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Lucas-Noll J, Clua-Espuny JL, Carles-Lavila M, Solà-Adell C, Roca-Burgueño Í, Panisello-Tafalla A, Gavaldà-Espelta E, Queralt-Tomas L, Lleixà-Fortuño M. Sex Disparities in the Direct Cost and Management of Stroke: A Population-Based Retrospective Study. Healthcare (Basel) 2024; 12:1369. [PMID: 39057512 PMCID: PMC11275613 DOI: 10.3390/healthcare12141369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 07/03/2024] [Accepted: 07/04/2024] [Indexed: 07/28/2024] Open
Abstract
(1) Background: Previous studies have identified disparities in stroke care and outcomes by sex. Therefore, the main objective of this study was to evaluate the average cost of stroke care and the existence of differences in care provision by biological sex. (2) Methods: This observational study adhered to the recommendations of the STROBE statement. The calculation of costs was performed based on the production cost of the service or the rate paid for a set of services, depending on the availability of the corresponding information. (3) Results: A total of 336 patients were included, of which 47.9% were women, with a mean age of 73.3 ± 11.6 years. Women were typically older, had a higher prevalence of hypertension (p = 0.005), lower pre-stroke proportion of mRS 0-2 (p = 0.014), greater stroke severity (p < 0.001), and longer hospital stays (p = 0.017), and more were referred to residential services (p = 0.001) at 90 days. Women also required higher healthcare costs related to cardiovascular risk factors, transient ischemic strokes, institutionalization, and support needs; in contrast, they necessitated lower healthcare costs when undergoing endovascular therapy and receiving rehabilitation services. The unadjusted averaged cost of stroke care was EUR 22,605.66 (CI95% 20,442.8-24,768.4), being higher in women [p = 0.027]. The primary cost concept was hospital treatment (38.8%), followed by the costs associated with dependence and support needs (36.3%). At one year post-stroke, the percentage of women not evaluated for a degree of dependency was lower (p = 0.008). (4) Conclusions: The total unadjusted costs averaged EUR 22,605.66 (CI95% EUR 20,442.8-24,768.4), being higher in women compared to men. The primary cost concept was hospital treatment (38.8%), followed by the costs associated with dependence and support needs (36.3%).
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Affiliation(s)
- Jorgina Lucas-Noll
- Terres de l’Ebre Healh Region, Catalan Health Service, 43500 Tortosa, Spain; (C.S.-A.); (Í.R.-B.)
| | - José L. Clua-Espuny
- Department of Primary Care, Institut Català de la Salut, 43500 Tortosa, Spain; (A.P.-T.); (E.G.-E.); (L.Q.-T.)
| | - Misericòrdia Carles-Lavila
- Department of Economic and Business, Universitat Rovira i Virgili, 43204 Reus, Spain;
- Research Centre on Economics and Sustainability (ECO-SOS), 43204 Reus, Spain
| | - Cristina Solà-Adell
- Terres de l’Ebre Healh Region, Catalan Health Service, 43500 Tortosa, Spain; (C.S.-A.); (Í.R.-B.)
| | - Íngrid Roca-Burgueño
- Terres de l’Ebre Healh Region, Catalan Health Service, 43500 Tortosa, Spain; (C.S.-A.); (Í.R.-B.)
| | - Anna Panisello-Tafalla
- Department of Primary Care, Institut Català de la Salut, 43500 Tortosa, Spain; (A.P.-T.); (E.G.-E.); (L.Q.-T.)
| | - Ester Gavaldà-Espelta
- Department of Primary Care, Institut Català de la Salut, 43500 Tortosa, Spain; (A.P.-T.); (E.G.-E.); (L.Q.-T.)
| | - Lluïsa Queralt-Tomas
- Department of Primary Care, Institut Català de la Salut, 43500 Tortosa, Spain; (A.P.-T.); (E.G.-E.); (L.Q.-T.)
| | - Mar Lleixà-Fortuño
- Department of Nursing, Universitat Rovira I Virgili, 43500 Tortosa, Spain;
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Yu AYX, Kapral MK, Park AL, Fang J, Hill MD, Kamal N, Field TS, Joundi RA, Peterson S, Zhao Y, Austin PC. Change in Hospital Risk-standardized Stroke Mortality Performance With and Without the Passive Surveillance Stroke Severity Score. Med Care 2023:00005650-990000000-00180. [PMID: 37962442 DOI: 10.1097/mlr.0000000000001944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND Adjustment for baseline stroke severity is necessary for accurate assessment of hospital performance. We evaluated whether adjusting for the Passive Surveillance Stroke SeVerity (PaSSV) score, a measure of stroke severity derived using administrative data, changed hospital-specific estimated 30-day risk-standardized mortality rate (RSMR) after stroke. METHODS We used linked administrative data to identify adults who were hospitalized with ischemic stroke or intracerebral hemorrhage across 157 hospitals in Ontario, Canada between 2014 and 2019. We fitted a random effects logistic regression model using Markov Chain Monte Carlo methods to estimate hospital-specific 30-day RSMR and 95% credible intervals with adjustment for age, sex, Charlson comorbidity index, and stroke type. In a separate model, we additionally adjusted for stroke severity using PaSSV. Hospitals were defined as low-performing, average-performing, or high-performing depending on whether the RSMR and 95% credible interval were above, overlapping, or below the cohort's crude mortality rate. RESULTS We identified 65,082 patients [48.0% were female, the median age (25th,75th percentiles) was 76 years (65,84), and 86.4% had an ischemic stroke]. The crude 30-day all-cause mortality rate was 14.1%. The inclusion of PaSSV in the model reclassified 18.5% (n=29) of the hospitals. Of the 143 hospitals initially classified as average-performing, after adjustment for PaSSV, 20 were reclassified as high-performing and 8 were reclassified as low-performing. Of the 4 hospitals initially classified as low-performing, 1 was reclassified as high-performing. All 10 hospitals initially classified as high-performing remained unchanged. CONCLUSION PaSSV may be useful for risk-adjusting mortality when comparing hospital performance. External validation of our findings in other jurisdictions is needed.
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Affiliation(s)
- Amy Y X Yu
- Department of Medicine (Neurology), Sunnybrook Health Sciences Centre, University of Toronto
- ICES
| | - Moira K Kapral
- ICES
- Department of Medicine (General Internal Medicine), University of Toronto-University Health Network, Toronto, ON
| | | | | | - Michael D Hill
- Departments of Clinical Neurosciences, Community Health Sciences, Medicine, Radiology and Hotchkiss Brain Institute, University of Calgary, Calgary, AB
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, NS
| | - Thalia S Field
- Department of Medicine (Neurology), Vancouver Stroke Program, University of British Columbia, Vancouver, BC
| | - Raed A Joundi
- Department of Medicine, Hamilton Health Sciences Centre, McMaster University, Hamilton, ON
| | - Sandra Peterson
- Centre for Health Services and Policy Research, University of British Columbia
| | - Yinshan Zhao
- Population Data BC, University of British Columbia, Vancouver, BC, Canada
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Huang D, Lu Y, Sun Y, Sun W, Huang Y, Tai L, Li G, Chen H, Zhang G, Zhang L, Sun X, Qiu J, Wei Y, Jin H. Effect of weekend versus weekday admission on the mortality of acute ischemic stroke patients in China: an analysis of data from the Chinese acute ischemic stroke treatment outcome registry. Front Neurol 2023; 14:1206846. [PMID: 37528854 PMCID: PMC10389271 DOI: 10.3389/fneur.2023.1206846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 06/29/2023] [Indexed: 08/03/2023] Open
Abstract
Background Due to disparities in medical resources in rural and urban areas as well as in different geographic regions in China, the effect of weekend versus weekday admission on the outcomes of acute ischemic stroke (AIS) patients is unknown. Our aim was to investigate whether the outcomes of AIS patients differ according to the day of admission in China. Methods The data were extracted from the Chinese Acute Ischemic Stroke Treatment Outcome Registry (CASTOR), a multicenter prospective study database of patients diagnosed with AIS. The chi-square test (χ2) and logistic regression were used to assess mortality for weekday and weekend admissions among AIS patients stratified by rural or urban status and geographic region (including the eastern, northeastern, central, and western regions). Results In total, 9,256 patients were included in this study. Of these patients, 57.2% were classified as urban, and 42.8% were classified as rural. A total of 6,760 (73%) patients were admitted on weekdays, and 2,496 (27%) were admitted on weekends. There was no significant difference in the mortality rate among patients admitted on weekends compared with those admitted on weekdays in urban (7.5% versus 7.4%) or rural areas (8.8% versus 8.1%; p > 0.05). The mortality rate was the highest among patients admitted on weekends and weekdays (11.6% versus 10.3%) in the northeastern area, without statistical significance before and after adjusting for the patients' background characteristics (p > 0.05). In addition, regression analysis revealed that the mortality of patients admitted on weekdays was more likely to be influenced by regional subgroup, hospital level and intravenous thrombolysis than that of patients admitted on weekends. Conclusion The weekend effect was not observed in the mortality of patients with AIS regardless of rural-urban status or geographic region in China.
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Affiliation(s)
- Diandian Huang
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yuxuan Lu
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yongan Sun
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Wei Sun
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yining Huang
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Liwen Tai
- Department of Neurology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Guozhong Li
- Department of Neurology, First Affiliated Hospital of Harbin Medical University, Neurology, Harbin, China
| | - Huisheng Chen
- Department of Neurology, The General Hospital of Shenyang Military Command, Shenyang, China
| | - Guiru Zhang
- Department of Neurology, Penglai People’s Hospital, Penglai, China
| | - Lei Zhang
- Department of Neurology, Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Xuwen Sun
- Department of Neurology, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
| | - Jinhua Qiu
- Department of Neurology, Huizhou First Hospital, Huizhou, China
| | - Yan Wei
- Department of Neurology, Harrison International Peace Hospital, Hengshui, China
| | - Haiqiang Jin
- Department of Neurology, Peking University First Hospital, Beijing, China
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Del Brutto VJ, Rundek T, Sacco RL. Prognosis After Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00017-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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5
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Ifejika NL, Vahidy F, Reeves M, Xian Y, Liang L, Matsouaka R, Fonarow GC, Savitz SI. Association Between 2010 Medicare Reforms and Utilization of Postacute Inpatient Rehabilitation in Ischemic Stroke. Am J Phys Med Rehabil 2021; 100:675-682. [PMID: 33002913 PMCID: PMC8004542 DOI: 10.1097/phm.0000000000001605] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to investigate whether the elimination of trial admissions and the initiation of documentation requirements, via the 2010 Centers for Medicare and Medicaid Services Inpatient Rehabilitation Facility Prospective Payment System Rule, limited inpatient rehabilitation facility access while increasing skilled nursing facility utilization compared with home discharge in ischemic stroke patients. DESIGN This is a retrospective observational study using Get with the Guidelines - Stroke hospital data between January 1, 2008 and December 31, 2015 (N = 1,643,553). RESULTS Between January 1, 2008 and December 31, 2009, 54.1% of patients went home, 25.4% to inpatient rehabilitation facility and 20.5% to skilled nursing facility. Between January 1, 2010 and December 31, 2015, there was a 1.4% absolute increase in home discharge, a 1.1% inpatient rehabilitation facility decline and a 0.3% skilled nursing facility decline.Within the 1.1% absolute decline in inpatient rehabilitation facility discharge, the adjusted odds of inpatient rehabilitation facility versus home discharge decreased 12% after 2010 Rule (adjusted odds ratio = 0.88, 95% confidence interval = 0.87-0.89, P < 0.0001). There was no statistically significant change in skilled nursing facility versus home discharge.Lower adjusted odds of inpatient rehabilitation facility discharge versus home discharge were identical across age groups and were present in all geographic regions. CONCLUSIONS In populations with ischemic stroke, the Centers for Medicare and Medicaid Services 2010 Inpatient Rehabilitation Facility Prospective Payment System Rule was associated with a 1.1% absolute decrease in inpatient rehabilitation facility discharge, with a concomitant increase in home discharge rather than to skilled nursing facility.
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Affiliation(s)
- Nneka L Ifejika
- From the Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, Dallas, Texas (NLI); Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, Texas (NLI); Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, Texas (NLI); Centers for Outcomes Research, Houston Methodist Research Institute, Houston, Texas (FV); Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, Lansing, Michigan (MR); Department of Neurology, Duke University Hospital, Durham, North Carolina (YX); Duke Clinical Research Institute, Durham, North Carolina (YX, LL, RM); Division of Cardiology, Ahmanson - UCLA Cardiomyopathy Center, University of California, Los Angeles Medical Center, Los Angeles, California (GCF); Institute for Stroke and Cerebrovascular Disease, UTHealth, Houston, Texas (SIS); and Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas (SIS)
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Davies A, Van Leer L, Chan J, Wijayaratna R, Singhal S, Ly J, Clissold B, Ma H, Phan TG. Stroke in patients with cancer in the era of hyper-acute stroke intervention. Intern Med J 2021; 52:1513-1518. [PMID: 33974349 DOI: 10.1111/imj.15353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/04/2021] [Accepted: 05/06/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The natural history of patients with stroke and cancer remains poorly understood in the modern era of hyper-acute stroke therapies (recombinant tissue plasminogen activator (tPA) and endovascular clot retrieval (ECR)). Prior to these advances in stroke treatment, a highly cited study reported median overall survival (mOS) 4.5 months after stroke in a cohort of patients with cancer (2004, n=96). Our aim is to evaluate outcome following stroke for patients with cancer in this modern era. Our hypothesis is that patients with stroke and cancer have better outcome than in earlier studies. DESIGN AND SETTING Retrospective analysis of admission to a tertiary Stroke Unit between January 2015 and September 2017 (N=1910), evaluation of hospital records and cancer treatment records. OUTCOME MEASURES Cancer was categorised as early stage (stage I and II) and advanced stage (stage III or IV, using the RD-Staging system). Survival analysis was performed in R. RESULTS There were 143 stroke patients with cancer (62% male) with mean age 73.2 +/- 12.5 years. Ischemic stroke occurred in 74.1% and 45 of 106 patients (42.5%) received intravenous thrombolysis (34/45) and / or endovascular clot retrieval (11/45). One patient who received ECR died within 30-days of stroke. Those with early-stage disease had mOS of 19.6 months (IQR 3.1, 31.5 months) and in advanced stage cancer mOS was 2.5 months (IQR 0.4, 6.3 months, p<0.01) CONCLUSION: In the modern era of stroke therapy, our cohort of patients with advanced cancer have lower survival post-stroke compared to those with early-stage cancer. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Amy Davies
- Department of Neurology, Monash Health, Melbourne, Australia
| | - Lyndal Van Leer
- Department of Neurology, Monash Health, Melbourne, Australia.,Stroke and Aging Research Group, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Jasmine Chan
- Department of Neurology, Monash Health, Melbourne, Australia
| | | | - Shaloo Singhal
- Department of Neurology, Monash Health, Melbourne, Australia.,Stroke and Aging Research Group, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - John Ly
- Department of Neurology, Monash Health, Melbourne, Australia.,Stroke and Aging Research Group, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Benjamin Clissold
- Department of Neurology, Monash Health, Melbourne, Australia.,Stroke and Aging Research Group, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Henry Ma
- Department of Neurology, Monash Health, Melbourne, Australia.,Stroke and Aging Research Group, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Thanh G Phan
- Department of Neurology, Monash Health, Melbourne, Australia.,Stroke and Aging Research Group, School of Clinical Sciences, Monash University, Melbourne, Australia
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Moalla KS, Damak M, Chakroun O, Farhat N, Sakka S, Hdiji O, Kacem HH, Rekik N, Mhiri C. [Prognostic factors for mortality due to acute arterial stroke in a North African population]. Pan Afr Med J 2020; 35:50. [PMID: 32537055 PMCID: PMC7250234 DOI: 10.11604/pamj.2020.35.50.16287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 12/12/2018] [Indexed: 01/04/2023] Open
Abstract
Introduction cerebrovascular accident (stroke) constitutes a major public health problem due to the number of people affected and to its medical social and economic consequences. This study aims to identify poor vital prognostic factors for survival in patients with acute arterial stroke. Methods we conducted a prospective study of patients with symptoms suggestive of stroke at the two University Hospitals of Sfax, Tunisia over a period of 4 months. Patients were followed-up for a period of 1 month. Results we collected data from 200 patients. After one month of follow-up, mortality was 19.9%. Poor prognostic factors were: male sex, consumption of tobacco, a history of stroke, low Glasgow score, high NIHSS, headaches, acute symptomatic epileptic seizures, Babinski's sign, mydriasis, aphasia, combined deviation of the head and the eyes, high PAS, PAD and PAM, hyperthermia, hyperglycaemia, leukocytosis, high concentration of CRP, creatinine, urea and troponin T, haemorrhagic stroke, perilesional oedema, a mass effect, commitment, total middle cerebral artery topography of ischemia, early signs of ischemia, meningeal hemorrhage, ventricular flood, hydrocephalus, the recourse to respiratory support, to anti-edematous treatment and to antihypertensive therapy, hemorrhagic transformation, vascular epilepsy, infectious, metabolic complications, complications of bed sores. Conclusion the identification of the predictive factors for survival allows for optimisation of therapeutic procedures and better implementation of patient' management. A comparative study will be considered to measure the impact of the corrective measures.
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Affiliation(s)
| | - Mariem Damak
- Service de Neurologie, Hôpital Universitaire Habib Bourguiba, Sfax, Tunisie
| | - Olfa Chakroun
- Service des Urgences et du SAMU, Hôpital Universitaire Habib Bourguiba, Sfax, Tunisie
| | - Nouha Farhat
- Service de Neurologie, Hôpital Universitaire Habib Bourguiba, Sfax, Tunisie
| | - Salma Sakka
- Service de Neurologie, Hôpital Universitaire Habib Bourguiba, Sfax, Tunisie
| | - Olfa Hdiji
- Service de Neurologie, Hôpital Universitaire Habib Bourguiba, Sfax, Tunisie
| | - Hanen Haj Kacem
- Service de Neurologie, Hôpital Universitaire Habib Bourguiba, Sfax, Tunisie
| | - Noureddine Rekik
- Service des Urgences et du SAMU, Hôpital Universitaire Habib Bourguiba, Sfax, Tunisie
| | - Chokri Mhiri
- Service de Neurologie, Hôpital Universitaire Habib Bourguiba, Sfax, Tunisie
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da Silva CF, Schwartz J, Belli VDS, Ferreira LE, Cabral NL, França PHCD. Ischemic Stroke and Genetic Variants: In Search of Association with Severity and Recurrence in a Brazilian Population. J Stroke Cerebrovasc Dis 2019; 29:104487. [PMID: 31757599 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/05/2019] [Accepted: 10/15/2019] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE The aim of this study was to investigate the relationship between genetic variants in candidate genes and clinical severity and prognosis (recurrence) of ischemic stroke (IS) in a Brazilian population. METHODS This was a retrospective study based on clinical and demographic data retrieved from the JOINVASC cohort-Epidemiological Study on Cerebrovascular Diseases in Joinville and on respective DNA samples available at the Joinville Stroke Biobank, over the period 2010-2015. Four hundred and thirty-five subjects were included. Patients were divided into large artery atherosclerosis (195 cases) and cardioembolic IS (240 cases) subgroups according to Trial of Org 10172 in the Acute Stroke Treatment standards. The severity of the event was established from the score obtained using the National Institutes of Health Stroke Scale. The genotypic and allelic frequencies of each variant were acquired by Real-Time Polymerase Chain Reaction. The codominance model was considered for the analysis of the genotypes' influence. RESULTS There was no association between clinical severity and recurrence with variants rs2383207 (CDKN2B-AS1) for atherothrombotic IS and variants rs879324 (ZFHX3), rs966221 (PDE4D), and rs152312 (PDE4D) for cardioembolic IS. The variants rs1396476, rs2910829, rs6843082, and rs2107595 were not in Hardy-Weinberg equilibrium in the evaluated population. CONCLUSIONS Although this study failed to identify an association between genetic variants and clinical response variability, the need to carry out related studies with larger number of cases covering other populations and genetic variants remains, which would allow the uncovering of hypothetical genetic factors governing stroke outcomes and recurrence.
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Affiliation(s)
| | - Julia Schwartz
- Medicine Department, University of Joinville Region-UNIVILLE, Joinville, Brazil
| | | | - Leslie Ecker Ferreira
- Medicine Department, University of Joinville Region-UNIVILLE, Joinville, Brazil; Joinville Stroke Biobank, University of Joinville Region-UNIVILLE, Joinville, Brazil
| | - Norberto Luiz Cabral
- Medicine Department, University of Joinville Region-UNIVILLE, Joinville, Brazil; Joinville Stroke Biobank, University of Joinville Region-UNIVILLE, Joinville, Brazil
| | - Paulo Henrique Condeixa de França
- Medicine Department, University of Joinville Region-UNIVILLE, Joinville, Brazil; Joinville Stroke Biobank, University of Joinville Region-UNIVILLE, Joinville, Brazil.
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Gattellari M, Goumas C, Jalaludin B, Worthington J. The impact of disease severity adjustment on hospital standardised mortality ratios: Results from a service-wide analysis of ischaemic stroke admissions using linked pre-hospital, admissions and mortality data. PLoS One 2019; 14:e0216325. [PMID: 31112556 PMCID: PMC6528964 DOI: 10.1371/journal.pone.0216325] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 04/18/2019] [Indexed: 11/19/2022] Open
Abstract
Background Administrative data are used to examine variation in thirty-day mortality across health services in several jurisdictions. Hospital performance measurement may be error-prone as information about disease severity is not typically available in routinely collected data to incorporate into case-mix adjusted analyses. Using ischaemic stroke as a case study, we tested the extent to which accounting for disease severity impacts on hospital performance assessment. Methods We linked all recorded ischaemic stroke admissions between July, 2011 and June, 2014 to death registrations and a measure of stroke severity obtained at first point of patient contact with health services, across New South Wales, Australia’s largest health service jurisdiction. Thirty-day hospital standardised mortality ratios were adjusted for either comorbidities, as is typically done, or for both comorbidities and stroke severity. The impact of stroke severity adjustment on mortality ratios was determined using 95% and 99% control limits applied to funnel plots and by calculating the change in rank order of hospital risk adjusted mortality rates. Results The performance of the stroke severity adjusted model was superior to incorporating comorbidity burden alone (c-statistic = 0.82 versus 0.75; N = 17,700 patients, 176 hospitals). Concordance in outlier classification was 89% and 97% when applying 95% or 99% control limits to funnel plots, respectively. The sensitivity rates of outlier detection using comorbidity adjustment compared with gold-standard severity and comorbidity adjustment was 74% and 83% with 95% and 99% control limits, respectively. Corresponding positive predictive values were 74% and 91%. Hospital rank order of risk adjusted mortality rates shifted between 0 to 22 places with severity adjustment (Median = 4.0, Inter-quartile Range = 2–7). Conclusions Rankings of mortality rates varied widely depending on whether stroke severity was taken into account. Funnel plots yielded largely concordant results irrespective of severity adjustment and may be sufficiently accurate as a screening tool for assessing hospital performance.
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Affiliation(s)
- Melina Gattellari
- Heart and Brain Collaboration, Ingham Institute for Applied Medical Research, Liverpool, Sydney, New South Wales, Australia
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Camperdown, Sydney, New South Wales, Australia
| | - Chris Goumas
- Heart and Brain Collaboration, Ingham Institute for Applied Medical Research, Liverpool, Sydney, New South Wales, Australia
| | - Bin Jalaludin
- Population Health Intelligence, Healthy People and Places Unit; South Western Sydney Local Health District, Liverpool, Sydney, New South Wales, Australia
- School of Public Health, The University of New South Wales, Kensington, Sydney, New South Wales, Australia
| | - John Worthington
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Camperdown, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Liverpool, Sydney, New South Wales, Australia
- * E-mail:
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Li HJ, Kuo CC, Li YC, Tsai KY, Wu HC. Depression may not be a risk factor for mortality in stroke patients with nonsurgical treatment: A retrospective case-controlled study. Medicine (Baltimore) 2019; 98:e15753. [PMID: 31145292 PMCID: PMC6708841 DOI: 10.1097/md.0000000000015753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Patients with depression have more comorbidities than those without depression. The cost of depression-associated comorbidities accounts for the largest portion of the growing cost of depression treatment. Patients with depression have a higher risk of stroke with poor prognoses than those without depression; however, previous studies evaluating the relationship between depression and stroke prognosis have not accounted for surgical treatment or other risk factors. Therefore, we investigated whether depression is a risk factor for mortality in stroke patients with nonsurgical treatment after adjusting for other risk factors.We retrospectively analyzed the data of patients with major depressive disorder (MDD) and age and sex-matched controls without MDD during 1999 to 2005. We then identified patients who developed stroke in both groups and analyzed risk factors for death in these stroke patients who received nonsurgical treatments during a follow-up period from 2006 to 2012.Patients with MDD had higher Charlson Comorbidity Index Scores (CCISs) and exhibited higher frequencies of comorbidities such as diabetes mellitus, hypertension, hyperlipidemia, and coronary heart disease than controls without MDD, and most of MDD patients had very low or high socioeconomic status (SES) and lived in urban settings. Most stroke patients with MDD who received nonsurgical treatment were female, had very low or high SES, and lived in urban settings; in addition, stroke patients with MDD who received nonsurgical treatment had higher CCISs and frequencies of hyperlipidemia and coronary heart disease than those without MDD who received nonsurgical treatment. However, depression was not a risk factor for death in stroke patients with nonsurgical treatment.Hemorrhagic stroke, age, sex, and CCISs were risk factors for death in stroke patients with nonsurgical treatment, but depression did not affect the mortality rate in these patients.
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Affiliation(s)
| | - Chao-Chan Kuo
- Department of Adult Psychiatry, Kai-Syuan Psychiatric Hospital
| | - Ying-Chun Li
- Department of Business Management, College of Management, National Sun Yat-Sen University
| | - Kuan-Yi Tsai
- Department of Community Psychiatry, Kai-Syuan Psychiatric Hospital, Kaohsiung City, Taiwan
| | - Hung-Chi Wu
- Department of Community Psychiatry, Kai-Syuan Psychiatric Hospital, Kaohsiung City, Taiwan
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Zhou F, Liu Y, Shi H, Huang Q, Zhou J. Relation between lipoprotein-associated phospholipase A 2 mass and incident ischemic stroke severity. Neurol Sci 2018; 39:1591-1596. [PMID: 29938341 DOI: 10.1007/s10072-018-3474-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 06/09/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Manifestations of ischemic stroke vary widely, and serum biomarkers may be useful for stratification of risk of severe stroke. This study evaluated the association of lipoprotein-associated phospholipase A2 (Lp-PLA2) mass and initial severity. METHODS We employed a retrospective analysis on our hospital-based registry and recruited 488 first-onset ischemic stroke patients admitted within 24 h after onset and with Lp-PLA2 mass measured. Stroke severities evaluated by National Institutes of Health Stroke Scale (NIHSS) were compared between Lp-PLA2 categories dichotomized by median. Multivariate logistic regression was used to detect the independent risk factors of severe stroke (NIHSS ≥ 7) and receiver operator curve (ROC) was constructed to detect the value of addition of Lp-PLA2 to the model of other risk factors for predicting severe stroke. RESULTS Of the overall patients, the median admission NIHSS scores was 3 and 28.1% had severe manifestation. Admission NIHSS scores were different between patients of Lp-PLA2 above and under the median (median NIHSS 4 vs. 3, P < 0.001). Lp-PLA2 levels was correlated with admission NIHSS (r = 0.268, P < 0.001). Logistic regression showed Lp-PLA2 category (OR 2.37, 95%CI 1.44-3.90, P < 0.001) and levels per 100 ng/ml (OR 1.69, 95%CI 1.35-2.11, P < 0.001) were both independently associated with severe stroke. Addition of Lp-PLA2 category and levels to other independent risk factors both increased the area under curves (from 0.676 to 0.718 with category and 0.734 with levels). CONCLUSION Lp-PLA2 was independently related to admission severity in ischemic stroke patients, implying a potential predictive value of Lp-PLA2 for severe stroke in prevention.
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Affiliation(s)
- Feng Zhou
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yukai Liu
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Hongchao Shi
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Qing Huang
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Junshan Zhou
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
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The importance of atrial fibrillation and selected echocardiographic parameters for the effectiveness and safety of thrombolytic therapy in patients with stroke. Neurol Neurochir Pol 2018; 52:156-161. [DOI: 10.1016/j.pjnns.2017.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 08/30/2017] [Accepted: 09/04/2017] [Indexed: 11/18/2022]
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Phan TG, Clissold BB, Ma H, Ly JV, Srikanth V. Predicting Disability after Ischemic Stroke Based on Comorbidity Index and Stroke Severity-From the Virtual International Stroke Trials Archive-Acute Collaboration. Front Neurol 2017; 8:192. [PMID: 28579970 PMCID: PMC5437107 DOI: 10.3389/fneur.2017.00192] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 04/20/2017] [Indexed: 11/13/2022] Open
Abstract
Background and aim The availability and access of hospital administrative data [coding for Charlson comorbidity index (CCI)] in large data form has resulted in a surge of interest in using this information to predict mortality from stroke. The aims of this study were to determine the minimum clinical data set to be included in models for predicting disability after ischemic stroke adjusting for CCI and clinical variables and to evaluate the impact of CCI on prediction of outcome. Method We leverage anonymized clinical trial data in the Virtual International Stroke Trials Archive. This repository contains prospective data on stroke severity and outcome. The inclusion criteria were patients with available stroke severity score such as National Institutes of Health Stroke Scale (NIHSS), imaging data, and outcome disability score such as 90-day Rankin Scale. We calculate CCI based on comorbidity data in this data set. For logistic regression, we used these calibration statistics: Nagelkerke generalised R2 and Brier score; and for discrimination we used: area under the receiver operating characteristics curve (AUC) and integrated discrimination improvement (IDI). The IDI was used to evaluate improvement in disability prediction above baseline model containing age, sex, and CCI. Results The clinical data among 5,206 patients (55% males) were as follows: mean age 69 ± 13 years, CCI 4.2 ± 0.8, and median NIHSS of 12 (IQR 8, 17) on admission and 9 (IQR 5, 15) at 24 h. In Model 2, adding admission NIHSS to the baseline model improved AUC from 0.67 (95% CI 0.65–0.68) to 0.79 (95% CI 0.78–0.81). In Model 3, adding 24-h NIHSS to the baseline model resulted in substantial improvement in AUC to 0.90 (95% CI 0.89–0.91) and increased IDI by 0.23 (95% CI 0.22–0.24). Adding the variable recombinant tissue plasminogen activator did not result in a further change in AUC or IDI to this regression model. In Model 3, the variable NIHSS at 24 h explains 87.3% of the variance of Model 3, follow by age (8.5%), comorbidity (3.7%), and male sex (0.5%). Conclusion Our results suggest that prediction of disability after ischemic stroke should at least include 24-h NIHSS and age. The variable CCI is less important for prediction of disability in this data set.
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Affiliation(s)
- Thanh G Phan
- Stroke Unit, Monash Health and Stroke and Aging Research Group, Monash University, Melbourne, VIC, Australia
| | - Benjamin B Clissold
- Stroke Unit, Monash Health and Stroke and Aging Research Group, Monash University, Melbourne, VIC, Australia
| | - Henry Ma
- Stroke Unit, Monash Health and Stroke and Aging Research Group, Monash University, Melbourne, VIC, Australia
| | - John Van Ly
- Stroke Unit, Monash Health and Stroke and Aging Research Group, Monash University, Melbourne, VIC, Australia
| | - Velandai Srikanth
- Stroke Unit, Monash Health and Stroke and Aging Research Group, Monash University, Melbourne, VIC, Australia
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Bhalla A, Wang Y, Rudd A, Wolfe CDA. Does Admission to Hospital Affect Trends in Survival and Dependency After Stroke Using the South London Stroke Register? Stroke 2016; 47:2269-77. [PMID: 27507866 DOI: 10.1161/strokeaha.116.014136] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 06/30/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Despite guidelines for specialist assessment in hospital for stroke, it is important to identify patient characteristics, trends, and outcome in patients not admitted to hospital compared with patients admitted to hospital. METHODS Population-based stroke register of first in a life time strokes between 1995 and 2012 were examined. Baseline data included admission or nonadmission, case mix, stroke subtype, and risk factors before stroke. Survival curves were estimated with Kaplan-Meier methods. Logistic regression was used to determine factors associated with poor outcome (dead and dependency: Barthel index, <15) at 3 months and 1 year. RESULTS Three thousand four hundred sixty-four patients were admitted to hospital for stroke. Patients admitted were more likely have more severe impairments (P<0.001). There was a significant trend for increasing admission over time; 1995 to 2000 (82%), 2001 to 2006 (90%), and 2007 to 2012 (94%); P<0.001. When survival analysis was stratified according to Barthel index ≥15 at day 7, there were no significant differences in survival curves between admission and nonadmission groups in 1995 to 2000 (P=0.15) or 2001 to 2006 (P=0.06), but there was a significant trend for higher survival rates for nonadmission in the 2007 to 2012 cohort (P=0.025). Admission to hospital (stroke unit) compared with nonadmission was also associated with poor outcome in the 2001 to 2006 time period (odds ratio, 2.66; confidence interval, 1.17-6.04) and the 2007 to 2012 time period (odds ratio, 5.26; confidence interval, 1.27-21.81). CONCLUSION There is a survival advantage from 2007 onward and lower levels of dependency from 2001 onward after adjusting for case mix for those patients who are not admitted to hospital, which requires further explanation.
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Affiliation(s)
- Ajay Bhalla
- From the Division of Health and Social Care Research, King's College London, London, United Kingdom (A.B., Y.W., A.R., C.D.A.W.); NIHR Comprehensive Biomedical Research Center, Guy's and St Thomas' NHS Foundation, Trust and King's College London, London, United Kingdom (Y.W., A.R., C.D.A.W.); and Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (A.B.).
| | - Yanzhong Wang
- From the Division of Health and Social Care Research, King's College London, London, United Kingdom (A.B., Y.W., A.R., C.D.A.W.); NIHR Comprehensive Biomedical Research Center, Guy's and St Thomas' NHS Foundation, Trust and King's College London, London, United Kingdom (Y.W., A.R., C.D.A.W.); and Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (A.B.)
| | - Anthony Rudd
- From the Division of Health and Social Care Research, King's College London, London, United Kingdom (A.B., Y.W., A.R., C.D.A.W.); NIHR Comprehensive Biomedical Research Center, Guy's and St Thomas' NHS Foundation, Trust and King's College London, London, United Kingdom (Y.W., A.R., C.D.A.W.); and Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (A.B.)
| | - Charles D A Wolfe
- From the Division of Health and Social Care Research, King's College London, London, United Kingdom (A.B., Y.W., A.R., C.D.A.W.); NIHR Comprehensive Biomedical Research Center, Guy's and St Thomas' NHS Foundation, Trust and King's College London, London, United Kingdom (Y.W., A.R., C.D.A.W.); and Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (A.B.)
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