By 2017, this disparity was -26.6%, having narrowed by 8.7 percentage points (95% CI, 6.6-10.8 percentage points). There was also narrowing in the rural-urban disparity in neurologist evaluation during admission (6.3% [95% CI, 4.2%-8.4%]). However, the rural-urban disparity widened or was similar with regard to receiving alteplase (0.5% [95% CI, 0.1%-0.8%]), mean days in an institution from admission (0.5 [95% CI, 0.2-0.8] days), and mortality at 90 days (0.3% [95% CI, -0.02% to 0.6%]), respectively. Conclusions and Relevance In the last decade, care for rural residents with acute ischemic stroke and transient ischemic attack has shifted to certified stroke centers and now more likely includes neurologist input. However, disparities in access to treatments, such as alteplase, and outcomes persist, highlighting that work still is needed to extend improvements in stroke care to all US residents.
Collapse
Affiliation(s)
- Andrew D. Wilcock
- Center for Health Services Research, Department of Family Medicine, The Larner College of Medicine, University of Vermont, Burlington
| | - Kori S. Zachrison
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Massachusetts General Hospital, Boston
| | - Lee H. Schwamm
- Massachusetts General Hospital, Boston
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | | | - Jose R. Zubizarreta
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| |
Collapse
|
26
|
Nalleballe K, Brown A, Sharma R, Sheng S, Veerapaneni P, Patrice KA, Shah V, Onteddu S, Culp W, Lowery C, Benton T, Joiner R, Kapoor N. When Telestroke Programs Work, Hospital Size Really Does Not Matter. J Neurosci Rural Pract 2020; 11:403-406. [PMID: 32753804 PMCID: PMC7394625 DOI: 10.1055/s-0040-1709362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Background There are still marked disparities in stroke care between rural and urban communities including difference in stroke-related mortality. We analyzed the efficiency of tissue plasminogen activator (tPA) delivery in the spoke sites in our telestroke network to assess impact of telecare in bridging these disparities. Methods We analyzed critical time targets in our telestroke network. These included door-to-needle (DTN) time, door-to-CT (D2CT) time, door-to-call center, door-to-neurocall, and total consult time. We compared these time targets between the larger and smaller spoke hospitals. Results Across all the 52 spokes sites, a total of 825 stroke consults received intravenous tPA. When compared with larger hospitals (>200 beds), the smaller hospital groups with 0 to 25 and 51 to 100 beds had significantly lower D2CT time ( p -value 0.01 and 0.005, respectively) and the ones with 26 to 50 and 151 to 200 beds had significantly lower consult time ( p -value 0.009 and 0.001, respectively). There was no significant difference in the overall DTN time when all the smaller hospital groups were compared with larger hospitals. Conclusion In our telestroke network, DTN times were not significantly affected by the hospital bed size. This shows that a protocol-driven telestroke network with frequent mock codes can ensure timely administration of tPA even in rural communities regardless of the hospital size and availability of local neurologists.
Collapse
Affiliation(s)
- Krishna Nalleballe
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Aliza Brown
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Rohan Sharma
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Sen Sheng
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Poornachand Veerapaneni
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Kelly-Ann Patrice
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Vishank Shah
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Sanjeeva Onteddu
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - William Culp
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Curtis Lowery
- Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Tina Benton
- Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Renee Joiner
- Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Nidhi Kapoor
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| |
Collapse
|
27
|
Two years' experience of implementing a comprehensive telemedical stroke network comprising in mainly rural region: the Transregional Network for Stroke Intervention with Telemedicine (TRANSIT-Stroke). BMC Neurol 2020; 20:104. [PMID: 32192438 PMCID: PMC7081707 DOI: 10.1186/s12883-020-01676-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 03/05/2020] [Indexed: 11/10/2022] Open
Abstract
Background Telemedicine improves the quality of acute stroke care in rural regions with limited access to specialized stroke care. We report the first 2 years’ experience of implementing a comprehensive telemedical stroke network comprising all levels of stroke care in a defined region. Methods The TRANSIT-Stroke network covers a mainly rural region in north-western Bavaria (Germany). All hospitals providing acute stroke care in this region participate in TRANSIT-Stroke, including four hospitals with a supra-regional certified stroke unit (SU) care (level III), three of those providing teleconsultation to two hospitals with a regional certified SU (level II) and five hospitals without specialized SU care (level I). For a two-year-period (01/2015 to 12/2016), data of eight of these hospitals were available; 13 evidence-based quality indicators (QIs) related to processes during hospitalisation were evaluated quarterly and compared according to predefined target values between level-I- and level-II/III-hospitals. Results Overall, 7881 patients were included (mean age 74.6 years ±12.8; 48.4% female). In level-II/III-hospitals adherence of all QIs to predefined targets was high ab initio. In level-I-hospitals, three patterns of QI-development were observed: a) high adherence ab initio (31%), mainly in secondary stroke prevention; b) improvement over time (44%), predominantly related to stroke specific diagnosis and in-hospital organization; c) no clear time trends (25%). Overall, 10 out of 13 QIs reached predefined target values of quality of care at the end of the observation period. Conclusion The implementation of the comprehensive TRANSIT-Stroke network resulted in an improvement of quality of care in level-I-hospitals.
Collapse
|
28
|
Mohr NM, Wu C, Ward MJ, McNaughton CD, Richardson K, Kaboli PJ. Potentially avoidable inter-facility transfer from Veterans Health Administration emergency departments: A cohort study. BMC Health Serv Res 2020; 20:110. [PMID: 32050947 PMCID: PMC7014752 DOI: 10.1186/s12913-020-4956-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 02/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inter-facility transfer is an important strategy for improving access to specialized health services, but transfers are complicated by over-triage, under-triage, travel burdens, and costs. The purpose of this study is to describe ED-based inter-facility transfer practices within the Veterans Health Administration (VHA) and to estimate the proportion of potentially avoidable transfers. METHODS This observational cohort study included all patients treated in VHA EDs between 2012 and 2014 who were transferred to another VHA hospital. Potentially avoidable transfers were defined as patients who were either discharged from the receiving ED or admitted to the receiving hospital for ≤1 day without having an invasive procedure performed. We conducted facility- and diagnosis-level analyses to identify subgroups of patients for whom potentially avoidable transfers had increased prevalence. RESULTS Of 6,173,189 ED visits during the 3-year study period, 18,852 (0.3%) were transferred from one VHA ED to another VHA facility. Rural residents were transferred three times as often as urban residents (0.6% vs. 0.2%, p < 0.001), and 22.8% of all VHA-to-VHA transfers were potentially avoidable transfers. The 3 disease categories most commonly associated with inter-facility transfer were mental health (34%), cardiac (12%), and digestive diagnoses (9%). CONCLUSIONS VHA inter-facility transfer is commonly performed for mental health and cardiac evaluation, particularly for patients in rural settings. The proportion that are potentially avoidable is small. Future work should focus on improving capabilities to provide specialty evaluation locally for these conditions, possibly using telehealth solutions.
Collapse
Affiliation(s)
- Nicholas M. Mohr
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA USA
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, USA
- Department of Anesthesia, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 1008 RCP, Iowa City, IA 52242 USA
| | - Chaorong Wu
- Institute for Clinical and Translational Sciences, University of Iowa, Iowa City, Iowa USA
| | - Michael J. Ward
- Tennessee Valley Healthcare System VA Medical Center, Nashville, Tennessee USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Candace D. McNaughton
- Tennessee Valley Healthcare System VA Medical Center, Nashville, Tennessee USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Kelly Richardson
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA USA
| | - Peter J. Kaboli
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa USA
| |
Collapse
|
29
|
Harrington RA, Califf RM, Balamurugan A, Brown N, Benjamin RM, Braund WE, Hipp J, Konig M, Sanchez E, Joynt Maddox KE. Call to Action: Rural Health: A Presidential Advisory From the American Heart Association and American Stroke Association. Circulation 2020; 141:e615-e644. [PMID: 32078375 DOI: 10.1161/cir.0000000000000753] [Citation(s) in RCA: 147] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Understanding and addressing the unique health needs of people residing in rural America is critical to the American Heart Association's pursuit of a world with longer, healthier lives. Improving the health of rural populations is consistent with the American Heart Association's commitment to health equity and its focus on social determinants of health to reduce and ideally to eliminate health disparities. This presidential advisory serves as a call to action for the American Heart Association and other stakeholders to make rural populations a priority in programming, research, and policy. This advisory first summarizes existing data on rural populations, communities, and health outcomes; explores 3 major groups of factors underlying urban-rural disparities in health outcomes, including individual factors, social determinants of health, and health delivery system factors; and then proposes a set of solutions spanning health system innovation, policy, and research aimed at improving rural health.
Collapse
|
30
|
Prior SJ, Reeves NS, Campbell SJ. Challenges of delivering evidence‐based stroke services for rural areas in Australia. Aust J Rural Health 2020; 28:15-21. [DOI: 10.1111/ajr.12579] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 09/01/2019] [Accepted: 09/10/2019] [Indexed: 11/30/2022] Open
Affiliation(s)
- Sarah Jane Prior
- College of Health and Medicine School of Medicine University of Tasmania Burnie TAS Australia
| | - Nicole S. Reeves
- College of Health and Medicine School of Medicine University of Tasmania Burnie TAS Australia
| | - Steven J. Campbell
- College of Health and Medicine School of Health Sciences University of Tasmania Newnham TAS Australia
| |
Collapse
|
31
|
Nichols LJ, Gall S, Stirling C. Determining rural risk for aneurysmal subarachnoid hemorrhages: A structural equation modeling approach. J Neurosci Rural Pract 2019; 7:559-565. [PMID: 27695237 PMCID: PMC5006469 DOI: 10.4103/0976-3147.188627] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
An aneurysmal subarachnoid hemorrhage (aSAH) carries a high disability burden. The true impact of rurality as a predictor of outcome severity is unknown. Our aim is to clarify the relationship between the proposed explanations of regional and rural health disparities linked to severity of outcome following an aSAH. An initial literature search identified limited data directly linking geographical location, rurality, rural vulnerability, and aSAH. A further search noting parallels with ischemic stroke and acute myocardial infarct literature presented a number of diverse and interrelated predictors. This a priori knowledge informed the development of a conceptual framework that proposes the relationship between rurality and severity of outcome following an aSAH utilizing structural equation modeling. The presented conceptual framework explores a number of system, environmental, and modifiable risk factors. Socioeconomic characteristics, modifiable risk factors, and timely treatment that were identified as predictors of severity of outcome following an aSAH and within each of these defined predictors a number of contributing specific individual predictors are proposed. There are considerable gaps in the current knowledge pertaining to the impact of rurality on the severity of outcome following an aSAH. Absent from the literature is any investigation of the cumulative impact and multiplicity of risk factors associated with rurality. The proposed conceptual framework hypothesizes a number of relationships between both individual level and system level predictors, acknowledging that intervening predictors may mediate the effect of one variable on another.
Collapse
Affiliation(s)
- Linda Jayne Nichols
- School of Health Sciences, Faculty of Health Science, University of Tasmania, Hobart Tasmania, Australia
| | - Seana Gall
- Menzies Institute for Medical Research, University of Tasmania, Hobart Tasmania, Australia
| | - Christine Stirling
- Menzies Institute for Medical Research, University of Tasmania, Hobart Tasmania, Australia
| |
Collapse
|
32
|
Hansen G, Bal S, Schellenberg KL, Alcock S, Ghrooda E. Prehospital Management of Acute Stroke in Rural versus Urban Responders. J Neurosci Rural Pract 2019; 8:S33-S36. [PMID: 28936069 PMCID: PMC5602258 DOI: 10.4103/jnrp.jnrp_2_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Objective: Stroke guideline compliance of rural Canadian prehospital emergency medical services (EMS) care in acute stroke is unknown. In this quality assurance study, we sought to compare rural and urban care by prehospital EMS evaluation/management indicators from patients assessed at an urban Canadian stroke center. Materials and Methods: One hundred adult patients were randomly selected from the stroke registry. Patients were transported through Rural EMS bypass protocols or urban EMS protocols (both bypass and direct) to our stroke center between January and December 2013. Patients were excluded if they were first evaluated at any other health center. Prehospital care was assessed using ten indicators for EMS evaluation/management, as recommended by acute stroke guidelines. Results: Compliance with acute stroke EMS evaluation/management indicators were statistically similar for both groups, except administrating a prehospital diagnostic tool (rural 31.8 vs. urban 70.3%; P = 0.002). Unlike urban EMS, rural EMS did not routinely document scene time. Conclusion: Rural EMS responders’ compliance to prehospital stroke evaluation/management was similar to urban EMS responders. Growth areas for both groups may be with prehospital stroke diagnostic tool utilization, whereas rural EMS responders may also improve with scene time documentation.
Collapse
Affiliation(s)
- Gregory Hansen
- Department of Pediatrics, Division of Critical Care, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan S7N 0W8, Canada
| | - Simerpreet Bal
- Department of Clinical Neurosciences, Division of Neurology, University of Calgary, Calgary, Alberta T2N 2T9, Canada
| | - Kerri Lynn Schellenberg
- Department of Medicine, Division of Neurology, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan S7N 0W8, Canada
| | - Susan Alcock
- Department of Medicine, Health Sciences Centre, Section of Neurology, University of Manitoba, Winnipeg, Manitoba R3A 1R9, Canada
| | - Esseddeeg Ghrooda
- Department of Medicine, Health Sciences Centre, Section of Neurology, University of Manitoba, Winnipeg, Manitoba R3A 1R9, Canada
| |
Collapse
|
33
|
Rose JS, Kocet MM, Thompson IA, Flores M, McKinney R, Suprina JS. Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling’s Best Practices in Addressing Conscience Clause Legislation in Counselor Education and Supervision. JOURNAL OF LGBT ISSUES IN COUNSELING 2019. [DOI: 10.1080/15538605.2019.1565800] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Jared S. Rose
- Clinical Mental Health and School Counseling Programs, Bowling Green State University, Bowling Green, Ohio, USA
| | - Michael M. Kocet
- Counselor Education Department, The Chicago School of Professional Psychology, Chicago, Illinois, USA
| | - Isabel A. Thompson
- Counseling Programs, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Marc Flores
- Counselor Education Department, The Chicago School of Professional Psychology, Chicago, Illinois, USA
| | - Robert McKinney
- Counselor Education Department, Gonzaga University, Spokane, Washington, USA
| | - Joffrey S. Suprina
- College of Counseling, Psychology, and Social, Services, Argosy University, Sarasota, Florida, USA
| |
Collapse
|
34
|
Javor A, Ferrari J, Posekany A, Asenbaum-Nan S. Stroke risk factors and treatment variables in rural and urban Austria: An analysis of the Austrian Stroke Unit Registry. PLoS One 2019; 14:e0214980. [PMID: 30970026 PMCID: PMC6457636 DOI: 10.1371/journal.pone.0214980] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 03/24/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Differences in stroke risk factors and treatment variables between rural and urban regions in Austria were analyzed retrospectively as European data on this topic are scarce. RESEARCH DESIGN AND METHODS We performed statistical analysis using group comparisons and time series analysis of data of the Austrian Stroke Unit Registry between 2005 and 2016. 87411 patients were divided into three groups (rural, intermediate, urban) according to the degree of urbanisation classification of the European Commission/Eurostat. RESULTS Patients in the rural group were significantly younger, more often female, had a lower pre-stroke disability, and were more frequently transported by an emergency physician. Vascular risk factors were significantly higher in urban patients, leading to a higher rate of microangiopathic etiology. Onset-to-door (ODT) and Onset-to-treatment times were significantly higher in the rural group, but ODTs decreased over time. Door-to-needle times and time to first vascular imaging were significantly lower in the rural group. Intravenous thrombolysis and rehabilitation rates were lower in urban patients. DISCUSSION AND IMPLICATIONS Contrary to previous literature predominantly from outside of Europe, vascular risk factors were higher in Austrian urban patients. Further, rural patients had higher intravenous thrombolysis and rehabilitation rates maybe because of lower pre-stroke disability. ODTs in rural patients were generally higher, but they decreased over time, which might be a consequence of better education of the public in noticing early stroke signs, better transportation and education of emergency medical personnel, better advance notification to the receiving hospital and implementation of Stroke Units in rural areas.
Collapse
Affiliation(s)
- Andrija Javor
- Department of Neurology, General Hospital Amstetten, Amstetten, Austria
| | - Julia Ferrari
- Department of Neurology, Hospital St. John´s of God, Vienna, Austria
| | - Alexandra Posekany
- Department of Clinical Neuroscience, Danube University Krems, Krems an der Donau, Austria
- Gesundheit Österreich GmbH/BIQG, Vienna, Austria
| | - Susanne Asenbaum-Nan
- Department of Neurology, General Hospital Amstetten, Amstetten, Austria
- * E-mail:
| |
Collapse
|
35
|
Hardy RY, Lindrooth RC, Peach RK, Ellis C. Urban-Rural Differences in Service Utilization and Costs of Care for Racial-Ethnic Groups Hospitalized With Poststroke Aphasia. Arch Phys Med Rehabil 2019; 100:254-260. [DOI: 10.1016/j.apmr.2018.06.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/21/2018] [Accepted: 06/26/2018] [Indexed: 11/26/2022]
|
36
|
Kapral MK, Austin PC, Jeyakumar G, Hall R, Chu A, Khan AM, Jin AY, Martin C, Manuel D, Silver FL, Swartz RH, Tu JV. Rural-Urban Differences in Stroke Risk Factors, Incidence, and Mortality in People With and Without Prior Stroke. Circ Cardiovasc Qual Outcomes 2019; 12:e004973. [DOI: 10.1161/circoutcomes.118.004973] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Moira K. Kapral
- Division of General Internal Medicine, Department of Medicine (M.K.K., J.V.T.), University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation (M.K.K., P.C.A., J.V.T.), University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
| | - Peter C. Austin
- Institute of Health Policy, Management and Evaluation (M.K.K., P.C.A., J.V.T.), University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
| | - Geerthana Jeyakumar
- Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland (G.J.)
| | - Ruth Hall
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
| | - Anna Chu
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
| | - Anam M. Khan
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
| | - Albert Y. Jin
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada (A.Y.J.)
| | - Cally Martin
- Kingston Health Sciences Centre, Kingston, Ontario, Canada (C.M.)
| | - Doug Manuel
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.M.)
| | - Frank L. Silver
- Division of Neurology, Department of Medicine (F.L.S., R.H.S.), University of Toronto, Toronto, Ontario, Canada
| | - Richard H. Swartz
- Division of Neurology, Department of Medicine (F.L.S., R.H.S.), University of Toronto, Toronto, Ontario, Canada
| | - Jack V. Tu
- Division of General Internal Medicine, Department of Medicine (M.K.K., J.V.T.), University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation (M.K.K., P.C.A., J.V.T.), University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
| |
Collapse
|
37
|
Dwyer M, Rehman S, Ottavi T, Stankovich J, Gall S, Peterson G, Ford K, Kinsman L. Urban-rural differences in the care and outcomes of acute stroke patients: Systematic review. J Neurol Sci 2018; 397:63-74. [PMID: 30594105 DOI: 10.1016/j.jns.2018.12.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/14/2018] [Accepted: 12/16/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To describe literature pertaining to urban-rural differences in both the quality of care and outcomes of acute stroke patients. METHODS We systematically searched CINAHL, PubMed, ProQuest Dissertations & Theses, and Scopus for published and unpublished literature until 9th December 2017. Studies were included if they compared the acute care provided to, or outcomes of, patients hospitalised for stroke in urban versus rural settings. Abstract, full-text review, and data extraction were conducted in duplicate. Findings are presented in the form of narrative syntheses. RESULTS A total of 28 studies were included in the review (16 on care, 12 on outcomes). With few exceptions, studies addressing the provision of care suggested that rural patients have less access to most aspects of acute stroke care. Studies reporting urban-rural differences in patient outcomes were inconsistent in their findings, however, few of these studies were primarily focused on the issue of urban-rural disparities. Overall, study findings did not appear to differ in line with study quality ratings, stroke subtypes included, or how inter-facility patient transfers were accounted for. CONCLUSIONS There is convincing, albeit not unanimous, evidence to suggest that stroke patients in rural areas receive less acute care than their urban counterparts. Despite this, the available data and methodology have largely not been used to study urban-rural differences in patient outcomes. PROSPERO registration information: URL: https://www.crd.york.ac.uk/prospero. Unique identifier: CRD42017073262.
Collapse
|
38
|
Nalleballe K, Sharma R, Brown A, Joiner R, Kapoor N, Morgan T, Benton T, Williamson C, Culp W, Lowery C, Onteddu S. Ideal telestroke time targets: Telestroke-based treatment times in the United States stroke belt. J Telemed Telecare 2018; 26:174-179. [PMID: 30352525 DOI: 10.1177/1357633x18805661] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Studying critical time interval requirements can enhance thrombolytic treatment for stroke patients in telestroke networks. We retrospectively examined 12 concurrent months of targeted time interval information in the South Central US telemedicine programme, Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES).Hypothesis: We hypothesised that consult data analysis would highlight areas for improvement to shorten overall door to Intra venous (IV) tissue plasminogen activator (tPA) administration time. Methods We analysed critical time targets for 238 consecutive telestroke neurology consults obtained over 12 months from AR SAVES spoke sites when tPA was administered. The following time intervals were analysed: emergency department (ED) door to Computed Tomography (D-CT); ED door to call centre (D-CC) for initiation of consult; ED door to neurology call (D-NC); neurology call to camera (NC-Cam); tele consult time (Con); ED door to tissue plasminogen activator (tPA)/needle (DTN). Results The median times of D-CT (13 min, inter quartile range (IQR) 6–22 min), D-CC (34 min, IQR 20–45 min), D-NC (40 min, IQR 21–71 min), NC-Cam (4 min, IQR 2–8 min), and Con (25 min, IQR 17–37 min) all contributed to a DTN median time of 71 min (IQR 50–104 min). A total of 238 patients received tPA with a 29.4% treatment rate and a DTN time of ≤60 min was achieved in 25.2% of patients. Conclusions Focusing on reducing D-CC and Con times may help to achieve the DTN time of < 60 min for the majority of patients. Having ideal time targets for telestroke patients akin to traditional patients will help identify and improve the overall goal of a DTN time < 60 min.
Collapse
Affiliation(s)
- Krishna Nalleballe
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Rohan Sharma
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Aliza Brown
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, USA.,Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Renee Joiner
- Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Nidhi Kapoor
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Tiffany Morgan
- Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Tina Benton
- Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Conelia Williamson
- Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock, USA
| | - William Culp
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, USA.,Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Curtis Lowery
- Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Sanjeeva Onteddu
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, USA
| |
Collapse
|
39
|
Faine BA, Dayal S, Kumar R, Lentz SR, Leira EC. Helicopter "Drip and Ship" Flights Do Not Alter the Pharmacological Integrity of rtPA. J Stroke Cerebrovasc Dis 2018; 27:2720-2724. [PMID: 30037651 PMCID: PMC6139266 DOI: 10.1016/j.jstrokecerebrovasdis.2018.05.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 05/23/2018] [Accepted: 05/28/2018] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Rural and critical access hospitals rely on the "drip and ship" practice using helicopter emergency medical services (HEMS). But those helicopter flights are an unusual environment with physical factors such as vibration and accelerations that could potentially affect the stability, and pharmacological properties of IV rtPA, an issue that has not been previously addressed. MATERIALS AND METHODS This was a prospective cohort study of consecutive acute ischemic stroke patients receiving IV rtPA through a Comprehensive Stroke Center from November 2015 to February 2017 to measure the effects of HEMS on the integrity and activity of rtPA by collecting residual medication left in the vial. CLINICAL TRIAL REGISTRATION http://www.clinicaltrials.gov. NCT02752256 RESULTS: A total of 33 patients and rtPA samples were included; 18 patients who presented directly to the Comprehensive Stroke Center emergency department and 15 patients who received rtPA during air ambulance transfer. The median rtPA antigen concentration in the residual medication vial was 3.04 mg/mL (IQR: 1.24-3.87) in the HEMS group and 1.91 mg/mL (IQR: 1.33-2.60) in the controls (P = .168). There were no significant differences in rtPA activity or specific activity between the HEMS and control groups and there was no association between total HEMS flight time on overall rtPA specific activity. CONCLUSIONS In summary, this study provides supportive evidence of the lack of a detrimental effect of the HEMS physical environment on the integrity of rtPA, therefore endorsing current drip and ship practices without infusion adjustments.
Collapse
Affiliation(s)
- Brett A Faine
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa; University of Iowa College of Pharmacy, Iowa City, Iowa.
| | - Sanjana Dayal
- Department of Molecular Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Rahul Kumar
- Department of Molecular Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Steven R Lentz
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Enrique C Leira
- Departments of Neurology and Neurosurgery, Carver College of Medicine, and Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
| |
Collapse
|
40
|
Bui KD, Johnson MJ. Designing robot-assisted neurorehabilitation strategies for people with both HIV and stroke. J Neuroeng Rehabil 2018; 15:75. [PMID: 30107849 PMCID: PMC6092818 DOI: 10.1186/s12984-018-0418-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 07/27/2018] [Indexed: 01/01/2023] Open
Abstract
There is increasing evidence that HIV is an independent risk factor for stroke, resulting in an emerging population of people living with both HIV and stroke all over the world. However, neurorehabilitation strategies for the HIV-stroke population are distinctly lacking, which poses an enormous global health challenge. In order to address this gap, a better understanding of the HIV-stroke population is needed, as well as potential approaches to design effective neurorehabilitation strategies for this population. This review goes into the mechanisms, manifestations, and treatment options of neurologic injury in stroke and HIV, the additional challenges posed by the HIV-stroke population, and rehabilitation engineering approaches for both high and low resource areas. The aim of this review is to connect the underlying neurologic properties in both HIV and stroke to rehabilitation engineering. It reviews what is currently known about the association between HIV and stroke and gaps in current treatment strategies for the HIV-stroke population. We highlight relevant current areas of research that can help advance neurorehabilitation strategies specifically for the HIV-stroke population. We then explore how robot-assisted rehabilitation combined with community-based rehabilitation could be used as a potential approach to meet the challenges posed by the HIV-stroke population. We include some of our own work exploring a community-based robotic rehabilitation exercise system. The most relevant strategies will be ones that not only take into account the individual status of the patient but also the cultural and economic considerations of their respective environment.
Collapse
Affiliation(s)
- Kevin D. Bui
- Department of Bioengineering, University of Pennsylvania, Philadelphia, USA
- Rehabilitation Robotics Lab (a GRASP Lab), University of Pennsylvania, 1800 Lombard Street, Philadelphia, 19146 USA
| | - Michelle J. Johnson
- Department of Bioengineering, University of Pennsylvania, Philadelphia, USA
- Rehabilitation Robotics Lab (a GRASP Lab), University of Pennsylvania, 1800 Lombard Street, Philadelphia, 19146 USA
- Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| |
Collapse
|
41
|
Geographic Variations of Stroke Hospitalization across France: A Diachronic Cluster Analysis. Stroke Res Treat 2018; 2018:1897569. [PMID: 30112160 PMCID: PMC6077614 DOI: 10.1155/2018/1897569] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 06/12/2018] [Indexed: 11/18/2022] Open
Abstract
Background This study evaluates the clustering of hospitalization rates for stroke and compares this clustering with two different time intervals 2009-2010 and 2012-2013, corresponding to the beginning of the French National Stroke Plan 2010–2014. In addition, these data will be compared with the deployment of stroke units as well as socioeconomic and healthcare characteristics at zip code level. Methods We used the PMSI data from 2009 to 2013, which lists all hospitalizations for stroke between 2009 and 2013, identified on the most detailed geographic scale allowed by this database. We identify statistically significant clusters with high or low rates in the zip code level using the Getis-Ord statistics. Each of the significant clusters is monitored over time and evaluated according to the nearest stroke unit distance and the socioeconomic profile. Results We identified clusters of low and high rate of stroke hospitalization (23.7% of all geographic codes). Most of these clusters are maintained over time (81%) but we also observed clusters in transition. Geographic codes with persistent high rates of stroke hospitalizations were mainly rural (78% versus 17%, P < .0001) and had a least favorable socioeconomic and healthcare profile. Conclusion Our study reveals that high-stroke hospitalization rates cluster remains the same during our study period. While access to the stroke unit has increased overall, it remains low for these clusters. The socioeconomic and healthcare profile of these clusters are poor but variations were observed. These results are valuable tools to implement more targeted strategies to improve stroke care accessibility and reduce geographic disparities.
Collapse
|
42
|
Salvatierra GG, Gulek BG, Erdik B, Bennett D, Daratha KB. In-Hospital Sepsis Mortality Rates Comparing Tertiary and Non-Tertiary Hospitals in Washington State. J Emerg Med 2018. [PMID: 29523426 DOI: 10.1016/j.jemermed.2018.01.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND More than a million people a year in the United States experience sepsis or sepsis-related complications, and sepsis remains the leading cause of in-hospital deaths. Unlike many other leading causes of in-hospital mortality, sepsis detection and treatment are not dependent on the presence of any technology or services that differ between tertiary and non-tertiary hospitals. OBJECTIVE To compare sepsis mortality rates between tertiary and non-tertiary hospitals in Washington State. METHODS A retrospective longitudinal, observational cohort study of 73 Washington State hospitals for 2010-2015 using data from a standardized state database of hospital abstracts. Abstract records on adult patients (n = 86,378) admitted through the emergency department (ED) from 2010 through 2015 in all tertiary (n = 7) and non-tertiary (n = 66) hospitals in Washington State. RESULTS The overall mortality rate for all hospitals was 6.5%. In the fully adjusted model, the odds ratio for in-hospital death was higher in non-tertiary hospitals compared with tertiary hospitals (odds ratio 1.25; 95% confidence interval 1.17-1.35; p < 0.001). CONCLUSIONS We observed higher sepsis mortality rates in non-tertiary hospitals, compared with tertiary hospitals. Because most patients who are treated for sepsis are treated outside of tertiary hospitals, and the number of patients treated for sepsis in non-tertiary hospitals seems to be rising, a better understanding of the cause or causes for this differential is crucial.
Collapse
Affiliation(s)
- Gail G Salvatierra
- School of Nursing, California State University San Marcos, San Marcos, California
| | - Bernice G Gulek
- College of Nursing, Washington State University, Spokane, Washington
| | - Baran Erdik
- College of Nursing, Washington State University, Spokane, Washington
| | - Deborah Bennett
- School of Nursing, California State University San Marcos, San Marcos, California
| | - Kenn B Daratha
- College of Nursing, Washington State University, Spokane, Washington; Providence Medical Research Center, Providence Sacred Heart Medical Center, Spokane, Washington; Department of Medical Education and Biomedical Informatics, University of Washington, Spokane and Seattle, Washington
| |
Collapse
|
43
|
Seabury S, Bognar K, Xu Y, Huber C, Commerford SR, Tayama D. Regional disparities in the quality of stroke care. Am J Emerg Med 2017; 35:1234-1239. [DOI: 10.1016/j.ajem.2017.03.046] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 03/17/2017] [Accepted: 03/18/2017] [Indexed: 11/24/2022] Open
|
44
|
Fassbender K, Grotta JC, Walter S, Grunwald IQ, Ragoschke-Schumm A, Saver JL. Mobile stroke units for prehospital thrombolysis, triage, and beyond: benefits and challenges. Lancet Neurol 2017; 16:227-237. [PMID: 28229894 DOI: 10.1016/s1474-4422(17)30008-x] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/02/2016] [Accepted: 01/11/2017] [Indexed: 10/20/2022]
Abstract
In acute stroke management, time is brain. Bringing swift treatment to the patient, instead of the conventional approach of awaiting the patient's arrival at the hospital for treatment, is a potential strategy to improve clinical outcomes after stroke. This strategy is based on the use of an ambulance (mobile stroke unit) equipped with an imaging system, a point-of-care laboratory, a telemedicine connection to the hospital, and appropriate medication. Studies of prehospital stroke treatment consistently report a reduction in delays before thrombolysis and cause-based triage in regard to the appropriate target hospital (eg, primary vs comprehensive stroke centre). Moreover, novel medical options for the treatment of stroke patients are also under investigation, such as prehospital differential blood pressure management, reversal of warfarin effects in haemorrhagic stroke, and management of cerebral emergencies other than stroke. However, crucial concerns regarding safety, clinical efficacy, best setting, and cost-effectiveness remain to be addressed in further studies. In the future, mobile stroke units might allow the investigation of novel diagnostic (eg, biomarkers and automated imaging evaluation) and therapeutic (eg, neuroprotective drugs and treatments for haemorrhagic stroke) options in the prehospital setting, thus functioning as a tool for research on prehospital stroke management.
Collapse
Affiliation(s)
- Klaus Fassbender
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany.
| | - James C Grotta
- Department of Neurology, University of Texas Medical School at Houston, Houston, TX, USA
| | - Silke Walter
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Iris Q Grunwald
- Neuroscience and Vascular Simulation Unit, Faculty of Medical Science, PMI, Anglia Ruskin University, Chelmsford, UK; Department of Stroke Medicine, Southend University Hospital, Southend, UK
| | | | - Jeffrey L Saver
- Stroke Center, University of California Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
45
|
Leira EC, Phipps MS, Jasne AS, Kleindorfer DO. Time to treat stroke patients in rural locations as an underserved minority. Neurology 2017; 88:422-423. [PMID: 28053007 DOI: 10.1212/wnl.0000000000003560] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Enrique C Leira
- From the Departments of Neurology and Epidemiology (E.C.L.), Carver College of Medicine and College of Public Health, University of Iowa, Iowa City; the Departments of Neurology and Epidemiology and Public Health (M.S.P.), University of Maryland School of Medicine, Baltimore; and the Department of Neurology (A.S.J., D.O.K.), University of Cincinnati, OH.
| | - Michael S Phipps
- From the Departments of Neurology and Epidemiology (E.C.L.), Carver College of Medicine and College of Public Health, University of Iowa, Iowa City; the Departments of Neurology and Epidemiology and Public Health (M.S.P.), University of Maryland School of Medicine, Baltimore; and the Department of Neurology (A.S.J., D.O.K.), University of Cincinnati, OH
| | - Adam S Jasne
- From the Departments of Neurology and Epidemiology (E.C.L.), Carver College of Medicine and College of Public Health, University of Iowa, Iowa City; the Departments of Neurology and Epidemiology and Public Health (M.S.P.), University of Maryland School of Medicine, Baltimore; and the Department of Neurology (A.S.J., D.O.K.), University of Cincinnati, OH
| | - Dawn O Kleindorfer
- From the Departments of Neurology and Epidemiology (E.C.L.), Carver College of Medicine and College of Public Health, University of Iowa, Iowa City; the Departments of Neurology and Epidemiology and Public Health (M.S.P.), University of Maryland School of Medicine, Baltimore; and the Department of Neurology (A.S.J., D.O.K.), University of Cincinnati, OH
| |
Collapse
|
46
|
Huseth-Zosel AL, Sanders G, O'Connor M, Fuller-Iglesias H, Langley L. Health Care Provider Mobility Counseling Provision to Older Adults: A Rural/Urban Comparison. J Community Health 2016; 41:1-10. [PMID: 26070871 DOI: 10.1007/s10900-015-0055-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The current study examined rural-urban differences in health care provider (HCP) perceptions, attitudes, and practices related to driving safety/cessation-related anticipatory guidance provision to older adults. A cross-sectional survey was conducted with HCPs in several north central states. Exploratory factor analysis was used to examine dimensions of HCP perceptions and attitudes related to mobility counseling. Binary logistic regression analyses were conducted to determine if HCP rurality was significantly predictive of HPC provision of mobility counseling by age. Rural HCPs were less likely than urban HCPs to provide mobility counseling to their patients aged 75 or older. Rural HCPs were less likely to refer patients to a driving fitness evaluation resource if they had questions related to driving issues, and were less likely to perceive there were adequate resources to help with driving issues. Rural-urban differences in HCP mobility counseling provision may contribute to potential health disparities between urban and rural patients. Both rural and urban HCPs need training about older driver issues, so they may educate their patients about driving safety/cessation. Future research should examine the association between rural-urban differences in HCP mobility counseling provision and rural older adult overrepresentation in motor vehicle injuries and fatalities statistics.
Collapse
Affiliation(s)
- Andrea L Huseth-Zosel
- Department of Public Health, College of Health Professions, Dept. 2662, North Dakota State University, PO Box 6050, Fargo, ND, 58108-6050, USA.
| | - Gregory Sanders
- College of Human Development and Education, Dept. 2600, North Dakota State University, PO Box 6050, Fargo, ND, 58108-6050, USA.
| | - Melissa O'Connor
- Human Development and Family Science, Dept. 2615, North Dakota State University, PO Box 6050, Fargo, ND, 58108-6050, USA.
| | - Heather Fuller-Iglesias
- Human Development and Family Science, Dept. 2615, North Dakota State University, PO Box 6050, Fargo, ND, 58108-6050, USA.
| | - Linda Langley
- Department of Psychology, Dept. 2765, North Dakota State University, PO Box 6050, Fargo, ND, 58108-6050, USA.
| |
Collapse
|
47
|
Moloczij N, Mosley I, Moss KM, Bagot KL, Bladin CF, Cadilhac DA. Is telemedicine helping or hindering the delivery of stroke thrombolysis in rural areas? A qualitative analysis. Intern Med J 2016; 45:957-64. [PMID: 25904209 DOI: 10.1111/imj.12793] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 04/15/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fast diagnosis and delivery of treatment to patients experiencing acute stroke can reduce subsequent disability. While telemedicine can improve rural community access to specialists and facilitate timely diagnosis and treatment decisions, it is not widely used for stroke in Australia. AIM Identifying the barriers and facilitators to clinician engagement with, and utilisation of, telemedicine consultations could expedite implementation in rural and remote locations. METHODS Purposive sampling was used to identify and recruit medical and nursing staff varying in telemedicine experience across one hospital department. Twenty-four in-depth, face-to-face interviews were conducted examining aspects surrounding stroke telemedicine uptake. Inductive qualitative thematic analysis was undertaken, and two further researchers verified coding. RESULTS The main barriers identified were contrasting opinions about the utility of thrombolysis for treating acute stroke, lack of confidence in the telemedicine system, perceived limited need for specialist advice and concerns about receiving advice from an unfamiliar doctor. Facilitators included assistance with diagnosis and treatment, the need for a user-friendly system and access to specialists for complex cases. CONCLUSIONS Acceptability of telemedicine for acute stroke was multifaceted and closely aligned with regional clinician beliefs about the value of thrombolysis for stroke, highlighting an important area for education. Addressing beliefs about treatment efficacy and other perceived barriers is important for establishing a stroke telemedicine programme.
Collapse
Affiliation(s)
- N Moloczij
- Medical and Cognitive Research Unit, Austin Health, Heidelberg, Victoria, Australia
| | - I Mosley
- National Trauma Research Institute, Alfred Health, Melbourne, Victoria, Australia
| | - K M Moss
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| | - K L Bagot
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| | - C F Bladin
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia.,Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - D A Cadilhac
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia.,Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
48
|
Bobb MR, Van Heukelom PG, Faine BA, Ahmed A, Messerly JT, Bell G, Harland KK, Simon C, Mohr NM. Telemedicine Provides Noninferior Research Informed Consent for Remote Study Enrollment: A Randomized Controlled Trial. Acad Emerg Med 2016; 23:759-65. [PMID: 26990899 DOI: 10.1111/acem.12966] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 02/09/2016] [Accepted: 03/10/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Telemedicine networks are beginning to provide an avenue for conducting emergency medicine research, but using telemedicine to recruit participants for clinical trials has not been validated. The goal of this consent study was to determine whether patient comprehension of telemedicine-enabled research informed consent is noninferior to standard face-to-face (F2F) research informed consent. METHODS A prospective, open-label randomized controlled trial was performed in a 60,000-visit Midwestern academic emergency department (ED) to test whether telemedicine-enabled research informed consent provided noninferior comprehension compared with standard consent. This study was conducted as part of a parent clinical trial evaluating the effectiveness of 0.12% oral chlorhexidine gluconate in preventing hospital-acquired pneumonia among adult ED patients with expected hospital admission. Prior to being recruited into the study, potential participants were randomized in a 1:1 allocation ratio to consent by telemedicine versus standard F2F consent. Telemedicine connectivity was provided using a commercially available interface (REACH platform, Vidyo Inc.) to an emergency physician located in another part of the ED. Comprehension of research consent (primary outcome) was measured using the modified quality of informed consent (QuIC) instrument, a validated tool for measuring research informed consent comprehension. Parent trial accrual rate and qualitative survey data were secondary outcomes. RESULTS A total of 131 patients were randomized (n = 64, telemedicine), and 101 QuIC surveys were completed. Comprehension of research informed consent using telemedicine was not inferior to F2F consent (QuIC scores 74.4 ± 8.1 vs. 74.4 ± 6.9 on a 100-point scale, p = 0.999). Subjective understanding of consent (p = 0.194) and parent trial study accrual rates (56% vs. 69%, p = 0.142) were similar. CONCLUSION Telemedicine is noninferior to F2F consent for delivering research informed consent, with no detected differences in comprehension and patient-reported understanding. This consent study will inform design of future telemedicine-enabled clinical trials.
Collapse
Affiliation(s)
- Morgan R. Bobb
- Department of Emergency Medicine; University of Iowa Carver College of Medicine; Iowa City IA
| | - Paul G. Van Heukelom
- Department of Emergency Medicine; University of Iowa Carver College of Medicine; Iowa City IA
| | - Brett A. Faine
- Department of Emergency Medicine; University of Iowa Carver College of Medicine; Iowa City IA
| | - Azeemuddin Ahmed
- Department of Emergency Medicine; University of Iowa Carver College of Medicine; Iowa City IA
| | - Jeffrey T. Messerly
- Department of Emergency Medicine; University of Iowa Carver College of Medicine; Iowa City IA
| | - Gregory Bell
- Department of Emergency Medicine; University of Iowa Carver College of Medicine; Iowa City IA
| | - Karisa K. Harland
- Department of Emergency Medicine; University of Iowa Carver College of Medicine; Iowa City IA
| | - Christian Simon
- Program in Bioethics and Humanities; Department of Internal Medicine; University of Iowa Carver College of Medicine; Iowa City IA
| | - Nicholas M. Mohr
- Department of Emergency Medicine; University of Iowa Carver College of Medicine; Iowa City IA
- Division of Critical Care; Department of Anesthesia; University of Iowa Carver College of Medicine; Iowa City IA
| |
Collapse
|
49
|
Leira EC, Stilley JD, Schnell T, Audebert HJ, Adams HP. Helicopter transportation in the era of thrombectomy: The next frontier for acute stroke treatment and research. Eur Stroke J 2016; 1:171-179. [PMID: 31008278 DOI: 10.1177/2396987316658994] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 06/18/2016] [Indexed: 11/15/2022] Open
Abstract
Purpose Many patients suffer a stroke at a significant distance from a specialized center capable of delivering endovascular therapy. As a result, they require rapid transport by helicopter emergency medical services, sometimes while receiving a recombinant tissue plasminogen activator infusion (drip and ship). Despite its critical role in the new era of reperfusion, helicopter emergency medical services remains a poorly evaluated aspect of stroke care. Method Comprehensive narrative review of all published articles of helicopter emergency medical services related to acute stroke care in the inter-hospital and pre-hospital settings, including technical aspects and physical environment implications. Findings Helicopter emergency medical services transports are conducted during a critical early time period when specific interventions and ancillary care practices may have a significant influence on outcomes. We have limited knowledge of the potential impact of the unusual physical factors generated by the helicopter on the ischemic brain, which affects our ability to establish rational guidelines for ancillary care and the delivery of specific interventions. Discussion Unlike the pre-hospital and hospital settings where stroke interventions are delivered, the inter-hospital helicopter emergency medical services transfer setting remains a "black box" for acute stroke care and research. This gap is particularly relevant for many patients living in rural areas, or in congested urban areas, that depend on helicopter emergency medical services for rapid access to a tertiary stroke center. Conclusion Addressing the helicopter emergency medical services stroke gap in clinical trials and acute care delivery would homogenize capabilities through all care settings, thus minimizing potential disparities in research access and outcomes based on geographical location.
Collapse
Affiliation(s)
- Enrique C Leira
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Joshua D Stilley
- Department of Emergency Medicine-AirCare, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Thomas Schnell
- Department of Mechanical and Industrial Engineering, College of Engineering, University of Iowa, Iowa City, IA, USA
| | - Heinrich J Audebert
- Center for Stroke Research, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Harold P Adams
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| |
Collapse
|
50
|
The association between rural residence and stroke care and outcomes. J Neurol Sci 2016; 363:16-20. [DOI: 10.1016/j.jns.2016.02.019] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 02/04/2016] [Accepted: 02/08/2016] [Indexed: 11/18/2022]
|