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Wen R, Wang M, Bian W, Zhu H, Xiao Y, Zeng J, He Q, Wang Y, Liu X, Shi Y, Hong Z, Xu B. Effectiveness of the acute stroke care map program in reducing in-hospital delay for acute ischemic stroke in a Chinese urban area: an interrupted time series analysis. Front Neurol 2024; 15:1364952. [PMID: 38699054 PMCID: PMC11063247 DOI: 10.3389/fneur.2024.1364952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 03/25/2024] [Indexed: 05/05/2024] Open
Abstract
Background Timely intravenous thrombolysis (IVT) is crucial for improving outcomes in acute ischemic stroke (AIS) patients. This study evaluates the effectiveness of the Acute Stroke Care Map (ASCaM) initiative in Shenyang, aimed at reducing door-to-needle times (DNT) and thus improving the timeliness of care for AIS patients. Methods An retrospective cohort study was conducted from April 2019 to December 2021 in 30 hospitals participating in the ASCaM initiative in Shenyang. The ASCaM bundle included strategies such as EMS prenotification, rapid stroke triage, on-call stroke neurologists, immediate neuroimaging interpretation, and the innovative Pre-hospital Emergency Call and Location Identification feature. An interrupted time series analysis (ITSA) was used to assess the impact of ASCaM on DNT, comparing 9 months pre-intervention with 24 months post-intervention. Results Data from 9,680 IVT-treated ischemic stroke patients were analyzed, including 2,401 in the pre-intervention phase and 7,279 post-intervention. The ITSA revealed a significant reduction in monthly DNT by -1.12 min and a level change of -5.727 min post-ASCaM implementation. Conclusion The ASCaM initiative significantly reduced in-hospital delays for AIS patients, demonstrating its effectiveness as a comprehensive stroke care improvement strategy in urban settings. These findings highlight the potential of coordinated care interventions to enhance timely access to reperfusion therapies and overall stroke prognosis.
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Affiliation(s)
- Rui Wen
- Shenyang Tenth People’s Hospital, Shenyang, China
| | - Miaoran Wang
- Affiliated Central Hospital of Shenyang Medical College, Shenyang Medical College, Shenyang, China
| | - Wei Bian
- Shenyang First People’s Hospital, Shenyang Medical College, Shenyang, China
| | - Haoyue Zhu
- Shenyang First People’s Hospital, Shenyang Medical College, Shenyang, China
| | - Ying Xiao
- Shenyang First People’s Hospital, Shenyang Medical College, Shenyang, China
| | - Jing Zeng
- ChongQing Medical University, ChongQing, China
| | - Qian He
- Shenyang Tenth People’s Hospital, Shenyang, China
| | - Yu Wang
- Shenyang Tenth People’s Hospital, Shenyang, China
| | - Xiaoqing Liu
- Shenyang Tenth People’s Hospital, Shenyang, China
| | - Yangdi Shi
- Shenyang Tenth People’s Hospital, Shenyang, China
| | - Zhe Hong
- Shenyang First People’s Hospital, Shenyang Medical College, Shenyang, China
| | - Bing Xu
- Shenyang Tenth People’s Hospital, Shenyang, China
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Buus SMØ, Behrndtz AB, Schmitz ML, Hedegaard JN, Cordsen P, Johnsen SP, Phan T, Andersen G, Simonsen CZ. Urban-rural inequalities in IV thrombolysis for acute ischemic stroke: A nationwide study. Eur Stroke J 2024:23969873241244591. [PMID: 38600682 DOI: 10.1177/23969873241244591] [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: 04/12/2024] Open
Abstract
INTRODUCTION Rural residency has been associated with lower reperfusion treatment rates for acute ischemic stroke in many countries. We aimed to explore urban-rural differences in IV thrombolysis rates in a small country with universal health care, and short transport times to stroke units. PATIENTS AND METHODS In this nationwide cohort study, adult ischemic stroke patients registered in the Danish Stroke Registry (DSR) between 2015 and 2020 were included. The exposure was defined by residence rurality. Data from the DSR, Statistics Denmark, and the Danish Health Data Authority, were linked on the individual level using the Civil Registration Number. Adjusted treatment rates were calculated by balancing baseline characteristics using inverse probability of treatment weights. RESULTS Among the included 56,175 patients, prehospital delays were shortest for patients residing in capital municipalities (median 4.7 h), and longest for large town residents (median 7.1 h). Large town residents were predominantly admitted directly to a comprehensive stroke center (98.5%), whereas 30.9% of capital residents were admitted to a hospital with no reperfusion therapy available (non-RT unit). Treatment rates were similar among all non-rural residents (18.5%-18.7%), but slightly lower among rural residents (17.2% [95% CI 16.5-17.8]). After adjusting for age, sex, immigrant status, and educational attainment, rural residents reached treatment rates comparable to capital and large town residents at 18.5% (95% CI 17.7-19.4). DISCUSSION AND CONCLUSION While treatment rates varied minimally by urban-rural residency, substantial differences in median prehospital delay and admission to non-RT units underscored marked urban-rural differences in potential obstacles to reperfusion therapies.
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Affiliation(s)
| | | | | | | | - Pia Cordsen
- Danish Center for Health Services Research, Aalborg University, Aalborg, Denmark
| | - Søren Paaske Johnsen
- Danish Center for Health Services Research, Aalborg University, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Thanh Phan
- Department of Medicine, School of Clinical Sciences at Monash health, Monash University, Melbourne, VIC, Australia
| | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Claus Ziegler Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Mullen MT. Location, Location, Location: Geographic Factors Drive Differential Receipt of Neurologist Evaluation After Stroke. Neurology 2024; 102:e209288. [PMID: 38484208 DOI: 10.1212/wnl.0000000000209288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/23/2024] [Indexed: 03/19/2024] Open
Affiliation(s)
- Michael T Mullen
- From the Lewis Katz School of Medicine at Temple University, Philadelphia, PA
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Hart S, Howard G, Cummings D, Albright KC, Reis P, Howard VJ. Differences in Receipt of Neurologist Evaluation During Hospitalization for Ischemic Stroke by Race, Sex, Age, and Region: The REGARDS Study. Neurology 2024; 102:e209200. [PMID: 38484277 DOI: 10.1212/wnl.0000000000209200] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/20/2023] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Improving access to health care providers with clinical expertise in stroke care may influence the use of recommended strategies for reducing disparities in quality of care. Few studies have examined differences in the receipt of evaluation by neurologists during the hospital stay. We examined the proportion of individuals hospitalized for acute ischemic stroke who received evaluation by a neurologist during the hospital stay and characterized differences in receipt of neurologist evaluation by race (Black vs White), sex, age, and study region (Stroke Belt residence vs other) among those experiencing a stroke who were participating in a national cohort study. METHODS This cross-sectional study was conducted using medical record data abstracted from 1,042 participants enrolled in the national Reasons for Geographic and Racial Differences in Stroke cohort study (2003-2007) who experienced an adjudicated ischemic stroke between 2003 and 2016. Participants with a history of stroke before baseline, in-hospital death, hospice discharge following their stroke, or incomplete records were excluded resulting in 839 cases. Differences were assessed using modified Poisson regression adjusting for participant-level and hospital-level factors. RESULTS Of the 839 incident strokes, 722 (86%) received evaluation by a neurologist during the hospital stay. There were no significant differences by age, race, or sex, yet Stroke Belt residents and those receiving care in rural hospitals were significantly less likely to receive neurologist evaluation compared with non-Stroke Belt residents (relative risk [RR] 0.95; 95% CI 0.90-1.01) and participants receiving care in urban hospitals (RR 0.74; 95% CI 0.63-0.86). Participants with a greater level of poststroke functional impairment (modified Rankin scale) and those with a greater number of risk factors were more likely to receive neurologist evaluation compared with those with lower levels of poststroke functional impairment (RR 1.04; 95% CI 1.01-1.06) and fewer risk factors (RR 1.02; 95% CI 1.00-1.04). DISCUSSION While differences in access to neurologists during the hospital stay were partially explained by patient need in our study, there were also significant differences in access by region and urban-rural hospital status. Ensuring access to neurologists during the hospital stay in such settings may require policy-level and/or system-level changes.
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Affiliation(s)
- Stephanie Hart
- From the School of Nursing (S.H.), and Duke Clinical and Translational Science Institute (S.H.), Duke University, Durham, NC; School of Public Health (G.H., V.J.H.), University of Alabama at Birmingham; Department of Public Health (D.C.), Brody School of Medicine, East Carolina University, Greenville, NC; Department of Neurology (K.C.A.), SUNY Upstate Medical University, Syracuse, NY; and College of Nursing (P.R.), East Carolina University, Greenville, NC
| | - George Howard
- From the School of Nursing (S.H.), and Duke Clinical and Translational Science Institute (S.H.), Duke University, Durham, NC; School of Public Health (G.H., V.J.H.), University of Alabama at Birmingham; Department of Public Health (D.C.), Brody School of Medicine, East Carolina University, Greenville, NC; Department of Neurology (K.C.A.), SUNY Upstate Medical University, Syracuse, NY; and College of Nursing (P.R.), East Carolina University, Greenville, NC
| | - Doyle Cummings
- From the School of Nursing (S.H.), and Duke Clinical and Translational Science Institute (S.H.), Duke University, Durham, NC; School of Public Health (G.H., V.J.H.), University of Alabama at Birmingham; Department of Public Health (D.C.), Brody School of Medicine, East Carolina University, Greenville, NC; Department of Neurology (K.C.A.), SUNY Upstate Medical University, Syracuse, NY; and College of Nursing (P.R.), East Carolina University, Greenville, NC
| | - Karen C Albright
- From the School of Nursing (S.H.), and Duke Clinical and Translational Science Institute (S.H.), Duke University, Durham, NC; School of Public Health (G.H., V.J.H.), University of Alabama at Birmingham; Department of Public Health (D.C.), Brody School of Medicine, East Carolina University, Greenville, NC; Department of Neurology (K.C.A.), SUNY Upstate Medical University, Syracuse, NY; and College of Nursing (P.R.), East Carolina University, Greenville, NC
| | - Pamela Reis
- From the School of Nursing (S.H.), and Duke Clinical and Translational Science Institute (S.H.), Duke University, Durham, NC; School of Public Health (G.H., V.J.H.), University of Alabama at Birmingham; Department of Public Health (D.C.), Brody School of Medicine, East Carolina University, Greenville, NC; Department of Neurology (K.C.A.), SUNY Upstate Medical University, Syracuse, NY; and College of Nursing (P.R.), East Carolina University, Greenville, NC
| | - Virginia J Howard
- From the School of Nursing (S.H.), and Duke Clinical and Translational Science Institute (S.H.), Duke University, Durham, NC; School of Public Health (G.H., V.J.H.), University of Alabama at Birmingham; Department of Public Health (D.C.), Brody School of Medicine, East Carolina University, Greenville, NC; Department of Neurology (K.C.A.), SUNY Upstate Medical University, Syracuse, NY; and College of Nursing (P.R.), East Carolina University, Greenville, NC
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Anderson TS, Herzig SJ, Marcantonio ER, Yeh RW, Souza J, Landon BE. Medicare Transitional Care Management Program and Changes in Timely Postdischarge Follow-Up. JAMA HEALTH FORUM 2024; 5:e240417. [PMID: 38607641 PMCID: PMC11065163 DOI: 10.1001/jamahealthforum.2024.0417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/13/2024] [Indexed: 04/13/2024] Open
Abstract
Importance In 2013, Medicare implemented payments for transitional care management (TCM) services, which provide increased reimbursement to clinicians providing ambulatory care to patients after discharge from medical facilities to the community. Objective To determine whether the introduction of TCM payments was associated with an increase in timely postdischarge follow-up. Design, Setting, and Participants This cross-sectional interrupted time-series study assessed quarterly postdischarge visit rates before (2010-2012) and after (2013-2019) TCM implementation 100% sample of Medicare fee-for-service beneficiaries discharged to the community after a hospital or skilled nursing facility stay. Data analyses were performed February 1 to December 15, 2023. Exposure Implementation of payments for TCM. Main Outcomes and Measures Timely postdischarge primary care follow-up, defined as receipt of a primary care ambulatory visit within 14 days of discharge. Secondary outcomes included receipt of a TCM visit and specialty care follow-up. Results The study sample comprised 79 125 965 eligible discharges. Of these, 55.4% were female; 1.5% were Asian, 12.1% Black, 5.6% Hispanic, and 79.0% were White individuals; and 79.6% were beneficiaries aged 65 years and older. Timely primary care follow-up increased from 31.5% in 2010 to 38.8% in 2019 (absolute increase 7.3%), whereas specialist follow-up increased from 27.6% to 30.8% (absolute increase 3.2%). By 2019, 11.3% of eligible patients received TCM services. Interrupted time-series analyses demonstrated an increased slope of timely primary care follow-up after the introduction of TCM services (pre-TCM slope, 0.12% per quarter vs post-TCM slope, 0.29% per quarter; difference, 0.13%; 95% CI, 0.02% to 0.22%). Receipt of timely follow-up increased for all demographic groups; however, Black, Hispanic, and Medicaid dual-eligible patients and patients residing in urban areas and counties with high-level social deprivation were less likely to receive follow-up during the study period. These disparities widened for Black patients (difference-in-differences in pre-TCM vs post-TCM slope, -0.14%; 95% CI, -0.25% to -0.2%) and patients who were Medicaid dual-eligible (difference-in-differences pre-TCM vs post-TCM slope, -0.21%; 95% CI, -0.35% to -0.07%). Conclusions These findings indicate that Medicare's introduction of payments for TCM services was associated with a persistent increase in the rate of timely postdischarge primary care but did not narrow demographic or socioeconomic disparities. Most beneficiaries did not receive timely primary care follow-up.
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Affiliation(s)
- Timothy S. Anderson
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shoshana J. Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Edward R. Marcantonio
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Robert W. Yeh
- Harvard Medical School, Boston, Massachusetts
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jeffrey Souza
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Bruce E. Landon
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Rasool A, Bailey M, Lue B, Omeaku N, Popoola A, Shantharam SS, Brown AA, Fulmer EB. Policy implementation strategies to address rural disparities in access to care for stroke patients. FRONTIERS IN HEALTH SERVICES 2023; 3:1280250. [PMID: 38130727 PMCID: PMC10733855 DOI: 10.3389/frhs.2023.1280250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/07/2023] [Indexed: 12/23/2023]
Abstract
Context Stroke systems of care (SSOC) promote access to stroke prevention, treatment, and rehabilitation and ensure patients receive evidence-based treatment. Stroke patients living in rural areas have disproportionately less access to emergency medical services (EMS). In the United States, rural counties have a 30% higher stroke mortality rate compared to urban counties. Many states have SSOC laws supported by evidence; however, there are knowledge gaps in how states implement these state laws to strengthen SSOC. Objective This study identifies strategies and potential challenges to implementing state policy interventions that require or encourage evidence-supported pre-hospital interventions for stroke pre-notification, triage and transport, and inter-facility transfer of patients to the most appropriate stroke facility. Design Researchers interviewed representatives engaged in implementing SSOC across six states. Informants (n = 34) included state public health agency staff and other public health and clinical practitioners. Outcomes This study examined implementation of pre-hospital SSOCs policies in terms of (1) development roles, processes, facilitators, and barriers; (2) implementation partners, challenges, and solutions; (3) EMS system structure, protocols, communication, and supervision; and (4) program improvement, outcomes, and sustainability. Results Challenges included unequal resource allocation and EMS and hospital services coverage, particularly in rural settings, lack of stroke registry usage, insufficient technologies, inconsistent use of standardized tools and protocols, collaboration gaps across SSOC, and lack of EMS stroke training. Strategies included addressing scarce resources, services, and facilities; disseminating, training on, and implementing standardized statewide SSOC protocols and tools; and utilizing SSOC quality and performance improvement systems and approaches. Conclusions This paper identifies several strategies that can be incorporated to enhance the implementation of evidence-based stroke policies to improve access to timely stroke care for all patient populations, particularly those experiencing disparities in rural communities.
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Affiliation(s)
- Aysha Rasool
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
- Oak Ridge Institute for Science and Education, Oak Ridge, TN, United States
| | - Moriah Bailey
- Applied Science, Research and Technology, Inc., Atlanta, GA, United States
| | - Brittany Lue
- Chenega Corporation, Anchorage, AK, United States
| | - Nina Omeaku
- Applied Science, Research and Technology, Inc., Atlanta, GA, United States
| | - Adebola Popoola
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Sharada S. Shantharam
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Amanda A. Brown
- Applied Science, Research and Technology, Inc., Atlanta, GA, United States
| | - Erika B. Fulmer
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
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Pierce JB, Ikeaba U, Peters AE, DeVore AD, Chiswell K, Allen LA, Albert NM, Yancy CW, Fonarow GC, Greene SJ. Quality of Care and Outcomes Among Patients Hospitalized for Heart Failure in Rural vs Urban US Hospitals: The Get With The Guidelines-Heart Failure Registry. JAMA Cardiol 2023; 8:376-385. [PMID: 36806447 PMCID: PMC9941973 DOI: 10.1001/jamacardio.2023.0241] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/30/2023] [Indexed: 02/22/2023]
Abstract
Importance Prior studies have suggested patients with heart failure (HF) from rural areas have worse clinical outcomes. Contemporary differences between rural and urban hospitals in quality of care and clinical outcomes for patients hospitalized for HF remain poorly understood. Objective To assess quality of care and clinical outcomes for US patients hospitalized for HF at rural vs urban hospitals. Design, Setting, and Participants This retrospective cohort study analyzed 774 419 patients hospitalized for HF across 569 sites in the Get With The Guidelines-Heart Failure (GWTG-HF) registry between January 1, 2014, and September 30, 2021. Postdischarge outcomes were assessed in a subset of 161 996 patients linked to Medicare claims. Data were analyzed from August 2022 to January 2023. Main Outcomes and Measures GWTG-HF quality measures, in-hospital mortality, length of stay, and 30-day mortality and readmission outcomes. Results This study included 19 832 patients (2.6%) and 754 587 patients (97.4%) hospitalized at 49 rural hospitals (8.6%) and 520 urban hospitals (91.4%), respectively. Of 774 419 included patients, 366 161 (47.3%) were female, and the median (IQR) age was 73 (62-83) years. Compared with patients at urban hospitals, patients at rural hospitals were older (median [IQR] age, 74 [64-84] years vs 73 [61-83] years; standardized difference, 10.63) and more likely to be non-Hispanic White (14 572 [73.5%] vs 498 950 [66.1%]; standardized difference, 34.47). In adjusted models, patients at rural hospitals were less likely to be prescribed cardiac resynchronization therapy (adjusted risk difference [aRD], -13.5%; adjusted odds ratio [aOR], 0.44; 95% CI, 0.22-0.92), angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (aRD, -3.7%; aOR, 0.71; 95% CI, 0.53-0.96), and an angiotensin receptor-neprilysin inhibitor (aRD, -5.0%; aOR, 0.68; 95% CI, 0.47-0.98) at discharge. In-hospital mortality was similar between rural and urban hospitals (460 of 19 832 [2.3%] vs 20 529 of 754 587 [2.7%]; aOR, 0.86; 95% CI, 0.70-1.07). Patients at rural hospitals were less likely to have a length of stay of 4 or more days (aOR, 0.75; 95% CI, 0.67-0.85). Among Medicare beneficiaries, there were no significant differences between rural and urban hospitals in 30-day HF readmission (adjusted hazard ratio [aHR], 1.03; 95% CI, 0.90-1.19), all-cause readmission (aHR, 0.97; 95% CI, 0.91-1.04), and all-cause mortality (aHR, 1.05; 95% CI, 0.91-1.21). Conclusions and Relevance In this large contemporary cohort of US patients hospitalized for HF, care at rural hospitals was independently associated with lower use of some guideline-recommended therapies at discharge and shorter length of stay. In-hospital mortality and 30-day postdischarge outcomes were similar at rural and urban hospitals.
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Affiliation(s)
- Jacob B. Pierce
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Anthony E. Peters
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Adam D. DeVore
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Karen Chiswell
- Duke Clinical Research Institute, Durham, North Carolina
| | - Larry A. Allen
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
| | - Nancy M. Albert
- Nursing Institute and Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Clyde W. Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Deputy Editor, JAMA Cardiology
| | - Gregg C. Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles
- Associate Editor for Health Care Quality and Guidelines, JAMA Cardiology
| | - Stephen J. Greene
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
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Amin HP, Madsen TE, Bravata DM, Wira CR, Johnston SC, Ashcraft S, Burrus TM, Panagos PD, Wintermark M, Esenwa C. Diagnosis, Workup, Risk Reduction of Transient Ischemic Attack in the Emergency Department Setting: A Scientific Statement From the American Heart Association. Stroke 2023; 54:e109-e121. [PMID: 36655570 DOI: 10.1161/str.0000000000000418] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
At least 240 000 individuals experience a transient ischemic attack each year in the United States. Transient ischemic attack is a strong predictor of subsequent stroke. The 90-day stroke risk after transient ischemic attack can be as high as 17.8%, with almost half occurring within 2 days of the index event. Diagnosing transient ischemic attack can also be challenging given the transitory nature of symptoms, often reassuring neurological examination at the time of evaluation, and lack of confirmatory testing. Limited resources, such as imaging availability and access to specialists, can further exacerbate this challenge. This scientific statement focuses on the correct clinical diagnosis, risk assessment, and management decisions of patients with suspected transient ischemic attack. Identification of high-risk patients can be achieved through use of comprehensive protocols incorporating acute phase imaging of both the brain and cerebral vasculature, thoughtful use of risk stratification scales, and ancillary testing with the ultimate goal of determining who can be safely discharged home from the emergency department versus admitted to the hospital. We discuss various methods for rapid yet comprehensive evaluations, keeping resource-limited sites in mind. In addition, we discuss strategies for secondary prevention of future cerebrovascular events using maximal medical therapy and patient education.
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Shimamura N, Katagai T, Ohkuma H, Fujiwara N, Nakahara I, Morioka J, Kawamata T, Ishikawa T, Kurita H, Suzuki K, Chin M, Uezato M, Sorimachi T, Shiokawa Y, Murayama Y, Ueba T, Ikawa F. Analysis of Factors Influencing Delayed Presentation in Japanese Patients with Subarachnoid Hemorrhage. World Neurosurg 2023; 171:e590-e595. [PMID: 36529428 DOI: 10.1016/j.wneu.2022.12.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 12/10/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Some aneurysmal subarachnoid hemorrhage (SAH) patients are delayed in their presentation. This can cause a washout of the subarachnoid hematoma and a potential misdiagnosis. As a result, they may suffer rerupture of the aneurysm and preventable deterioration. We investigated the factors that influence delayed SAH presentation. METHODS Aneurysmal SAH patients treated at 9 stroke centers from 2002 to 2020 were included. Age, gender, pre-SAH modified Rankin scale, World Federation of Neurological Surgeons grade, Fisher group, day of presentation, aneurysm treatment method, past history of cerebral stroke, comorbidity of hypertension and/or diabetes mellitus, and modified Rankin scaleat discharge were assessed retrospectively. We formed 2 groups based on the day of presentation after the onset of SAH: day 0-3 (early) and other (delayed). Logistic regression analyses detected the factors that influenced the day of presentation and outcome for SAH. A P- value <0.05 was considered significant. RESULTS Delayed presentation comprised 282 cases (6.3%) of 4507 included cases. Logistic regression analyses showed that patients in an urban area, of male gender, low WFNS grade and low Fisher group correlated significantly with a delayed presentation. But delayed presentation did not influence outcome at discharge. CONCLUSIONS Area of residency and gender correlated with delayed presentation after SAH in Japan. Urbanization, male gender, and mild SAH lead patients to delay presentation. The factors underlying these tendencies will be analyzed in a future prospective study.
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Affiliation(s)
- Norihito Shimamura
- Department of Neurosurgery, Hirosaki General Medical Center, Aomori, Japan; Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Aomori, Japan.
| | - Takeshi Katagai
- Department of Neurosurgery, Hirosaki General Medical Center, Aomori, Japan; Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Hiroki Ohkuma
- Department of Neurosurgery, Hirosaki General Medical Center, Aomori, Japan
| | - Nozomi Fujiwara
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Ichiro Nakahara
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, Aichi, Japan
| | - Jun Morioka
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, Aichi, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Tatsuya Ishikawa
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Hiroki Kurita
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Saitama, Japan
| | - Kaima Suzuki
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Saitama, Japan
| | - Masaki Chin
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | - Minami Uezato
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | | | - Yoshiaki Shiokawa
- Department of Neurosurgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Tetsuya Ueba
- Department of Neurosurgery, Kochi Medical School, Kochi University, Kochi, Japan
| | - Fusao Ikawa
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Shimane, Japan
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Erdur H, Weber JE, Angermaier A, Kinze S, Sotoodeh A, Gorski C, Bollweg K, Ernst S, Kandil FI, Behrens J, Ganeshan R, Keysers A, Kotlarz-Böttcher M, Peters D, Schlemm L, Stangenberg-Gliss K, Witt C, Hennig B, Reber KC, Schneider U, Franke C, Schmehl I, Straub HB, Flöel A, Theen S, Endres M, Kurth T, Audebert HJ. A Managed Care System with Telemedicine Support for Neurological Emergencies. Ann Neurol 2023; 93:511-521. [PMID: 36401341 DOI: 10.1002/ana.26556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 11/15/2022] [Accepted: 11/17/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Telemedicine is frequently used to provide remote neurological expertise for acute stroke workup and was associated with better functional outcomes when combined with a stroke unit system-of-care. We investigated whether such system-of-care yields additional benefits when implemented on top of neurological competence already available onsite. METHODS Quality improvement measures were implemented within a "hub-and-spoke" teleneurology network in 11 hospitals already provided with onsite or telestroke expertise. Measures included dedicated units for neurological emergencies, standardization of procedures, multiprofessional training, and quality-of-care monitoring. Intervention effects were investigated in a controlled study enrolling patients insured at 3 participating statutory health insurances diagnosed with acute stroke or other neurological emergencies. Outcomes during the intervention period between November 2017 and February 2020 were compared with those pre-intervention between October 2014 and March 2017. To control for temporal trends, we compared outcomes of patients with respective diagnoses in 11 hospitals of the same region. Primary outcome was the composite of up-to-90-day death, new disability with the need of ambulatory or nursing home care, expressed by adjusted hazard ratio (aHR). RESULTS We included 1,418 patients post-implementation (55% female, mean age 76.7 ± 12.8 year) and 2,306 patients pre-implementation (56%, 75.8 ± 13.0 year, respectively). The primary outcome occurred in 479/1,418 (33.8%) patients post-implementation and in 829/2,306 (35.9%) pre-implementation. The aHR for the primary outcome was 0.89 (95% confidence interval [CI]: 0.79-0.99, p = 0.04) with no improvement seen in non-participating hospitals between post- versus pre-implementation periods (aHR 1.04; 95% CI: 0.95-1.15). INTERPRETATION Implementation of a multicomponent system-of-care was associated with a lower risk of poor outcomes. ANN NEUROL 2023;93:511-521.
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Affiliation(s)
- Hebun Erdur
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik für Neurologie, Berlin, Germany.,Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Joachim E Weber
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik für Neurologie, Berlin, Germany.,Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Berlin, Germany.,Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Anselm Angermaier
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Stephan Kinze
- Unfallkrankenhaus Berlin, Klinik für Neurologie, Berlin, Germany
| | - Ali Sotoodeh
- Epilepsiezentrum Berlin-Brandenburg, Epilepsieklinik Tabor, Bernau bei Berlin, Germany
| | - Claudia Gorski
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik für Neurologie, Berlin, Germany.,Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Public Health, Berlin, Germany
| | - Kerstin Bollweg
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik für Neurologie, Berlin, Germany
| | - Stefanie Ernst
- Department of Biostatistics, Parexel International GmbH, Berlin, Germany
| | - Farid I Kandil
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Public Health, Berlin, Germany.,Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute for Biometry and Clinical Epidemiology, Berlin, Germany
| | - Janina Behrens
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik für Neurologie, Berlin, Germany
| | - Ramanan Ganeshan
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik für Neurologie, Berlin, Germany
| | - Anne Keysers
- Unfallkrankenhaus Berlin, Klinik für Neurologie, Berlin, Germany
| | | | - Daniel Peters
- Unfallkrankenhaus Berlin, Klinik für Neurologie, Berlin, Germany
| | - Ludwig Schlemm
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik für Neurologie, Berlin, Germany.,Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | | | - Carl Witt
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | | | | | | | - Christiana Franke
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik für Neurologie, Berlin, Germany
| | - Ingo Schmehl
- Unfallkrankenhaus Berlin, Klinik für Neurologie, Berlin, Germany
| | - Hans-Beatus Straub
- Epilepsiezentrum Berlin-Brandenburg, Epilepsieklinik Tabor, Bernau bei Berlin, Germany
| | - Agnes Flöel
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany.,German Center for Neurodegenerative Diseases, partner site, Rostock, Germany
| | - Sarah Theen
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Public Health, Berlin, Germany
| | - Matthias Endres
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik für Neurologie, Berlin, Germany.,Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Berlin, Germany.,Excellence Cluster NeuroCure, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Tobias Kurth
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Public Health, Berlin, Germany
| | - Heinrich J Audebert
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik für Neurologie, Berlin, Germany.,Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Berlin, Germany
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11
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Nakamoto CH, Wilcock AD, Schwamm LH, Majersik JJ, Zachrison KS, Mehrotra A. Trends in characteristics of neurologists who provide stroke consultations in the USA, 2008-2021. Stroke Vasc Neurol 2023; 8:86-88. [PMID: 35902139 PMCID: PMC9985800 DOI: 10.1136/svn-2022-001662] [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: 04/26/2022] [Accepted: 07/09/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Patients with acute ischaemic strokes (AIS), on average, fare better with timely neurologist consultation, and a growing proportion of them receive one. However, little is known about trends in the characteristics of neurologists who treat AIS. METHODS We identified AIS and transient ischaemic attack (TIA) episodes with neurologist consults in fee-for-service Medicare from January 2008 to September 2021. For each episode, we determined whether the neurologist was a vascular neurologist, was a high-volume provider, whether the patient was transferred between hospitals and the distance between the patient's home and physician's practice. RESULTS From 2008 to 2021, the share of AIS/TIA episodes (n=5 073 294) with neurologist consults increased (52.9% to 61.7%). Among episodes with consults, the fraction conducted by a vascular neurologist (5.2% to 13.7%) or by a high-volume neurologist (13.2% to 14.9%) also increased. The fraction with the patient's home and neurologist greater than 100 miles apart (4.8% to 9.6%) or in different states (5.1% to 8.1%) increased, as did the fraction with transfers (4.2% to 8.5%). DISCUSSION Over the study period, the proportion of AIS/TIA episodes with consultations from neurologists with either vascular neurology certifications or high volumes increased substantially.
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Affiliation(s)
- Carter H Nakamoto
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew D Wilcock
- Department of Family Medicine, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA .,Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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12
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Wang Q, Han B, Man X, Gu H, Sun J. Chuanzhitongluo regulates microglia polarization and inflammatory response in acute ischemic stroke. Brain Res Bull 2022; 190:97-104. [PMID: 36152772 DOI: 10.1016/j.brainresbull.2022.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/06/2022] [Accepted: 09/19/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND PURPOSE Chuanzhitongluo (CZTL), a traditional Chinese medicine mixture, is used in the recovery period of acute ischemic stroke (AIS), and effectively improves the prognosis of AIS patients. This study aims to evaluate whether CZTL regulates microglia polarization and inflammatory response to reduce brain damage in the acute phase of AIS. METHODS A mouse model of AIS was prepared by the photochemical method. Cerebral infarct volume was detected by 2,3,5-Triphenyltetrazolium chloride (TTC) staining. Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay was used to assess neuronal apoptosis. Gene expression profile change was explored by Gene chip. Inflammatory factors were analyzed by Protein microarray. The Immunofluorescence double-labeling assay was executed to elucidate the effects of CD16+ / Iba-1+ and CD206+ / Iba-1+ in the peripheral area of cerebral ischemia. RESULTS Results revealed that CZTL treatment alleviated the neurological impairment, reduced cerebral infarct volume, and inhibited neuronal apoptosis. CZTL altered gene expression profiles, which indicate that CZTL may be involved in regulating neuroinflammation. CZTL restrained inflammatory responses by down-regulated pro-inflammatory cytokines expression and enhanced anti-inflammatory cytokines level. Further experiments demonstrated that CZTL inhibited the activation of NLRP3 inflammasome, which decreasing the inflammatory response. In addition, CZTL promoted the transformation of microglia from M1 to M2 phenotype. CONCLUSIONS These results indicate that CZTL alleviates neuroinflammation and brain damage after AIS in mice, which may be mediated by modulating microglia polarization.
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Affiliation(s)
- Qingqing Wang
- Department of Neurology, the Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Bin Han
- Department of Neurology, the Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Xu Man
- Department of Integrated Medicine, the Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Huali Gu
- Department of Emergency Internal Medicine, the Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Jinping Sun
- Department of Neurology, the Affiliated Hospital of Qingdao University, Qingdao 266000, China; Department of Emergency Medicine, the Affiliated Hospital of Qingdao University, Qingdao 266000, China.
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13
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Zachrison KS, Ganti L, Sharma D, Goyal P, Decker‐Palmer M, Adeoye O, Goldstein JN, Jauch EC, Lo BM, Madsen TE, Meurer W, Oostema JA, Mendez‐Hernandez C, Venkatesh AK. A survey of stroke-related capabilities among a sample of US community emergency departments. J Am Coll Emerg Physicians Open 2022; 3:e12762. [PMID: 35898236 PMCID: PMC9307290 DOI: 10.1002/emp2.12762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/20/2022] [Accepted: 02/09/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives Most acute stroke research is conducted at academic and larger hospitals, which may differ from many non-academic (ie, community) and smaller hospitals with respect to resources and consultant availability. We describe current emergency department (ED) and hospital-level stroke-related capabilities among a sample of community EDs participating in the Emergency Quality Network (E-QUAL) stroke collaborative. Methods Among E-QUAL-participating EDs, we conducted a survey to collect data on ED and hospital stroke-related structural and process capabilities associated with quality of stroke care delivery and patient outcomes. EDs submitted data using a web-based submission portal. We present descriptive statistics of self-reported capabilities. Results Of 154 participating EDs in 30 states, 97 (63%) completed the survey. Many were rural (33%); most (82%) were not certified stroke centers. Although most reported having stroke protocols (67%), many did not include hemorrhagic stroke or transient ischemic attack (45% and 57%, respectively). Capability to perform emergent head computed tomography and to administer thrombolysis were not universal (absent in 4% and 5%, respectively). Access to neurologic consultants varied; 18% reported no 24/7 availability onsite or remotely. Of those with access, 48% reported access through telemedicine only. Admission capabilities also varied with patient transfer commonly performed (79%). Conclusion Stroke-related capabilities vary substantially between community EDs and are different from capabilities typically found in larger stroke centers. These data may be valuable for identifying areas for future investment. Additionally, the design of stroke quality improvement interventions and metrics to evaluate emergency stroke care delivery should account for these key structural differences.
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Affiliation(s)
- Kori S. Zachrison
- Department of Emergency MedicineMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Latha Ganti
- Department of Emergency MedicineUniversity of Central FloridaOrlandoFloridaUSA
| | - Dhruv Sharma
- American College of Emergency PhysiciansIrvingTexasUSA
| | - Pawan Goyal
- American College of Emergency PhysiciansIrvingTexasUSA
| | | | - Opeolu Adeoye
- Department of Emergency MedicineWashington UniversitySt. LouisMissouriUSA
| | - Joshua N. Goldstein
- Department of Emergency MedicineMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | | | - Bruce M. Lo
- Department of Emergency MedicineEastern Virginia Medical School/Sentara Norfolk General HospitalNorfolkVirginiaUSA
| | - Tracy E. Madsen
- Department of Emergency MedicineWarren Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - William Meurer
- Department of Emergency MedicineUniversity of Michigan School of MedicineAnn ArborMichiganUSA
| | - John A. Oostema
- Department of Emergency MedicineMichigan State UniversityEast LansingMichiganUSA
| | | | - Arjun K. Venkatesh
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
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14
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Hammond G, Waken RJ, Johnson DY, Towfighi A, Joynt Maddox KE. Racial Inequities Across Rural Strata in Acute Stroke Care and In-Hospital Mortality: National Trends Over 6 Years. Stroke 2022; 53:1711-1719. [PMID: 35172607 PMCID: PMC9324215 DOI: 10.1161/strokeaha.121.035006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 11/19/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are glaring racial and rural-urban inequities in stroke outcomes. The objective of this study was to determine whether there were recent changes to trends in racial inequities in stroke treatment and in-hospital mortality, and whether racial inequities differed across rural strata. METHODS Retrospective analysis of Black and White patients >18 years old admitted to US acute care hospitals with a primary discharge diagnosis of stroke (unweighted N=652 836) from the National Inpatient Sample from 2012 to 2017. Rural residence was classified by county as urban, town, or rural. The primary outcomes were intravenous thrombolysis and endovascular therapy use among patients with acute ischemic stroke, and in-hospital mortality for all stroke patients. Logistic regression models were run for each outcome adjusting for age, comorbidities, primary payer, and ZIP code median income. RESULTS The sample was 53% female, 81% White, and 19% Black. Black patients from rural areas had the lowest odds of receiving intravenous thrombolysis (adjusted odds ratio [aOR], 0.43 [95% CI, 0.37-0.50]) and endovascular therapy (aOR, 0.60 [0.46-0.78]), compared with White urban patients. Black rural patients were the least likely to be discharged home after a stroke compared with White/urban patients (aOR, 0.79 [0.75-0.83]), this was true for Black patients across the urban-rural spectrum when compared with Whites. Black patients from urban areas had lower mortality than White patients from urban areas (aOR, 0.87 [0.84-0.91]), while White patients from rural areas (aOR, 1.14 [1.10-1.19]) had the highest mortality of all groups. CONCLUSIONS Black patients living in rural areas represent a particularly high-risk group for poor access to advanced stroke care and impaired poststroke functional status. Rural White patients have the highest in-hospital mortality. Clinical and policy interventions are needed to improve access and reduce inequities in stroke care and outcomes.
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Affiliation(s)
- Gmerice Hammond
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
| | - RJ Waken
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
| | - Daniel Y. Johnson
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
| | - Amytis Towfighi
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Karen E. Joynt Maddox
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
- Center for Health Economics and Policy, Institute for Public Health at Washington University, St. Louis, MO
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15
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Zachrison KS, Samuels‐Kalow ME, Li S, Yan Z, Reeves MJ, Hsia RY, Schwamm LH, Camargo CA. The relationship between stroke system organization and disparities in access to stroke center care in California. J Am Coll Emerg Physicians Open 2022; 3:e12706. [PMID: 35316966 PMCID: PMC8921441 DOI: 10.1002/emp2.12706] [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: 10/20/2021] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 11/08/2022] Open
Abstract
Background There are significant racial and ethnic disparities in receipt of reperfusion interventions for acute ischemic stroke. Our objective was to determine whether there are disparities in access to stroke center care by race or ethnicity that help explain differences in reperfusion therapy and to understand whether interhospital patient transfer plays a role in improving access. Methods Using statewide administrating data including all emergency department and hospital discharges in California from 2010 to 2017, we identified all acute ischemic stroke patients. Primary outcomes of interest included presentation to primary or comprehensive stroke center (PSC or CSC), interhospital transfer, discharge from PSC or CSC, and discharge from CSC alone. We used hierarchical logistic regression modeling to identify the relationship between patient‐ and hospital‐level characteristics and outcomes of interest. Results Of 336,247 ischemic stroke patients, 55.4% were non‐Hispanic White, 19.6% Hispanic, 10.6% non‐Hispanic Asian/Pacific Islander, and 10.3% non‐Hispanic Black. There was no difference in initial presentation to stroke center hospitals between groups. However, adjusted odds of reperfusion intervention, interhospital transfer and discharge from CSC did vary by race and ethnicity. Adjusted odds of interhospital transfer were lower among Hispanic (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.89 to 0.98) and non‐Hispanic Asian/Pacific Islander patients (OR 0.84, 95% CI 0.79 to 0.90) and odds of discharge from a CSC were lower for Hispanic (OR 0.91, 95% CI 0.85 to 0.97) and non‐Hispanic Black patients (OR 0.74, 95% CI 0.67 to 0.81). Conclusions There are racial and ethnic disparities in reperfusion intervention receipt among stroke patients in California. Stroke system of care design, hospital resources, and transfer patterns may contribute to this disparity.
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Affiliation(s)
- Kori S. Zachrison
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
| | | | - Sijia Li
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
| | - Zhiyu Yan
- Department of Neurology Massachusetts General Hospital Boston Massachusetts USA
| | - Mathew J. Reeves
- Department of Epidemiology and Biostatistics Michigan State University East Lansing Michigan USA
| | - Renee Y. Hsia
- Department of Emergency Medicine University of California San Francisco San Francisco California USA
- Philip R. Lee Institute for Health Policy Studies University of California San Francisco San Francisco California USA
| | - Lee H. Schwamm
- Department of Neurology Massachusetts General Hospital Boston Massachusetts USA
| | - Carlos A. Camargo
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
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16
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Chen J, Lin X, Cai Y, Huang R, Yang S, Zhang G. A Systematic Review of Mobile Stroke Unit Among Acute Stroke Patients: Time Metrics, Adverse Events, Functional Result and Cost-Effectiveness. Front Neurol 2022; 13:803162. [PMID: 35356455 PMCID: PMC8959845 DOI: 10.3389/fneur.2022.803162] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/28/2022] [Indexed: 12/23/2022] Open
Abstract
BackgroundMobile stroke unit (MSU) is deployed to shorten the duration of ischemic stroke recognition to thrombolysis treatment, thus reducing disability, mortality after an acute stroke attack, and related economic burden. Therefore, we conducted a comprehensive systematic review of the clinical trial and economic literature focusing on various outcomes of MSU compared with conventional emergency medical services (EMS).MethodsAn electronic search was conducted in four databases (PubMed, OVID Medline, Embase, and the Cochrane Controlled Register of Trials) from 1990 to 2021. In these trials, patients with acute stroke were assigned to receive either MSU or EMS, with clinical and economic outcomes. First, we extracted interested data in the pooled population and conducted a subgroup analysis to examine related heterogeneity. We then implemented a descriptive analysis of economic outcomes. All analyses were performed with R 4.0.1 software.ResultsA total of 22,766 patients from 16 publications were included. In total 7,682 (n = 33.8%) were treated in the MSU and 15,084 (n = 66.2%) in the conventional EMS. Economic analysis were available in four studies, of which two were based on trial data and the others on model simulations. The pooled analysis of time metrics indicated a mean reduction of 32.64 min (95% confidence interval: 23.38–41.89, p < 0.01) and 28.26 minutes (95% CI: 16.11–40.41, p < 0.01) in the time-to-therapy and time-to-CT completion, respectively in the MSU. However, there was no significant difference on stroke-related neurological events (OR = 0.94, 95% CI: 0.70–1.27, p = 0.69) and in-hospital mortality (OR = 1.11, 95% CI: 0.83–1.50, p = 0.48) between the MSU and EMS. The proportion of patients with modified Ranking scale (mRS) of 0–2 at 90 days from onset was higher in the MSU than EMS (p < 0.05). MSU displayed favorable benefit-cost ratios (2.16–6.85) and incremental cost-effectiveness ratio ($31,911 /QALY and $38,731 per DALY) comparing to EMS in multiple economic publications. Total cost data based on 2014 USD showed that the MSU has the highest cost in Australia ($1,410,708) and the lowest cost in the USA ($783,463).ConclusionA comprehensive analysis of current research suggests that MUS, compared with conventional EMS, has a better performance in terms of time metrics, safety, long-term medical benefits, and cost-effectiveness.
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Affiliation(s)
- Jieyun Chen
- Quanzhou First Hospital, Fujian Medical University, Fujian, China
- *Correspondence: Jieyun Chen
| | - Xiaoying Lin
- Quanzhou First Hospital, Fujian Medical University, Fujian, China
| | - Yali Cai
- Quanzhou First Hospital, Fujian Medical University, Fujian, China
| | - Risheng Huang
- Quanzhou First Hospital, Fujian Medical University, Fujian, China
| | - Songyu Yang
- Department of Radiology, Affiliated Hospital of Zunyi Medical University, Guizhou, China
| | - Gaofeng Zhang
- Department of Radiology, Affiliated Hospital of Zunyi Medical University, Guizhou, China
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17
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Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (K.S.Z.)
| | - Danielle Cross
- Division of Neurology, Penn Medicine Lancaster General Health, Lancaster, PA (D.C.)
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18
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Loccoh EC, Maddox KEJ, Wang Y, Kazi DS, Yeh RW, Wadhera RK. Rural-Urban Disparities in Outcomes of Myocardial Infarction, Heart Failure, and Stroke in the United States. J Am Coll Cardiol 2022; 79:267-279. [PMID: 35057913 PMCID: PMC8958031 DOI: 10.1016/j.jacc.2021.10.045] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 10/22/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND U.S. policy efforts have focused on reducing rural-urban health inequities. However, it is unclear whether gaps in care and outcomes remain among older adults with acute cardiovascular conditions. OBJECTIVES This study aims to evaluate rural-urban differences in procedural care and mortality for acute myocardial infarction (AMI), heart failure (HF), and ischemic stroke. METHODS This is a retrospective cross-sectional study of Medicare fee-for-service beneficiaries aged ≥65 years with acute cardiovascular conditions from 2016 to 2018. Cox proportional hazards models with random hospital intercepts were fit to examine the association of presenting to a rural (vs urban) hospital and 30- and 90-day patient-level mortality. RESULTS There were 2,182,903 Medicare patients hospitalized with AMI, HF, or ischemic stroke from 2016 to 2018. Patients with AMI were less likely to undergo cardiac catherization (49.7% vs 63.6%, P < 0.001), percutaneous coronary intervention (42.1% vs 45.7%, P < 0.001) or coronary artery bypass graft (9.0% vs 10.2%, P < 0.001) within 30 days at rural versus urban hospitals. Thrombolysis rates (3.1% vs 10.1%, P < 0.001) and endovascular therapy (1.8% vs 3.6%, P < 0.001) for ischemic stroke were lower at rural hospitals. After adjustment for demographics and clinical comorbidities, the 30-day mortality HR was significantly higher among patients presenting to rural hospitals for AMI (HR: 1.10, 95% CI: 1.08 to 1.12), HF (HR: 1.15; 95% CI: 1.13 to 1.16), and ischemic stroke (HR: 1.20; 95% CI: 1.18 to 1.22), with similar patterns at 90 days. These differences were most pronounced for the subset of critical access hospitals that serve remote, rural areas. CONCLUSIONS Clinical, public health, and policy efforts are needed to improve rural-urban gaps in care and outcomes for acute cardiovascular conditions.
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Affiliation(s)
- Eméfah C. Loccoh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA,Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | | | - Yun Wang
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA
| | - Dhruv S. Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA
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de Havenon A, Sheth K, Johnston KC, Delic A, Stulberg E, Majersik J, Anadani M, Yaghi S, Tirschwell D, Ney J. Acute Ischemic Stroke Interventions in the United States and Racial, Socioeconomic, and Geographic Disparities. Neurology 2021; 97:e2292-e2303. [PMID: 34649872 PMCID: PMC8665433 DOI: 10.1212/wnl.0000000000012943] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/27/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In patients with ischemic stroke (IS), IV alteplase (tissue plasminogen activator [tPA]) and endovascular thrombectomy (EVT) reduce long-term disability, but their utilization has not been fully optimized. Prior research has also demonstrated disparities in the use of tPA and EVT specific to sex, race/ethnicity, socioeconomic status, and geographic location. We sought to determine the utilization of tPA and EVT in the United States from 2016-2018 and if disparities in utilization persist. METHODS This is a retrospective, longitudinal analysis of the 2016-2018 National Inpatient Sample. We included adult patients who had a primary discharge diagnosis of IS. The primary study outcomes were the proportions who received tPA or EVT. We fit a multivariate logistic regression model to our outcomes in the full cohort and also in the subset of patients who had an available baseline National Institutes of Health Stroke Scale (NIHSS) score. RESULTS The full cohort after weighting included 1,439,295 patients with IS. The proportion who received tPA increased from 8.8% in 2016 to 10.2% in 2018 (p < 0.001) and who had EVT from 2.8% in 2016 to 4.9% in 2018 (p < 0.001). Comparing Black to White patients, the odds ratio (OR) of receiving tPA was 0.82 (95% confidence interval [CI] 0.79-0.86) and for having EVT was 0.75 (95% CI 0.70-0.81). Comparing patients with a median income in their zip code of ≤$37,999 to >$64,000, the OR of receiving tPA was 0.81 (95% CI 0.78-0.85) and for having EVT was 0.84 (95% CI 0.77-0.91). Comparing patients living in a rural area to a large metro area, the OR of receiving tPA was 0.48 (95% CI 0.44-0.52) and for having EVT was 0.92 (95% CI 0.81-1.05). These associations were largely maintained after adjustment for NIHSS, although the effect size changed for many of them. Contrary to prior reports with older datasets, sex was not consistently associated with tPA or EVT. DISCUSSION Utilization of tPA and EVT for IS in the United States increased from 2016 to 2018. There are racial, socioeconomic, and geographic disparities in the accessibility of tPA and EVT for patients with IS, with important public health implications that require further study.
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Affiliation(s)
- Adam de Havenon
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA.
| | - Kevin Sheth
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - Karen C Johnston
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - Alen Delic
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - Eric Stulberg
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - Jennifer Majersik
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - Mohammad Anadani
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - Shadi Yaghi
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - David Tirschwell
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - John Ney
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
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Willis A, Skolarus LE, Faigle R, Menon U, Redwine H, Brown AM, Felton E, Mendizabal A, Nath A, Jensen F, McArthur JC. Strengthened through Diversity: A Blueprint for Organizational Change. Ann Neurol 2021; 90:524-536. [PMID: 34236104 PMCID: PMC8478779 DOI: 10.1002/ana.26165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 07/06/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Allison Willis
- Department of Neurology, University of Pennsylvania, Philadelphia, PA
| | | | - Roland Faigle
- Department of Neurology, Johns Hopkins University, Baltimore, MD
| | - Uma Menon
- Ochsner Neuroscience Institute, Covington, LA
| | - Hannah Redwine
- University of the Incarnate Word School of Osteopathic Medicine, San Antonio, TX
| | - Amanda M Brown
- Department of Neurology, Johns Hopkins University, Baltimore, MD
| | | | - Adys Mendizabal
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA
| | | | - Frances Jensen
- Department of Neurology, University of Pennsylvania, Philadelphia, PA
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21
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Zachrison KS, Richard JV, Wilcock A, Zubizaretta JR, Schwamm LH, Uscher-Pines L, Mehrotra A. Association of Hospital Telestroke Adoption With Changes in Initial Hospital Presentation and Transfers Among Patients With Stroke and Transient Ischemic Attacks. JAMA Netw Open 2021; 4:e2126612. [PMID: 34554236 PMCID: PMC8461501 DOI: 10.1001/jamanetworkopen.2021.26612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
IMPORTANCE It has been proposed that the implementation of telestroke services (a web-based approach to using video telecommunication to treat patients with stroke before hospital admission) changes where patients with stroke symptoms receive care, but this proposal has not been rigorously assessed. OBJECTIVE To assess whether the implementation of telestroke services is associated with changes in where and how patients initially present with stroke symptoms, in their decision to be transferred to another hospital, and which hospitals they are transferred to. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study compared changes in stroke systems of care between a sample of 593 US hospitals that adopted telestroke during the period from 2009 to 2016 but were not comprehensive stroke centers, major teaching hospitals, or thrombectomy-capable hospitals vs 593 matched control hospitals without telestroke based on rural location, critical access hospital status, bed size, primary stroke center status, presence of hospital alternatives in the community, hospital stroke volume, census region, and ownership. With the use of data on 100% of Medicare fee-for-service beneficiaries, all stroke and transient ischemic attack admissions from 2008 to 2018 were identified. EXPOSURES For each hospital pair (telestroke plus matched control), the telestroke hospital's implementation date and difference-in-differences approach were used to quantify the association between telestroke implementation and changes in care from 2 years before implementation to 2 years after implementation. Models also controlled for differences in observed patient characteristics. MAIN OUTCOMES AND MEASURES Hospital stroke volume, patients' ambulance transport distance to initial hospital, hospital case mix, interhospital transfer proportion, and size of the receiving hospital for transferred patients. RESULTS Of the 669 telestroke hospitals and 2143 potential control hospitals, 593 hospital pairs were matched; in each category, 261 hospitals (44.0%) were located in a rural area, 179 (30.2%) were primary stroke centers, and 130 (21.9%) were critical access hospitals. The changes in the preimplementation to postimplementation period were similar at telestroke and control hospitals in mean annual stroke volume (telestroke hospitals, decreased from 79.6 to 76.3 patients; control hospitals, decreased from 78.8 to 75.5 patients [-3.3 patients per year for both; difference-in-differences, 0.009; P ≥ .99]). Similarly, no differences were seen in ambulance transport distance, case mix, interhospital transfers, or bed size of receiving hospitals among transferred patients. CONCLUSIONS AND RELEVANCE This study suggests that, across a national sample of hospitals implementing telestroke, no association between telestroke adoption and changes in stroke systems of care were found.
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Affiliation(s)
- Kori S. Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | - Jessica V. Richard
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Andrew Wilcock
- Department of Family Medicine, University of Vermont College of Medicine, Burlington
| | - Jose R. Zubizaretta
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston
| | | | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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22
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Jiang HJ, Fingar KR, Liang L, Henke RM, Gibson TP. Quality of Care Before and After Mergers and Acquisitions of Rural Hospitals. JAMA Netw Open 2021; 4:e2124662. [PMID: 34542619 PMCID: PMC8453322 DOI: 10.1001/jamanetworkopen.2021.24662] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
IMPORTANCE Rural hospitals are increasingly merging with other hospitals. The associations of hospital mergers with quality of care need further investigation. OBJECTIVES To examine changes in quality of care for patients at rural hospitals that merged compared with those that remained independent. DESIGN, SETTING, AND PARTICIPANTS In this case-control study, mergers at community nonrehabilitation hospitals in Federal Office of Rural Health Policy-eligible zip codes during 2009 to 2016 in 32 states were identified from Irving Levin Associates and the American Hospital Association Annual Survey. Outcomes for inpatient stays for select conditions and elective procedures were derived from the Healthcare Cost and Utilization Project State Inpatient Databases. Difference-in-differences linear probability models were used to assess premerger to postmerger changes in outcomes for patients discharged from merged vs comparison hospitals that remained independent. Data were analyzed from February to December 2020. EXPOSURES Hospital mergers. MAIN OUTCOMES AND MEASURES The main outcome was in-hospital mortality among patients admitted for acute myocardial infarction (AMI), heart failure, stroke, gastrointestinal hemorrhage, hip fracture, or pneumonia, as well as complications during stays for elective surgeries. RESULTS A total of 172 merged hospitals and 266 comparison hospitals were analyzed. After matching, baseline patient characteristics were similar for 303 747 medical stays and 175 970 surgical stays at merged hospitals and 461 092 medical stays and 278 070 surgical stays at comparison hospitals. In-hospital mortality among AMI stays decreased from premerger to postmerger at merged hospitals (9.4% to 5.0%) and comparison hospitals (7.9% to 6.3%). Adjusting for patient, hospital, and community characteristics, the decrease in in-hospital mortality among AMI stays 1 year postmerger was 1.755 (95% CI, -2.825 to -0.685) percentage points greater at merged hospitals than at comparison hospitals (P < .001). This finding held up to 4 years postmerger (DID, -2.039 [95% CI, -3.388 to -0.691] percentage points; P = .003). Greater premerger to postmerger decreases in mortality at merged vs comparison hospitals were also observed at 5 years postmerger among stays for heart failure (DID, -0.756 [95% CI, -1.448 to -0.064] percentage points; P = .03), stroke (DID, -1.667 [95% CI, -3.050 to -0.283] percentage points; P = .02), and pneumonia (DID, -0.862 [95% CI, -1.681 to -0.042] percentage points; P = .04). CONCLUSIONS AND RELEVANCE These findings suggest that rural hospital mergers were associated with better mortality outcomes for AMI and several other conditions. This finding is important to enhancing rural health care and reducing urban-rural disparities in quality of care.
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Affiliation(s)
- H. Joanna Jiang
- Agency for Healthcare Research and Quality, Rockville, Maryland
| | | | - Lan Liang
- Agency for Healthcare Research and Quality, Rockville, Maryland
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Affiliation(s)
- Lewis B Morgenstern
- Michigan Medicine and School of Public Health, University of Michigan, Ann Arbor (L.B.M.)
| | - Amytis Towfighi
- University of Southern California (A.T.).,Los Angeles County Department of Health Services (A.T.).,LAC+USC Medical Center (A.T.)
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Moody K, Santos D, Stein LK, Dhamoon MS. Decompressive Hemicraniectomy for Acute Ischemic Stroke in the US: Characteristics and Outcomes. J Stroke Cerebrovasc Dis 2021; 30:105703. [PMID: 33706194 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105703] [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: 12/11/2020] [Revised: 02/04/2021] [Accepted: 02/18/2021] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVES Decompressive hemicraniectomy can be life-saving for malignant middle cerebral artery acute ischemic stroke (AIS). However, utilization and outcomes for hemicraniectomy in the US are not known. We sought to analyze baseline characteristics and outcomes of patients receiving hemicraniectomy for AIS in the US. MATERIALS AND METHODS We identified adults who received hemicraniectomy for AIS, identified with validated International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9) code in the Nationwide Readmissions Database 2014. We calculated 30-day readmission rates, reasons for readmission, and procedures performed. RESULTS 2850 of 531,896 AIS patients (0.54%) received hemicraniectomy. Although patients receiving hemicraniectomy were more likely to be younger (57.0, 95% CI 56.0-58.0; vs 70.9, 95% CI 70.6-71.2; p < 0.0001) and male (40% vs 51.2% female; p<0.0001), 46.3% of patients who received hemicraniectomy were age 60 years and older. Patients 60 years or older receiving hemicraniectomy were more likely to die (29.9% vs 21.9%, p = 0.0081). Hemicraniectomy was more frequently performed at large hospitals (75.3% vs 57.7%; p < 0.0001) in urban areas (99.1% vs 90.3%; p < 0.0001) designated as metropolitan teaching hospitals (88.3% vs 63.4%; p < 0.0001). 30-day readmissions were most commonly due to infection (31.5%), non-infectious medical complications (17.7%), and surgical complications (13.8%). These readmissions were critical. CONCLUSIONS Although hemicraniectomy is used more frequently in the treatment of younger, male, ischemic stroke patients, only half of the patients receiving hemicraniectomy in 2014 were <60 years old. Regardless of age, hemicraniectomy is a geographically segregated procedure, only being performed in large metropolitan teaching hospitals.
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Affiliation(s)
- Kate Moody
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Daniel Santos
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Laura K Stein
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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25
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Aggarwal R, Chiu N, Loccoh EC, Kazi DS, Yeh RW, Wadhera RK. Rural-Urban Disparities: Diabetes, Hypertension, Heart Disease, and Stroke Mortality Among Black and White Adults, 1999-2018. J Am Coll Cardiol 2021; 77:1480-1481. [PMID: 33736831 DOI: 10.1016/j.jacc.2021.01.032] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/18/2020] [Accepted: 01/05/2021] [Indexed: 10/21/2022]
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Loccoh E, Joynt Maddox KE, Xu J, Shen C, Figueroa JF, Kazi DS, Yeh RW, Wadhera RK. Rural-Urban Disparities In All-Cause Mortality Among Low-Income Medicare Beneficiaries, 2004-17. Health Aff (Millwood) 2021; 40:289-296. [PMID: 33523738 DOI: 10.1377/hlthaff.2020.00420] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There is growing concern about the health of older US adults who live in rural areas, but little is known about how mortality has changed over time for low-income Medicare beneficiaries residing in rural areas compared with their urban counterparts. We evaluated whether all-cause mortality rates changed for rural and urban low-income Medicare beneficiaries dually enrolled in Medicaid, and we studied disparities between these groups. The study cohort included 11,737,006 unique dually enrolled Medicare beneficiaries. Between 2004 and 2017 all-cause mortality declined from 96.6 to 92.7 per 1,000 rural beneficiaries (relative percentage change: -4.0 percent). Among urban beneficiaries, declines in mortality were more pronounced (from 86.9 to 72.8 per 1,000 beneficiaries, a relative percentage change of -16.2 percent). The gap in mortality between rural and urban beneficiaries increased over time. Rural mortality rates were highest in East North Central states and increased modestly in West North Central states during the study period. Public health and policy efforts are urgently needed to improve the health of low-income older adults living in rural areas.
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Affiliation(s)
- Emefah Loccoh
- Emefah Loccoh is a research associate and Sarnoff Fellow in the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, in Boston, Massachusetts
| | - Karen E Joynt Maddox
- Karen E. Joynt Maddox is an assistant professor of medicine at the Washington University School of Medicine and codirector of the Center for Health Economics and Policy at the Institute for Public Health at Washington University in St. Louis, in St. Louis, Missouri
| | - Jiaman Xu
- Jiaman Xu is a data analyst in the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center
| | - Changyu Shen
- Changyu Shen is an associate professor and statistical director at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center
| | - José F Figueroa
- José F. Figueroa is an assistant professor of health policy and management in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, in Boston, Massachusetts
| | - Dhruv S Kazi
- Dhruv S. Kazi is an associate director in the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center
| | - Robert W Yeh
- Robert W. Yeh is the director of the Richard A. and Susan F. Smith Center for Outcomes Research at Beth Israel Deaconess Medical Center and the Katz Silver Family Endowed Chair and associate professor of medicine in the field of outcomes research in cardiology at Harvard Medical School, in Boston, Massachusetts
| | - Rishi K Wadhera
- Rishi K. Wadhera is an assistant professor of medicine at Harvard Medical School and an investigator at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center
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