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Norlock V, Vazquez R, Dunn A, Siegfried C, Wadhwa M, Medic G. Comparing the outcomes and costs of cardiac monitoring with implantable loop recorders and mobile cardiac outpatient telemetry following stroke using real-world evidence. J Comp Eff Res 2024; 13:e240008. [PMID: 38602503 PMCID: PMC11145532 DOI: 10.57264/cer-2024-0008] [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: 01/26/2024] [Accepted: 03/22/2024] [Indexed: 04/12/2024] Open
Abstract
Aim: Patients with ischemic stroke (IS) commonly undergo monitoring to identify atrial fibrillation with mobile cardiac outpatient telemetry (MCOT) or implantable loop recorders (ILRs). The authors compared readmission, healthcare cost and survival in patients monitored post-stroke with either MCOT or ILR. Materials & methods: The authors used claims data from Optum's de-identified Clinformatics® Data Mart Database to identify patients with IS hospitalized from January 2017 to December 2020 who were prescribed ambulatory cardiac monitoring via MCOT or ILR. They compared the costs associated with the initial inpatient visit as well as the rate and causes of readmission, survival and healthcare costs over the following 18 months. Datasets were balanced using patient baseline and hospitalization characteristics. Multivariable generalized linear gamma regression was used for cost comparisons. Cox proportional hazard regression was used for survival and readmission analysis. Sub-cohorts were analyzed based on the severity of the index IS. Results: In 2244 patients, readmissions were significantly lower in the MCOT monitored group (30.2%) compared with the ILR group (35.4%) (hazard ratio [HR] 1.23; 95% CI: 1.04-1.46). Average cost over 18 months starting with the index IS was $27,429 (USD) lower in the MCOT group (95% CI: $22,353-$32,633). Survival difference bordered on statistical significance and trended to lower mortality in MCOT (8.9%) versus ILR (11.3%) (HR 1.30; 95% CI: 1:00-1.69), led by significance in patients with complications or comorbidities with the index event (MCOT 7.5%, ILR 11.5%; HR 1.62; 95% CI: 1.11-2.36). Conclusion: The use of MCOT versus ILR as the primary monitor following IS was associated with significant decreases in readmission, lower costs for the initial IS and total care over the next 18 months, significantly lower mortality for patients with complications and comorbidities at the index stroke, and a trend toward improved survival across all patients.
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Kwok CS, Gillani SA, Bains NK, Gomez CR, Hanley DF, Ford DE, Hassan AE, Nguyen TN, Siddiq F, Spiotta AM, Qureshi AI. Mechanical thrombectomy in patients with acute ischemic stroke in the USA before and after time window expansion. J Neurointerv Surg 2024; 16:447-452. [PMID: 37438102 DOI: 10.1136/jnis-2023-020286] [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: 03/03/2023] [Accepted: 05/22/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND In 2018, the time window for mechanical thrombectomy eligibility in patients with acute ischemic stroke increased from within 6 hours to within 24 hours of symptom onset. The purpose of this study was to evaluate the effect of window expansion on procedural and hospital volumes and patient outcomes at a national level. METHODS We conducted a retrospective cohort study of patients with acute ischemic stroke undergoing mechanical thrombectomy using data from the National Inpatient Sample. We compared the numbers of mechanical thrombectomy procedures and performing hospitals between 2017 and 2019 in the USA, and the proportion of patients discharged home/self-care, those with in-hospital mortality and post-procedural intracranial hemorrhage (2019 vs 2017) after adjustment for potential confounders. RESULTS The number of patients with ischemic stroke who underwent mechanical thrombectomy increased from 16 960 in 2017 to 28 120 in 2019. There was an increase in the number of hospitals performing mechanical thrombectomy (501 in 2017, 585 in 2019) and those performing ≥50 procedures/year (97 in 2017, 199 in 2019; P<0.001). The odds of in-hospital mortality decreased (OR 0.79, 95% CI 0.66 to 0.94, P=0.008) and the odds of intracranial hemorrhage increased (OR 1.18, 95% CI 1.06 to 1.31, P=0.003) in 2019 compared with 2017, with no change in odds of discharge to home. CONCLUSIONS The window expansion for mechanical thrombectomy for patients with acute ischemic stroke was associated with an increase in the numbers of mechanical thrombectomy procedures and performing hospitals with a reduction of in-hospital mortality in the USA.
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Affiliation(s)
- Chun Shing Kwok
- Department of Post Qualifying Healthcare Practice, Birmingham City University, Birmingham, UK
- Department of Cardiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Syed A Gillani
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Navpreet K Bains
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Camilo R Gomez
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Daniel F Hanley
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Daniel E Ford
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Thanh N Nguyen
- Neurology, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Farhan Siddiq
- Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
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de Havenon A, Zhou LW, Koo AB, Matouk C, Falcone GJ, Sharma R, Ney J, Shu L, Yaghi S, Kamel H, Sheth KN. Endovascular Treatment of Acute Ischemic Stroke After Cardiac Interventions in the United States. JAMA Neurol 2024; 81:264-272. [PMID: 38285452 PMCID: PMC10825786 DOI: 10.1001/jamaneurol.2023.5416] [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: 09/07/2023] [Accepted: 11/25/2023] [Indexed: 01/30/2024]
Abstract
Importance Ischemic stroke is a serious complication of cardiac intervention, including surgery and percutaneous procedures. Endovascular thrombectomy (EVT) is an effective treatment for ischemic stroke and may be particularly important for cardiac intervention patients who often cannot receive intravenous thrombolysis. Objective To examine trends in EVT for ischemic stroke during hospitalization of patients with cardiac interventions vs those without in the United States. Design, Setting, and Participants This cohort study involved a retrospective analysis using data for 4888 US hospitals from the 2016-2020 National Inpatient Sample database. Participants included adults (age ≥18 years) with ischemic stroke (per codes from the International Statistical Classification of Diseases, Tenth Revision, Clinical Modification), who were organized into study groups of hospitalized patients with cardiac interventions vs without. Individuals were excluded from the study if they had either procedure prior to admission, EVT prior to cardiac intervention, EVT more than 3 days after admission or cardiac intervention, or endocarditis. Data were analyzed from April 2023 to October 2023. Exposures Cardiac intervention during admission. Main Outcomes and Measures The odds of undergoing EVT by cardiac intervention status were calculated using multivariable logistic regression. Adjustments were made for stroke severity in the subgroup of patients who had a National Institutes of Health Stroke Scale (NIHSS) score documented. As a secondary outcome, the odds of discharge home by EVT status after cardiac intervention were modeled. Results Among 634 407 hospitalizations, the mean (SD) age of the patients was 69.8 (14.1) years, 318 363 patients (50.2%) were male, and 316 044 (49.8%) were female. A total of 12 093 had a cardiac intervention. An NIHSS score was reported in 218 576 admissions, 216 035 (34.7%) without cardiac intervention and 2541 (21.0%) with cardiac intervention (P < .001). EVT was performed in 23 660 patients (3.8%) without cardiac intervention vs 194 (1.6%) of those with cardiac intervention (P < .001). After adjustment for potential confounders, EVT was less likely to be performed in stroke patients with cardiac intervention vs those without (adjusted odds ratio [aOR], 0.27; 95% CI, 0.23-0.31), which remained consistent after adjusting for NIHSS score (aOR, 0.28; 95% CI, 0.22-0.35). Among individuals with a cardiac intervention, receiving EVT was associated with a 2-fold higher chance of discharge home (aOR, 2.21; 95% CI, 1.14-4.29). Conclusions and Relevance In this study, patients hospitalized with ischemic stroke and cardiac intervention may be less than half as likely to receive EVT as those without cardiac intervention. Given the known benefit of EVT, there is a need to better understand the reasons for lower rates of EVT in this patient population.
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Affiliation(s)
- Adam de Havenon
- Department of Neurology, Center for Brain and Mind Health, Yale University, New Haven, Connecticut
| | - Lily W. Zhou
- Department of Neurology, The University of British Columbia, Vancouver, Canada
| | - Andrew B. Koo
- Department of Neurosurgery, Yale University, New Haven, Connecticut
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, Connecticut
| | - Guido J. Falcone
- Department of Neurology, Center for Brain and Mind Health, Yale University, New Haven, Connecticut
| | - Richa Sharma
- Department of Neurology, Center for Brain and Mind Health, Yale University, New Haven, Connecticut
| | - John Ney
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Liqi Shu
- Department of Neurology, Brown University, Providence, Rhode Island
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, Rhode Island
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, New York
- Deputy Editor, JAMA Neurology
| | - Kevin N. Sheth
- Department of Neurology, Center for Brain and Mind Health, Yale University, New Haven, Connecticut
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Qureshi AI, Suri MFK, Shah QA, Maqsood H, Siddiq F, Gomez CR, Kwok CS. Acute ischemic stroke patients admitted to hospitals that perform percutaneous coronary interventions in the United States. J Stroke Cerebrovasc Dis 2023; 32:107405. [PMID: 37924778 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107405] [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: 07/16/2023] [Revised: 09/05/2023] [Accepted: 10/01/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND We explored the potential of mechanical thrombectomy (MT) for acute ischemic stroke patients at hospitals that perform percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) in the United States. METHODS We analyzed nationally representative data between 2017 and 2020 to determine the numbers, characteristics, and outcomes of acute ischemic stroke patients admitted to hospitals that perform both primary PCI and MT, hospitals that perform primary PCI but not MT and hospitals that perform neither PCI or MT. Multiple logistic regressions were performed to evaluate the effect of hospital type on in-hospital mortality and discharge home (without palliative care). RESULTS A total of 1,210,415, 1,002,950, and 488,845 acute ischemic stroke patients were admitted to hospitals that performed both primary PCI and MT, performed primary PCI but not MT, or performed neither PCI nor MT, respectively. Compared with hospitals that performed both PCI and MT, the odds of in-hospital mortality were lower in hospitals that performed PCI only (odds ratio (OR) 0.88 95 % confidence interval (CI) 0.86-0.91, p<0.001) and hospitals that performed neither PCI or MT (OR 0.85 95 %CI 0.82-0.89, p<0.0010). There was no significant difference in the odds of discharge home between the three types of hospitals. CONCLUSIONS Almost 37 % the patients with acute ischemic stroke are admitted to hospitals that perform primary PCI (but not MT) supporting strategies to increase the performance of MT in such hospitals as an option to increase rapid availability of MT in the United States.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
| | - M Fareed K Suri
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA; Department of Neurosurgery, University of Missouri, Columbia, MO, USA
| | - Qaisar A Shah
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA; Department of Neurosurgery, University of Missouri, Columbia, MO, USA
| | - Hamza Maqsood
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Farhan Siddiq
- Department of Neurosurgery, University of Missouri, Columbia, MO, USA
| | - Camilo R Gomez
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA; Department of Neurosurgery, University of Missouri, Columbia, MO, USA
| | - Chun Shing Kwok
- Department of Cardiology, University Hospitals of North Midlands NHS Trust, United Kingdom.
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Zachrison KS, Hsia RY, Schwamm LH, Yan Z, Samuels-Kalow ME, Reeves MJ, Camargo CA, Onnela JP. Insurance-Based Disparities in Stroke Center Access in California: A Network Science Approach. Circ Cardiovasc Qual Outcomes 2023; 16:e009868. [PMID: 37746725 PMCID: PMC10592016 DOI: 10.1161/circoutcomes.122.009868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 08/18/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Our objectives were to determine whether there is an association between ischemic stroke patient insurance and likelihood of transfer overall and to a stroke center and whether hospital cluster modified the association between insurance and likelihood of stroke center transfer. METHODS This retrospective network analysis of California data included every nonfederal hospital ischemic stroke admission from 2010 to 2017. Transfers from an emergency department to another hospital were categorized based on whether the patient was discharged from a stroke center (primary or comprehensive). We used logistic regression models to examine the relationship between insurance (private, Medicare, Medicaid, uninsured) and odds of (1) any transfer among patients initially presenting to nonstroke center hospital emergency departments and (2) transfer to a stroke center among transferred patients. We used a network clustering method to identify clusters of hospitals closely connected through transfers. Within each cluster, we quantified the difference between insurance groups with the highest and lowest proportion of transfers discharged from a stroke center. RESULTS Of 332 995 total ischemic stroke encounters, 51% were female, 70% were ≥65 years, and 3.5% were transferred from the initial emergency department. Of 52 316 presenting to a nonstroke center, 3466 (7.1%) were transferred. Relative to privately insured patients, there were lower odds of transfer and of transfer to a stroke center among all groups (Medicare odds ratio, 0.24 [95% CI, 0.22-0.26] and 0.59 [95% CI, 0.50-0.71], Medicaid odds ratio, 0.26 [95% CI, 0.23-0.29] and odds ratio, 0.49 [95% CI, 0.38-0.62], uninsured odds ratio, 0.75 [95% CI, 0.63-0.89], and 0.72 [95% CI, 0.6-0.8], respectively). Among the 14 identified hospital clusters, insurance-based disparities in transfer varied and the lowest performing cluster (also the largest; n=2364 transfers) fully explained the insurance-based disparity in odds of stroke center transfer. CONCLUSIONS Uninsured patients had less stroke center access through transfer than patients with insurance. This difference was largely explained by patterns in 1 particular hospital cluster.
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Affiliation(s)
- Kori S Zachrison
- Departments of Emergency Medicine (K.S.Z., Z.Y., M.E.S.-K., C.A.C.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California San Francisco, San Francisco (R.Y.H.)
| | - Lee H Schwamm
- Neurology (L.H.S.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Zhiyu Yan
- Departments of Emergency Medicine (K.S.Z., Z.Y., M.E.S.-K., C.A.C.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Margaret E Samuels-Kalow
- Departments of Emergency Medicine (K.S.Z., Z.Y., M.E.S.-K., C.A.C.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
| | - Carlos A Camargo
- Departments of Emergency Medicine (K.S.Z., Z.Y., M.E.S.-K., C.A.C.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Jukka-Pekka Onnela
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (J.-P.O.)
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Etges APBDS, de Souza AC, Jones P, Liu H, Zhang X, Marcolino M, Polanczyk CA, Martins SO, Sampaio G, Lioutas VA. Variation in Ischemic Stroke Payments in the USA: A Medicare Beneficiary Study. Cerebrovasc Dis 2023; 53:298-306. [PMID: 37717574 DOI: 10.1159/000533513] [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: 06/14/2023] [Accepted: 08/03/2023] [Indexed: 09/19/2023] Open
Abstract
INTRODUCTION The growing cost of stroke care has created the need for outcome-oriented and cost-saving payment models. Identifying imbalances in the current reimbursement model is an essential step toward designing impactful value-based reimbursement strategies. This study describes the variation in reimbursement fees for ischemic stroke management across the USA. METHODS This Medicare Fee-For-Service claims study examines USA beneficiaries who suffered an ischemic stroke from 2021Q1 to 2022Q2 identified using the Medicare-Severity Diagnosis-Related Groups (MS-DRGs). Demographic national and regional US data were extracted from the Census Bureau. The MS-DRG codes were grouped into four categories according to treatment modality and clinical complexity. Our primary outcome of interest was payments made across individual USA and US geographic regions, assessed by computing the mean incremental payment in cases of comparable complexity. Differences between states for each MS-DRG were statistically evaluated using a linear regression model of the logarithmic transformed payments. RESULTS 227,273 ischemic stroke cases were included in our analysis. Significant variations were observed among all DRGs defined by medical complexity, treatment modality, and states (p < 0.001). Differences in mean payment per case with the same MS-DRG vary by as high as 500% among individual states. Although higher payment rates were observed in MS-DRG codes with major comorbidities or complexity (MCC), the variation was more expressive for codes without MCC. It was not possible to identify a standard mean incremental fee at a state level. At a regional level, the Northeast registered the highest fees, followed by the West, Midwest, and South, which correlate with poverty rates and median household income in the regions. CONCLUSIONS The payment variability observed across USA suggests that the current reimbursement system needs to be aligned with stroke treatment costs. Future studies may go one step further to evaluate accurate stroke management costs to guide policymakers in introducing health policies that promote better care for stroke patients.
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Affiliation(s)
- Ana Paula Beck da Silva Etges
- Avant-garde Health, Boston, Massachusetts, USA,
- National Institute of Science and Technology for Health Technology Assessment (IATS) - CNPq/Brazil (Project: 465518/2014-1), Porto Alegre, Brazil,
- Graduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil,
| | | | | | - Harry Liu
- Avant-garde Health, Boston, Massachusetts, USA
| | | | - Miriam Marcolino
- National Institute of Science and Technology for Health Technology Assessment (IATS) - CNPq/Brazil (Project: 465518/2014-1), Porto Alegre, Brazil
- Graduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Carisi Anne Polanczyk
- National Institute of Science and Technology for Health Technology Assessment (IATS) - CNPq/Brazil (Project: 465518/2014-1), Porto Alegre, Brazil
- Graduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Hospital Moinhos de Vento, Porto Alegre, Brazil
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Sheila Ouriques Martins
- Hospital Moinhos de Vento, Porto Alegre, Brazil
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Gisele Sampaio
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vasileios Arsenios Lioutas
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Kwok CS, Bains NK, Ford DE, Gomez CR, Hanley DF, Hassan AE, Nguyen TN, Siddiq F, Spiotta AM, Zaidi SF, Qureshi AI. Intra-arterial thrombolysis as adjunct to mechanical thrombectomy in acute ischemic stroke patients in the United States: A case control analysis. J Stroke Cerebrovasc Dis 2023; 32:107093. [PMID: 37149924 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107093] [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: 02/04/2023] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 05/09/2023] Open
Abstract
BACKGROUND Although observational studies have reported favorable clinical outcomes associated with intra-arterial thrombolysis as adjunct to mechanical thrombectomy, the cost and length of hospitalization associated with this intervention has not been studied. METHODS We analyzed the nationally representative data of the United States data from Nationwide Inpatient Sample (NIS) to compare hospitalization cost and duration in addition to other outcomes in patients receiving (n = 1990) with those not receiving intra-arterial thrombolysis (n = 1990) in acute ischemic stroke patients undergoing mechanical thrombectomy using a case control design matched for age, gender, and presence of aphasia, hemiplegia, neglect, coma/stupor, hemianopsia and dysphagia. RESULTS There was no difference in the median hospitalization cost in patients treated with intra-arterial thrombolysis compared with those not treated with intra-arterial thrombolysis: $36,992 [28,361 to 54,336] versus $35,440 [24,383 to 50,438], (regression coefficient 2,485 [-1,947 to 6,917], p = 0.27). There was no difference in the median length of hospitalization in patients treated with intra-arterial thrombolysis compared with those not treated with intra-arterial thrombolysis: 6 days [3 to 10] versus 6 days [4 to 10], (regression coefficient -0.34 [-1.47 to 0.80], p = 0.56). There was no difference in odds of home-discharge (OR 1.02 95%CI 0.72-1.43, p = 0.93) or post-procedural intracranial hemorrhage (OR 1.16 95%CI 0.83-1.64, p = 0.39) between the two groups. CONCLUSIONS We did not observe an increase in the cost or length of hospitalization associated with the use of intra-arterial thrombolysis as adjunct to mechanical thrombectomy in acute ischemic stroke patients. If the ongoing randomized clinical trials demonstrate therapeutic efficacy in reducing death or disability, this intervention has a high likelihood of being beneficial overall.
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Affiliation(s)
- Chun Shing Kwok
- Department of Post Qualifying Healthcare Practice, Birmingham City University, Birmingham, United Kingdom; Department of Cardiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom.
| | - Navpreet K Bains
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Daniel E Ford
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Camilo R Gomez
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Daniel F Hanley
- Departments of Neurology and Neurosurgery, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ameer E Hassan
- Department of Neurology, UTRGV - Valley Baptist Neuroscience Institute, Harlingen, TX, USA
| | - Thanh N Nguyen
- Division of Interventional Neurology/Neuroradiology, Boston Medical Center, Boston, MA, USA
| | - Farhan Siddiq
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Syed F Zaidi
- Department of Neurology, The University of Toledo, Toledo, OH, USA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
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de Havenon A, Zhou LW, Yaghi S, Frontera JA, Sheth KN. Effect of COVID-19 on Acute Ischemic Stroke Severity and Mortality in 2020: Results From the 2020 National Inpatient Sample. Stroke 2023; 54:e194-e198. [PMID: 37021563 PMCID: PMC10121243 DOI: 10.1161/strokeaha.122.041929] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/03/2023] [Accepted: 02/22/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND There is a paucity of nationally representative data regarding the impact of COVID-19 on acute ischemic stroke (AIS) outcome. METHODS We created a cross-sectional cohort of nationally weighted National Inpatient Sample nonelective hospital discharges aged ≥18 years with a diagnosis of ischemic stroke from 2016 to 2020. The outcome was in-hospital mortality and exposure was COVID-19 status. To understand the effect of COVID-19 on AIS severity, we report National Institutes of Health Stroke Scale by exposure status. In a final analysis, we used a nationally weighted logistic regression and marginal effects to compare April to December 2020 to the same period in 2019 to understand how the pandemic modified the effect of race and ethnicity and median household income on in-hospital AIS mortality. RESULTS We observed significantly higher AIS mortality in 2020 than prior years (2020 versus 2016-19, 7.3% versus 6.3%, P<0.001) and higher National Institutes of Health Stroke Scale in those with COVID-19 than those without (mean: 9.7±9.1 versus 6.6±7.4, P<0.001), but patients with AIS without COVID in 2020 had only marginally higher mortality (2020 versus 2016-2019, 6.6% versus 6.3%, P=0.001). Comparing April to December 2020 to 2019, the adjusted risk of in-hospital AIS mortality was most notably increased in Hispanics (2020 versus 2019: 9.2% versus 5.8%, P<0.001) and the lowest quartile of income (2020 versus 2019: 8.0% versus 6.0%, P<0.001). CONCLUSIONS In-hospital stroke mortality increased in 2020 in the United States because of comorbid AIS and COVID-19, which had higher stroke severity. The increase in AIS mortality during April-December 2020 was significantly more pronounced in Hispanics and those in the lowest quartile of household income.
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Affiliation(s)
- Adam de Havenon
- Department of Neurology, Yale University, New Haven, CT (A.d.H., K.N.S.)
| | - Lily W. Zhou
- Department of Neurology, The University of British Columbia, Vancouver, Canada (L.W.Z.)
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, RI (S.Y.)
| | | | - Kevin N. Sheth
- Department of Neurology, Yale University, New Haven, CT (A.d.H., K.N.S.)
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Keller K, Haghi SHR, Hahad O, Schmidtmann I, Chowdhury S, Lelieveld J, Münzel T, Hobohm L. Air pollution impacts on in-hospital case-fatality rate of ischemic stroke patients. Thromb Res 2023; 225:116-125. [PMID: 36990953 DOI: 10.1016/j.thromres.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 03/15/2023] [Accepted: 03/17/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND A growing body of evidence suggests that air pollution exposure is associated with an increased risk for cardiovascular diseases. Data regarding the impact of long-term air pollution exposure on ischemic stroke mortality are sparse. METHODS The German nationwide inpatient sample was used to analyse all cases of hospitalized patients with ischemic stroke in Germany 2015-2019, which were stratified according to their residency. Data of the German Federal Environmental Agency regarding average values of air pollutants were assessed from 2015 to 2019 at district-level. Data were combined and the impact of different air pollution parameters on in-hospital case-fatality was analyzed. RESULTS Overall, 1,505,496 hospitalizations of patients with ischemic stroke (47.7% females; 67.4 % ≥70 years old) were counted in Germany 2015-2019, of whom 8.2 % died during hospitalization. When comparing patients with residency in federal districts with high vs. low long-term air pollution, enhanced levels of benzene (OR 1.082 [95%CI 1.034-1.132],P = 0.001), ozone (O3, OR 1.123 [95%CI 1.070-1.178],P < 0.001), nitric oxide (NO, OR 1.076 [95%CI 1.027-1.127],P = 0.002) and PM2.5 fine particulate matter concentrations (OR 1.126 [95%CI 1.074-1.180],P < 0.001) were significantly associated with increased case-fatality independent from age, sex, cardiovascular risk-factors, comorbidities, and revascularization treatments. Conversely, enhanced carbon monoxide, nitrogen dioxide, PM10, and sulphur dioxide (SO2) concentrations were not significantly associated with stroke mortality. However, SO2-concentrations were significantly associated with stroke-case-fatality rate of >8 % independent of residence area-type and area use (OR 1.518 [95%CI 1.012-2.278],P = 0.044). CONCLUSION Elevated long-term air pollution levels in residential areas in Germany, notably of benzene, O3, NO, SO2, and PM2.5, were associated with increased stroke mortality of patients. RESEARCH IN CONTEXT Evidence before this study: Besides typical, established risk factors, increasing evidence suggests that air pollution is an important and growing risk factor for stroke events, estimated to be responsible for approximately 14 % of all stroke-associated deaths. However, real-world data regarding the impact of long-term exposure to air pollution on stroke mortality are sparse. Added value of this study: The present study demonstrates that the long-term exposure to the air pollutants benzene, O3, NO, SO2 and PM2.5 are independently associated with increased case-fatality of hospitalized patients with ischemic stroke in Germany. Implications of all the available evidence: The results of our study support the urgent need to reduce the exposure to air pollution by tightening emission controls to reduce the stroke burden and stroke mortality.
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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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Zachrison KS, Amati V, Schwamm LH, Yan Z, Nielsen V, Christie A, Reeves MJ, Sauser JP, Lomi A, Onnela JP. Influence of Hospital Characteristics on Hospital Transfer Destinations for Patients With Stroke. Circ Cardiovasc Qual Outcomes 2022; 15:e008269. [PMID: 35369714 DOI: 10.1161/circoutcomes.121.008269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Patients with stroke are frequently transferred between hospitals. This may have implications on the quality of care received by patients; however, it is not well understood how the characteristics of sending and receiving hospitals affect the likelihood of a transfer event. Our objective was to identify hospital characteristics associated with sending and receiving patients with stroke. METHODS Using a comprehensive statewide administrative dataset, including all 78 Massachusetts hospitals, we identified all transfers of patients with ischemic stroke between October 2007 and September 2015 for this observational study. Hospital variables included reputation (US News and World Report ranking), capability (stroke center status, annual stroke volume, and trauma center designation), and institutional affiliation. We included network variables to control for the structure of hospital-to-hospital transfers. We used relational event modeling to account for complex temporal and relational dependencies associated with transfers. This method decomposes a series of patient transfers into a sequence of decisions characterized by transfer initiations and destinations, modeling them using a discrete-choice framework. RESULTS Among 73 114 ischemic stroke admissions there were 7189 (9.8%) transfers during the study period. After accounting for travel time between hospitals and structural network characteristics, factors associated with increased likelihood of being a receiving hospital (in descending order of relative effect size) included shared hospital affiliation (5.8× higher), teaching hospital status (4.2× higher), stroke center status (4.3× and 3.8× higher when of the same or higher status), and hospitals of the same or higher reputational ranking (1.5× higher). CONCLUSIONS After accounting for distance and structural network characteristics, in descending order of importance, shared hospital affiliation, hospital capabilities, and hospital reputation were important factor in determining transfer destination of patients with stroke. This study provides a starting point for future research exploring how relational coordination between hospitals may ensure optimized allocation of patients with stroke for maximal patient benefit.
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Affiliation(s)
- Kori S Zachrison
- Departments of Emergency Medicine (K.S.Z.), Massachusetts General Hospital, Boston.,Harvard Medical School (K.S.Z., L.H.S.), Boston, MA
| | - Viviana Amati
- Social Networks Lab of the Department of Humanities, Social, and Political Sciences, ETH Zurich, Switzerland (V.A.)
| | - Lee H Schwamm
- Neurology (L.H.S., Z.Y.), Massachusetts General Hospital, Boston.,Harvard Medical School (K.S.Z., L.H.S.), Boston, MA
| | - Zhiyu Yan
- Neurology (L.H.S., Z.Y.), Massachusetts General Hospital, Boston
| | - Victoria Nielsen
- Massachusetts Department of Public Health, Boston, MA (V.N., A.C.)
| | - Anita Christie
- Massachusetts Department of Public Health, Boston, MA (V.N., A.C.)
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics of Michigan State University, East Lansing (M.J.R.)
| | - Joseph P Sauser
- Hankamer School of Business at Baylor University, Waco, TX (J.P.S.)
| | - Alessandro Lomi
- Faculty of Economics of the University of Italian Switzerland, Lugano, Switzerland (A.L.)
| | - Jukka-Pekka Onnela
- Department of Biostatistics at the Harvard T.H. Chan School of Public Health, Boston, MA (J.P.O.)
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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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Sadeh M, Patel S, Souter J, Chiu R, Ansari D, Atwal GS. Clinical and radiographic risk indicators for decompressive hemicraniectomy in patients with ischemic stroke: an institutional and national analysis. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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14
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Aroor SR, Asif KS, Potter-Vig J, Sharma A, Menon BK, Inoa V, Zevallos CB, Romano JG, Ortega-Gutierrez S, Goldstein LB, Yavagal DR. Mechanical Thrombectomy Access for All? Challenges in Increasing Endovascular Treatment for Acute Ischemic Stroke in the United States. J Stroke 2022; 24:41-48. [PMID: 35135058 PMCID: PMC8829477 DOI: 10.5853/jos.2021.03909] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 01/11/2022] [Indexed: 11/11/2022] Open
Abstract
Mechanical thrombectomy (MT) is the most effective treatment for selected patients with an acute ischemic stroke due to emergent large vessel occlusions (LVOs). There is an urgent need to identify and address challenges in access to MT to maximize the numbers of patients who can benefit from this treatment. Barriers in access to MT include delays in evaluation and accurate diagnosis of LVO leading to inappropriate triage, logistical delays related to availability of facilities and trained interventionalists, and financial hurdles that affect treatment reimbursement. Collection of regional data related to these barriers is critical to better understand current access gaps and a measurable access score to thrombectomy could be useful to plan local public health intervention.
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Affiliation(s)
- Sushanth Rao Aroor
- Department of Neurology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Kaiz S. Asif
- Department of Neurosurgery, University of Illinois and AMITA Health, Chicago, IL, USA
| | | | - Arun Sharma
- University of Miami, Herbert Business School, Miami, FL, USA
| | - Bijoy K. Menon
- Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Violiza Inoa
- Semmes Murphey Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Cynthia B. Zevallos
- Department of Neurology, University of Iowa Hospital and Clinics, Iowa City, IA, USA
| | - Jose G. Romano
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Larry B. Goldstein
- Department of Neurology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Dileep R. Yavagal
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Correspondence: Dileep R. Yavagal Departments of Neurology and Neurosurgery, University of Miami Miller School of Medicine, 1600 NW 10th Ave 1140, Miami, FL 33136, USA Tel: +1-305-355-1103 E-mail:
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Neves G, Cole T, Lee J, Bueso T, Shaw C, Montalvan V. Demographic and institutional predictors of stroke hospitalization mortality among adults in the United States. eNeurologicalSci 2022; 26:100392. [PMID: 35146139 PMCID: PMC8802002 DOI: 10.1016/j.ensci.2022.100392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 12/24/2021] [Accepted: 01/13/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction Stroke remains a primary source of functional disability and inpatient mortality in the United States (US). Recent evidence reveals declining mortality associated with stroke hospitalizations in the US. However, data updating trends in inpatient mortality is lacking. This study aims to provide a renewed inpatient stroke mortality rate in a national sample and identify common predictors of inpatient stroke mortality. Methods In this cross-sectional study, we analyzed data from a nationwide database between 2010 and 2017. We included patient encounters for both ischemic (ICD9 433–434, ICD10 I630–I639) and hemorrhagic stroke (ICD9 430–432, ICD10 I600–I629). We performed an annual comparison of in-hospital stroke mortality rates, and a cross-sectional analytic approach of multiple variables identified common predictors of inpatient stroke mortality. Results Between 2010 and 2017, we identified 518,185 total stroke admissions (86.6% ischemic stroke and 13.4% hemorrhagic strokes). Stroke admissions steadily increased during the studied period, whereas we observed a steady decline in in-hospital mortality during the same time. The inpatient stroke mortality rate gradually declined from 4.8% in 2010 (95% CI 4.6–5.1) to 2.1% in 2017 (95% CI 2.0–2.1). Predictors of higher odds of dying from ischemic stroke were female (OR 1.059, 95% CI 1.015–1.105, p = 0.008), older age (OR 1.028, 95% CI 1.026–1.029, p < 0.001), and sicker patients (OR 1.091, 95% CI 1.089–1.093, p < 0.001). Predictors of higher odds of dying from hemorrhagic stroke were Hispanic ethnicity (OR 1.459, 95% CI 1.084–1.926, p < 0.001), older age (OR 1.021, 95% CI 1.019–1.023, p < 0.001), and sicker patients (OR 1.042, 95% CI 1.039–1.045, p < 0.001). All census regions and hospital types demonstrated improvements in in-hospital mortality. Conclusion This study identified a continuous declining rate in in-hospital mortality due to stroke in the United States, and it also identified demographic and hospital predictors of inpatient stroke mortality. Stroke remains a leading cause of morbidity and mortality in the United States Stroke hospitalization mortality trends are important to guide efforts in acute stroke care Vascular risk factors are still prevalent in the population admitted due to stroke and continue to be associated with higher odds of death There are important regional disparities in stroke hospitalization deaths in the United States Hospital characteristics influence odds of death from a stroke independent of stroke etiology
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Affiliation(s)
- Gabriel Neves
- Department of Neurology, Texas Tech University Medical Sciences Center, Lubbock, TX, USA
- Corresponding author at: Department of Neurology, Texas Tech University Health Sciences Center, Room 3A105, 3601 4 street, Lubbock, TX 79430, USA.
| | - Travis Cole
- Graduate School of Biomedical Sciences, Texas Tech University Medical Sciences Center, Lubbock, TX, USA
| | - Jeannie Lee
- Department of Neurology, Texas Tech University Medical Sciences Center, Lubbock, TX, USA
| | - Tulio Bueso
- Department of Neurology, Texas Tech University Medical Sciences Center, Lubbock, TX, USA
| | - Chip Shaw
- Graduate School of Biomedical Sciences, Texas Tech University Medical Sciences Center, Lubbock, TX, USA
| | - Victor Montalvan
- Department of Neurology, Texas Tech University Medical Sciences Center, Lubbock, TX, USA
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