A meta-analysis of the global impact of the COVID-19 pandemic on stroke care & the Houston Experience

COVID-19 Pandemic and Stroke Care in Patients with Dementia Compared to Other Stroke Patients

OBJECTIVES

The primary objective of this study was to examine the impact of the COVID-19 pandemic on the quality of stroke care for patients with preexisting dementia, compared with patients who had only stroke. The secondary aim was to investigate how the quality of stroke care changed during the pandemic and post-pandemic periods compared with the pre-pandemic period in patients with preexisting dementia.

DESIGN

A registry-based, nationwide cohort study in Sweden.

SETTING AND PARTICIPANTS

We included patients with a first stroke between 2019 and 2022, both with and without dementia. The study periods were defined as follows: pre-pandemic (January 1, 2019, to February 29, 2020), COVID-19 pandemic (March 1, 2020, to February 24, 2022), and post-COVID-19 pandemic period (February 25, 2022, to September 19, 2022). The outcomes examined were the following quality indicators of stroke care, suggested by the national guideline of stroke care in Sweden: stroke admission site, performance of swallowing assessment, reperfusion treatment, assessment for rehabilitation, and early supported discharge.

METHODS

The associations were studied through group comparisons and binary logistic regressions.

RESULTS

Of the 21,795 patients with strokes, 1357 had documented preexisting dementia, and 20,438 had stroke without a dementia diagnosis. Throughout all study periods, a significantly lower proportion of patients with stroke with preexisting dementia, compared with stroke-only patients, received reperfusion treatment, assessments for rehabilitation, and early supported discharge from stroke units. In the subgroup of stroke patients with preexisting dementia, no significant associations were found regarding the quality indicators of stroke care before, during, and after the pandemic.

CONCLUSIONS AND IMPLICATIONS

Disparities in quality of stroke care were observed between stroke patients with preexisting dementia and those with only stroke during the COVID-19 pandemic. However, there were no statistically significant differences in stroke care for patients with dementia across the pandemic.

Changes in stroke and TIA admissions during the COVID-19 pandemic: A meta-analysis

PURPOSE

To perform a meta-analysis on how the admissions of stroke and transient ischemic attack (TIA) changed during the Corona Virus infection-19 (COVID-19) pandemic and evaluate if the effect was depending on stroke severity.

METHODS

Observational cohort studies comparing the number of stroke and/or TIA admissions during a period of the pandemic compared to a period before the pandemic were identified in PubMed and Embase. After excluding studies with overlapping populations and studies without satisfactory case ascertainment, data was extracted and meta-analyzed.

FINDINGS

A total of 59 studies were included. During the pandemic, there was a decrease in admissions of ischemic stroke (admission rate ratio (ARR) = 0.77, 95% confidence interval (CI): 0.72, 0.82), intracerebral hemorrhage (ARR = 0.79, 95% CI: 0.70, 0.90) and TIA (ARR = 0.66, 95% CI: 0.58, 0.75). Albeit admission rates of both mild (ARR = 0.61, 95% CI: 0.49, 0.77) and severe (ARR = 0.82, 95% CI = 0.71, 0.95) strokes decreased, milder strokes decreased more (proportion ratio (PR) = 0.76, 95% CI: 0.65, 0.89).

DISCUSSION

Potential causes for the admission reduction could be strict prioritizations within the health care, patients' fear of acquiring COVID-19, or decreased access to health care due to lockdowns.

CONCLUSION

During the COVID-19 pandemic, there was a reduction in admissions of stroke and TIA, possibly caused by reluctance to seek medical care.

Acute care pathway assessed through performance indicators during the COVID-19 pandemic in OECD countries (2020-2021): a scoping review

BACKGROUND

The COVID-19 pandemic severely impacted care for non-COVID patients. Performance indicators to monitor acute care, timely reported and internationally accepted, lacked during the pandemic in OECD countries. This study aims to summarize the performance indicators available in the literature to monitor changes in the quality of acute care in OECD countries during the first year and a half of the pandemic (2020-July 2021) and to assess their trends.

METHODS

Scoping review. Search in Embase and MEDLINE (07-07-2022). Acute care performance indicators and indicators related to acute general surgery were collected and collated following a care pathway approach. Indicators assessing identical clinical measures were grouped under a common indicator title. The trends from each group of indicators were collated (increase/decrease/stable).

RESULTS

A total of 152 studies were included. 2354 indicators regarding general acute care and 301 indicators related to acute general surgery were included. Indicators focusing on pre-hospital services reported a decreasing trend in the volume of patients: from 225 indicators, 110 (49%) reported a decrease. An increasing trend in pre-hospital treatment times was reported by most of the indicators (n = 41;70%) and a decreasing trend in survival rates of out-of-hospital cardiac arrest (n = 61;75%). Concerning care provided in the emergency department, most of the indicators (n = 752;71%) showed a decreasing trend in admissions across all levels of urgency. Concerning the mortality rate after admission, most of the indicators (n = 23;53%) reported an increasing trend. The subset of indicators assessing acute general surgery showed a decreasing trend in the volume of patients (n = 50;49%), stability in clinical severity at admission (n = 36;53%), and in the volume of surgeries (n = 14;47%). Most of the indicators (n = 28;65%) reported no change in treatment approach and stable mortality rate (n = 11,69%).

CONCLUSION

This review signals relevant disruptions across the acute care pathway. A subset of general surgery performance indicators showed stability in most of the phases of the care pathway. These results highlight the relevance of assessing this care pathway more regularly and systematically across different clinical entities to monitor disruptions and to improve the resilience of emergency services during a crisis.

Impact of COVID-19 outbreak on stroke admission in Thailand: a quasi-experimental, ecological study on national database

This study aimed to evaluate the effect of COVID-19 outbreak on stroke admission by using a national database. A quasi-experimental, ecological study using the national database of Thailand was conducted. The study period was between January 2017 and August 2020 before and after COVID-19 outbreak starting from March 2020. Numbers of stroke admission were evaluated before and after the COVID-19 outbreak by an interrupted time series analysis for both pre- and post-COIVD-19 outbreak. There were 381,891 patients admitted throughout Thailand. Of those, 292,382 patients (76.56%) were admitted due to thrombotic stroke followed by hemorrhagic stroke (73,130 patients; 19.15%) and embolic stroke (16,379 patients; 4.29%). During pre-COVID-19 outbreak, all stroke subtypes had an increasing trend with a coefficient of 0.076 (p value < 0.001) for thrombotic stroke, 0.003 (p value < 0.001) for embolic stroke and 0.012 (p value = 0.025) for hemorrhagic stroke. The COVID-19 outbreak had significantly effect on reductions of incidence rates of thrombotic and hemorrhagic stroke with a coefficient of -2.412 (p value < 0.001) and -0.803 (p value = 0.023). The incidence rates of three stroke subtypes were increasing prior to the COVID-19 outbreak. The COVID-19 outbreak significantly impacts hospital admission rates of both thrombotic and hemorrhagic stroke subtypes.

A tale of two cities: A retrospective observational cohort study of the impact of COVID-19 on acute stroke presentation, timing, and outcomes

OBJECTIVES

The purpose of this study was to identify the impact of COVID-19-related "shelter in place" restrictions on stroke metrics in two metropolitan Texas cities, Austin and San Antonio.

MATERIALS AND METHODS

Data was derived from stroke quality metric registries and compared between two treatment periods: (1) during the state's COVID-19 "shelter in place" restriction period, and (2) the corresponding period during the previous year for Austin and San Antonio, Texas. Primary outcomes include the dichotomized process measures of time last known well (TLKW) to arrival, arrival to brain imaging initiation, and arrival to administration of thrombolytic therapy. Secondary outcomes are clinical endpoints: independent ambulation at discharge, discharge to home, and in-hospital mortality.

RESULTS

Austin patients were older and presented with less-severe strokes. San Antonio patients were more likely to be Hispanic, suffer from a large vessel occlusion, and have independent ambulation at discharge (adjusted odds ratio, 2.04; 95% confidence intervals, (1.25-3.37). Within-city analyses revealed a trend toward increased TLKW to arrival in Austin and San Antonio during COVID-19. During COVID, Austin patients had decreased length of stay (LOS) while a higher proportion of San Antonio patients had a favorable outcome (discharged home & independent ambulation).

CONCLUSIONS

Longer TLKW to hospital arrival during COVID did not impact arrival-to-imaging, arrival-to-treatment times nor patient outcomes, even in patients at higher risk for stroke. Future studies should continue to assess the impact of COVID-19 on stroke care and outcomes pre- and post-introduction of the COVID-19 vaccine, and as infectivity rates spike or recede.

The impact of SARS-CoV-2 infection on the outcome of acute ischemic stroke-A retrospective cohort study

BACKGROUND

Acute ischemic stroke (AIS) is a common complication of severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) infection (COVID-19), but the prognosis of these patients is poorly understood.

PURPOSE

To explore the impact of COVID-19 on neurological outcomes in AIS patients.

METHODS

A comparative retrospective cohort study was conducted in 32 consecutive AIS patients with and 51 without COVID-19 between the 1st of March 2020 and 1st of May 2021. The evaluation was based on a detailed chart review for demographic data, medical history, stroke severity, cranial and vessel imaging results, laboratory parameters, COVID-19 severity, hospitalization time, in-hospital mortality, and functional deficits at discharge (modified Rankin Scale, mRS).

RESULTS

COVID-19 AIS patients showed tendency to worse initial neurological deficit (NIHSS 9 (3-13) vs. 4 (2-10); p = 0.06), higher rate of large vessel occlusion (LVO; 13/32 vs. 14/51; p = 0.21), had prolonged hospitalization (19.4 ± 17.7 vs. 9.7 ± 7 days; p = 0.003), had lower chance of functional independence (mRS≤2) (12/32 vs. 32/51; p = 0.02) and showed higher in-hospital mortality (10/32 vs. 6/51; p = 0.02). In COVID-19 AIS patients, LVO was more common with COVID-19 pneumonia than without (55.6% vs. 23.1%; p = 0.139).

CONCLUSION

COVID-19-related AIS carries a worse prognosis. COVID-19 with pneumonia seems to be associated with a higher rate of LVO.

Cerebro-/Cardiovascular Collateral Damage During the COVID-19 Pandemic: Fact or Fiction?

Numerous observational studies have identified a decline in cerebro-/cardiovascular (CV) admissions during the initial phase of the COVID-19 pandemic. Recent studies and meta-analyses indicated that the overall decrease was smaller than that found in initial studies during the first months of 2020. Two years later we still do not have clear evidence about the potential causes and impacts of the reduction of CV hospitalizations during the COVID-19 pandemic. It has becoming increasingly evident that collateral damage (i.e., incidental damage to the public and patients) from the COVID-19 outbreak is the main underlying cause that at least somewhat reflects the effects of imposed measures such as social distancing and self-isolation. However, a smaller true decline in CV events in the community due to a lack of triggers associated with such acute syndromes cannot be excluded. There is currently indirect epidemiological evidence about the immediate impact that the collateral damage had on excess mortality, but possible late consequences including a rebound increase in CV events are yet to be observed. In the present narrative review, we present the reporting milestones in the literature of the rates of CV admissions and collateral damage during the last 2 years, and discuss all possible factors contributing to the decline in CV hospitalizations during the COVID-19 pandemic. Healthcare systems need to be prepared so that they can cope with the increased hospitalization rates for CV events in the near future.

Stroke care during the COVID-19 pandemic: Case numbers, treatments, and mortality in two large German stroke registries

Background and purpose

At the beginning of the SARS-CoV-2 pandemic, an alarming decline in hospitalizations for stroke was reported in several countries, including Germany. We assessed hospitalization numbers and indicators of the quality of stroke care in 2020 during the pandemic containment measures.

Materials and methods

The analysis was based on data of two large stroke quality assurance registries in the north and the south of Germany (Qualitätssicherung Schlaganfall Nordwestdeutschland and Bayerische Arbeitsgemeinschaft für Qualitätssicherung in der stationären Versorgung). We included 395 hospitals with 467,931 documented cases in 2018–2020. The time interval between admission and thrombolysis, frequency of systemic thrombolysis and intra-arterial therapy (IAT), National Institutes of Health Stroke Scale (NIHSS) score on admission and in-hospital mortality were assessed. Changes in the second (Q2) and fourth (Q4) quarters of 2020 were compared to corresponding quarters in 2019 by chi-squared tests.

Results

Hospitalization numbers decreased in the two stroke registries by 8% and 10% in Q2 of 2020 and by 5% and 15% in Q4 of 2020 compared to the same quarters in 2019, respectively. The decline was particularly seen in women and patients with transient ischemic attacks. In cases with cerebral infarction, no increase in NIHSS scores on admission was observed, and the proportion of patients with a time interval between admission and thrombolysis of ≤60 min was unchanged. No clear pattern was found in the frequency of systemic thrombolysis and IAT. In one of the registries, in-hospital mortality of patients with cerebral infarction increased in Q2 of 2020 compared to Q2 of 2019.

Conclusion

Case numbers slightly decreased under pandemic conditions, while our quarterly analysis indicated that the quality of stroke care was largely unchanged throughout the year 2020.

Time Metrics in Acute Ischemic Stroke Care During the Second and First Wave of COVID 19 Pandemic: A Tertiary Care Center Experience from South India

Background

During the first wave of the pandemic, stroke care suffered globally and there were reduced stroke admissions and delays in time metrics. Stroke care was reorganized during the second wave learning from the experience of previous wave. This study shares our experience in stroke time metrics during the second wave of pandemic compared to the first wave.

Methods

We did a single-center prospective study, where consecutive acute ischemic stroke patients within 24 hours of the onset of symptoms and aged more than 18 years, who presented to Stroke Unit, Department of Neurology, Government Medical College, Thiruvananthapuram from June 1st to 31st August, 2020 and June 1st to 31st August in 2021 were included. In-hospital time metrics (door to CT time and door to Needle time) were compared during the two time periods. We also compared functional outcomes at discharge and in-hospital mortality during the two periods. Functional outcome at discharge was assessed by modified Rankin scale (mRS).

Results

From June to August 2021 (second wave of the COVID 19 pandemic), compared to the same months during the first wave (2020), our study demonstrated better in-hospital time metrics (door to CT time and door to needle time). We also found lower admission systolic blood pressure and higher baseline CT early ischemic changes during the second wave. There was no difference in functional outcome at discharge and in-hospital mortality. Intravenous thrombolysis rates also remained the same during the two periods.

Conclusion

Our study has confirmed that time metrics in stroke care can be improved through system rearrangement even during the pandemic. Acute stroke treatments are time-dependent and hospital administrators must stick to the maxim “Time is Brain” while restructuring stroke workflows during future challenges.

Impact of COVID-19 pandemic on acute stroke admissions and case-fatality rate in lower-income and middle-income countries: a protocol for systematic review and meta-analysis

INTRODUCTION

The current review primarily aims to ascertain the impact of COVID-19 on stroke admission as well as stroke case fatality in Low-income and Middle-Income Countries (LMICs).

METHODS AND ANALYSIS

Four international databases (PubMed/Medline, Google Scholar, African Journals Online, Latin American and Caribbean Health Sciences Literature) and one preprint database (medRxiv). Studies will be included if they are conducted in LMICs, all stroke types without age and language restriction, from December 2019 to 31 December 2021. Two authors will screen the titles and abstracts against the prespecified eligibility criteria for inclusion in the review, and then repeat the process after retrieving the full text. Joanna Briggs critical appraisal checklist for analytical cross-sectional studies will be used for the quality assessment and risk of bias by two coauthors. The characteristics of the studies will be presented and summarised in a table. We aim to perform meta-analyses on a pooled proportional change in acute stroke admissions and case fatality with 95% CI using a random-effects meta-analysis. Publication bias will be assessed using funnel plot and Egger's regression test if ≥10 studies are involved. A sub group analysis will be performed to determine the sources of heterogeneity. Leave-one-out sensitivity analysis will be performed to examine the impact of a single study on the overall pool estimate.

ETHICS AND DISSEMINATION

Ethical approval is not required as this is secondary research and will use reported data in scientific literature. A full manuscript will be submitted to a reputable peer-review journal for publication and disseminated electronically and in print.

PROSPERO REGISTRATION NUMBER

CRD42021281580.

The impact of home quarantine during COVID-19 lockdown on neurological hospitalizations, in-hospital mortality, and acute ischemic stroke management in older patients without COVID-19

INTRODUCTION

This study aimed to investigate the impact of home quarantine in older patients without COVID-19 hospitalized due to neurological disorders.

METHODS

We consecutively enrolled 255 elderly patients(median age: 75 years, female: 54%), including 180 (70%) in the pre-home quarantine period and 75 (30%) home quarantine period from January to May 2020 (ten weeks before and ten weeks after the March 21, 2020, lockdown for older patients in Turkey) in a tertiary referral neurological center.

RESULTS

In the home quarantine period, we documented a fall in the number of neurological admissions by 58.3%, but an increased need for intensive care in older patients. Patients in the home quarantine period were younger [73 (65-91) vs 76 (65-95), p = 0.005], had worse Glasgow Coma Scores (12.3 ± 3.6 vs 13.7 ± 2.5, p = 0.007), higher in-hospital mortality rate (21.3% vs. 6.7%, p = 0.001), had a lower prevalence of comorbidities such as diabetes mellitus, hypertension, and cardiovascular disease, and chronic neurologic disease, albeit had a higher prevalence of the acute cerebrovascular disease (hemorrhagic/ ischemic stroke)(90.7% vs 78.9, p = 0.025). In this period, even there was an increase in the proportion of the patients undergoing reperfusion therapy, it wasn't statistically significant (20.3% vs. 10.1%, p: 0.054). Multivariate analysis revealed that high NIHSS (The National Institutes of Health Stroke Scale) score (OR=1.25; p < 0.001) and hospitalization in the home quarantine period (OR=3.21; p = 0.043) were independently associated with in-hospital mortality.

CONCLUSION

Our study indicated that during the COVID-19 home quarantine period, despite a significantly fewer number of patients admitted to the hospitalization, there was a higher percentage of those hospitalized needing intensive care and an overall worse prognosis.

Managing Post-Stroke Care During the COVID-19 Pandemic at a Tertiary Care Level Hospital in Peru

OBJECTIVES

To understand the hospital-to-outpatient care transition and how the discharge process of stroke patients is managed; and to identify potential opportunities to improve these processes, while contrasting pre- and during COVID-19 experiences in Peru.

METHODS

A qualitative study was conducted between February and March 2021 consisting of in-depth interviews of patients with stroke, their caregivers and healthcare personnel regarding stroke care at a national tertiary referral center for stroke care in Lima, Peru. We explored the following phases of the patients' journeys: pre-hospitalization, emergency room, hospitalization, discharge process and post-discharge. For each phase, we explored experiences, feelings and expectations using thematic analysis.

RESULTS

We conducted a total of 11 interviews with patients or caregivers and 7 with health care personnel and found disruption in the continuity of care for patients with stroke. Mainly, caregivers and patients referred to problems related to communication with healthcare personnel and an absence of training to provide post-discharge care at home. Potential solutions included increasing human resources and caregiver participation in care, implementation of electronic healthcare records, improving the referral system and reinforcing telemedicine services.

CONCLUSION

The continuity of care of patients with stroke was negatively affected during the COVID-19 pandemic. In LMICs, the impact was likely greater due to the already weak and fragmented healthcare systems. The COVID-19 pandemic presents an opportunity to improve post-stroke care services, and address patients' experiences and feelings by developing solutions in a participatory manner.