A comparison of characteristics and resource use between in-hospital and admitted patients with stroke

In-Hospital Versus Out-of-Hospital Stroke Onset Comparison of Process Metrics in a Community Primary Stroke Center

Objective

To examine in-hospital stroke onset metrics and outcomes, quality of care, and mortality compared with out-of-hospital stroke in a single community-based primary stroke center.

Patients and Methods

Medical records of in-hospital stroke onset were compared with out-of-hospital stroke onset alert data between January 1, 2013 and December 31, 2019. Time-sensitive stroke process metric data were collected for each incident stroke alert. The primary focus of interest was the time-sensitive stroke quality metrics. Secondary focus pertained to thrombolysis treatment or complications, and mortality. Descriptive and univariable statistical analyses were applied. Kruskal-Wallis and χ2 tests were used to compare median values and categorical data between prespecified groups. The statistical significance was set at α=0.05.

Results

The out-of-hospital group reported a more favorable response to time-sensitive stroke process metrics than the in-hospital group, as measured by median stroke team response time (15.0 vs 26.0 minutes; P≤.0001) and median head computed tomography scan completion time (12.0 vs 41.0 minutes; P=.0001). There was no difference in the stroke alert time between the 2 groups (14.0 vs 8.0 minutes; P=.089). Longer hospital length of stay (4 vs 3 days; P=.004) and increased hospital mortality (19.3% vs 7.4%; P=.0032) were observed for the in-hospital group.

Conclusions

The key findings in this study were that time-sensitive stroke process metrics and stroke outcome measures were superior for the out-of-hospital groups compared with the in-hospital groups. Focusing on improving time-sensitive stroke process metrics may improve outcomes in the in-hospital stroke cohort.

Comparing characteristics and outcomes of in-hospital stroke and community-onset stroke

BACKGROUND

In-hospital strokes account for 4-17% of all strokes and usually lead to urgent and severe conditions. However, features of in-hospital strokes have been scarcely reported in China, and the management systems of in-hospital strokes are unestablished. The study aims to analyze the characteristics of in-hospital strokes in comparison to community-onset strokes and provides evidence for the development of national in-patient stroke care systems.

METHODS

We retrospectively analyzed consecutive patients with in-hospital strokes (IHS group) and community-onset strokes (COS group) hospitalized in our hospital between June 2012, and January 2022. Clinical characteristics, care measures, and outcomes were compared between the two groups.

RESULTS

A total of 1162 patients (age 61 ± 16 and 65% male) were included, of whom 193 (16.6%) had an in-hospital stroke and 969 (83.4%) had community-onset stroke. Compared with COS group, patients in IHS group had higher NIHSS at onset (7.25 vs 5.96, P = 0.054), higher use of endovascular therapy (10.4% vs 2.0%, P < 0.001), and lower use of intravascular thrombolysis (1.6% vs 7.2%, P = 0.003). Also, in-hospital strokes were associated with lower rate of mRS0-2 at discharge (OR[95%CI] = 0.674[0.49, 0.926], P = 0.015) and increased in-hospital mobility (OR[95%CI] = 3.621[1.640, 7.996], P = 0.001), after adjusting for age, sex, and cardiovascular risk factors.

CONCLUSION

Compared with community-onset strokes, the patients with in-hospital stroke had insufficient urgent treatment and poorer outcomes, reflecting the need for increased awareness of in-patient stroke, and strategies to streamline in-hospital acute stroke care.

In-Hospital Stroke Care: A Six-Year Community-Based Primary Stroke Center Experience

Background and purpose

In-hospital stroke-onset assessment and management present numerous challenges, especially in community hospitals. Comprehensive analysis of key stroke care metrics in community-based primary stroke centers is under-studied.

Methods

Medical records were reviewed for patients admitted to a community hospital for non-cerebrovascular indications and for whom a stroke alert was activated between 2013 and 2019. Demographic, clinical, radiologic and laboratory information were collected for each incident stroke. Descriptive statistical analysis was employed. When applicable, Kruskal-Wallis and Chi-Square tests were used to compare median values and categorical data between pre-specified groups. Statistical significance was set at alpha = 0.05.

Results

There were 192 patients with in-hospital stroke-alert activation; mean age (SD) was 71.0 years (15.0), 49.5% female. 51.6% (99/192) had in-hospital ischemic and hemorrhagic stroke. The most frequent mechanism of stroke was cardioembolism. Upon stroke activation, 45.8% had ischemic stroke while 40.1% had stroke mimics. Stroke team response time from activation was 26 minutes for all in-hospital activations. Intravenous thrombolysis was utilized in 8% of those with ischemic stroke; 3.4% were transferred for consideration of endovascular thrombectomy. In-hospital mortality was 17.7%, and the proportion of patients discharged to home was 34.4% for all activations.

Conclusion

The in-hospital stroke mortality was high, and the proportions of patients who either received or were considered for acute intervention were low. Quality improvement targeting increased use of acute stroke intervention in eligible patients and reducing hospital mortality in this patient cohort is needed.

A comparison of trends in stroke care and outcomes between in-hospital and community-onset stroke - The South London Stroke Register

Background

Stroke care and outcomes have improved significantly over the past decades. It is unclear if patients who had a stroke in hospital (in-hospital stroke, IHS) experienced similar improvements to those who were admitted with stroke (community-onset stroke, COS).

Methods

Data from the South London Stroke Register were analysed to estimate trends in processes of care and outcomes across three cohorts (1995–2001, 2002–2008, 2009–2015). Kaplan-Meier survival curves were calculated for each cohort. Associations between patient location at stroke onset, processes of care, and outcomes were investigated using multiple logistic regression and Cox proportional hazards models.

Results

Of 5,119 patients admitted to hospital and registered between 1995 and 2015, 552(10.8%) had IHS. Brain imaging rates increased from 92.4%(COS) and 78.3%(IHS) in 1995–2001 to 100% for COS and IHS in 2009–2015. Rates of stroke unit admission rose but remained lower for IHS (1995–2001: 32.2%(COS) vs. 12.4%(IHS), 2002–2008: 77.1%(COS) vs. 50.0%(IHS), 2009–2015: 86.3%(COS) vs. 65.4%(IHS)). After adjusting for patient characteristics and case-mix, IHS was independently associated with lower rates of stroke unit admission in each cohort (1995–2001: OR 0.49, 95%CI 0.29–0.82, 2002–2008: 0.29, 0.18–0.45, 2009–2015: 0.22, 0.11–0.43). In 2009–2015, thrombolysis rates were lower for ischaemic IHS (17.8%(COS) vs. 13.8%(IHS)). Despite a decline, in-hospital mortality remained significantly higher after IHS in 2009–2015 (13.7%(COS) vs. 26.7%(IHS)). Five-year mortality rates declined for COS from 58.9%(1995–2001) to 35.2%(2009–2015) and for IHS from 80.8%(1995–2001) to 51.1%(2009–2015). In multivariable analysis, IHS was associated with higher mortality over five years post-stroke in each cohort (1995–2001: HR 1.27, 95%CI 1.03–1.57, 2002–2008: 1.24, 0.99–1.55, 2009–2016: 1.39, 0.95–2.04).

Conclusions

Despite significant improvements for IHS patients similar to those for COS patients, rates of stroke unit admission and thrombolysis remain lower, and short- and long-term outcomes poorer after IHS. Factors preventing IHS patients from entering evidence-based stroke-specific hospital pathways in a timely fashion need further investigation.

Variables That Best Differentiate In-Patient Acute Stroke from Stroke-Mimics with Acute Neurological Deficits

Introduction. Strokes and stroke-mimics have been extensively studied in the emergency department setting. Although in-hospital strokes are less studied in comparison to strokes in the emergency department, they are a source of significant direct and indirect costs. Differentiating in-hospital strokes from stroke-mimics is important. Thus, our study aimed to identify variables that can differentiate in-hospital strokes from stroke-mimics. Methods. We present here a retrospective analysis of 93 patients over a one-year period (2009 to 2010), who were evaluated for a concern of in-hospital strokes. Results. About two-thirds (57) of these patients were determined to have a stroke, and the remaining (36) were stroke-mimics. Patients with in-hospital strokes were more likely to be obese (p = 0.03), have been admitted to the cardiology service (p = 0.01), have atrial fibrillation (p = 0.03), have a weak hand or hemiparesis (p = 0.03), and have a prior history of stroke (p = 0.05), whereas, when the consults were called for “altered mental status” but no other deficits (p < 0.0001), it is likely a stroke-mimic. Conclusion. This study demonstrates that in-hospital strokes are a common occurrence, and knowing the variables can aid in their timely diagnosis and treatment.

Characteristics of the stroke alert process in a general Hospital

Background:

The organized stroke alert is critical in quickly evaluating and treating patients with acute stroke. The purpose of this paper was to further understand how this process functions in a moderate sized general hospital by exploring the effects of patient location and time of day on the pace of evaluation and the eventual outcome of evaluation.

Methods:

Retrospective chart review.

Results:

The rate of stroke alerts depended on the time of day and patient location. There was a low probability (41%) that the eventual diagnosis was stroke after a stroke alert, but there was no effect of diagnosis on the pace of evaluation. The time between stroke alert and a computed tomography (CT) scan being read was shortest for patients in the emergency room (ER) and longer for patients in the intensive care unit (ICU) or medical/surgical floors. Patients evaluated on medical/surgical floors were less likely to receive tissue plasminogen activator (tPA) than those evaluated in the ER, even though the comorbidities were similar. This may be due to the greater severity of the comorbidities in patients who were already admitted to the hospital.

Conclusion:

The rate of tPA administration was lower for stroke alerts called from medical/surgical floors than from the ER. Stroke alerts were most frequent in late afternoon.

Modelling, evaluating and implementing cost-effective services to reduce the impact of stroke

Background

Stroke is a leading cause of death and disability but there is little information on the longer-term needs of patients and those of different ethnic groups.

Objectives

To estimate risk of stroke, longer-term needs and outcomes, risk of recurrence, trends and predictors of effective care, to model cost-effective configurations of care, to understand stakeholders’ perspectives of services and to develop proposals to underpin policy.

Design

Population-based stroke register, univariate and multivariate analyses, Markov and discrete event simulation, and qualitative methods for stakeholder perspectives of care and outcome.

Setting

South London, UK, with modelling for estimates of cost-effectiveness.

Participants

Inner-city population of 271,817 with first stroke in lifetime between 1995 and 2012.

Outcome measures

Stroke incidence rates and trends, recurrence, survival, activities of daily living, anxiety, depression, quality of life, appropriateness and cost-effectiveness of care, and qualitative narratives of perspectives.

Data sources

South London Stroke Register (SLSR), qualitative data, group discussions.

Results

Stroke incidence has decreased since 1995, particularly in the white population, but with a higher stroke risk in black groups. There are variations in risk factors and types of stroke between ethnic groups and a large number of strokes occurred in people with untreated risk factors with no improvement in detection observed over time. A total of 30% of survivors have a poor range of outcomes up to 10 years after stroke with differences in outcomes by sociodemographic group. Depression affects over half of all stroke patients and the prevalence of cognitive impairment remains 22%. Survival has improved significantly, particularly in the older black groups, and the cumulative risk of recurrence at 10 years is 24.5%. The proportion of patients receiving effective acute stroke care has significantly improved, yet inequalities of provision remain. Using register data, the National Audit Office (NAO) compared the levels of stroke care in the UK in 2010 with previous provision levels and demonstrated that improvements have been cost-effective. The treatment of, and productivity loss arising from, stroke results in total societal costs of £8.9B a year and 5% of UK NHS costs. Stroke unit care followed by early supported discharge is a cost-effective strategy, with the main gain being years of life saved. Half of stroke survivors report unmet long-term needs. Needs change over time, but may not be stroke specific. Analysis of patient journeys suggests that provision of care is also influenced by structural, social and personal characteristics.

Conclusions/recommendations

The SLSR has been a platform for a range of health services research activities of international relevance. The programme has produced data to inform policy and practice with estimates of need for stroke prevention and care services, identification of persistent sociodemographic inequalities in risk and care despite a reduction in stroke risk, quantification of the effectiveness and cost-effectiveness of care and development of models to simulate configurations of care. Stroke is a long-term condition with significant social impact and the data on need and economic modelling have been utilised by the Department of Health, the NAO and Healthcare for London to assess need and model cost-effective options for stroke care. Novel approaches are now required to ensure that such information is used effectively to improve population and patient outcomes.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme and the Department of Health via the National Institute for Health Research Biomedical Research Centre award to Guy’s and St Thomas’ NHS Foundation Trust in partnership with King’s College London.

Provision of acute stroke care and associated factors in a multiethnic population: prospective study with the South London Stroke Register

OBJECTIVES

To investigate time trends in receipt of effective acute stroke care and to determine the factors associated with provision of care.

DESIGN

Population based stroke register.

SETTING

South London.

PARTICIPANTS

3800 patients with first ever ischaemic stroke or primary intracerebral haemorrhage registered between January 1995 and December 2009.

MAIN OUTCOME MEASURES

Acute care interventions, admission to hospital, care on a stroke unit, acute drugs, and inequalities in access to care.

RESULTS

Between 2007 and 2009, 5% (33/620) of patients were still not admitted to a hospital after an acute stroke, particularly those with milder strokes, and 21% (124/584) of patients admitted to hospital were not admitted to a stroke unit. Rates of admission to stroke units and brain imaging, between 1995 and 2009, and for thrombolysis, between 2005 and 2009, increased significantly (P<0.001). Black patients compared with white patients had a significantly increased odds of admission to a stroke unit (odds ratio 1.76, 95% confidence interval 1.35 to 2.29, P<0.001) and of receipt of occupational therapy or physiotherapy (1.90, 1.21 to 2.97, P=0.01), independent of age or stroke severity. Patients with motor or swallowing deficits were also more likely to be admitted to a stroke unit (1.52, 1.12 to 2.06, P=0.001 and 1.32, 1.02 to 1.72, P<0.001, respectively). Length of stay in hospital decreased significantly between 1995 and 2009 (P<0.001). The odds of brain imaging were lowest in patients aged 75 or more years (P=0.004) and those of lower socioeconomic status (P<0.001). The likelihood of those with a functional deficit receiving rehabilitation increased significantly over time (P<0.001). Patients aged 75 or more were more likely to receive occupational therapy or physiotherapy (P=0.002).

CONCLUSION

Although the receipt of effective acute stroke care improved between 1995 and 2009, inequalities in its provision were significant, and implementation of evidence based care was not optimal.