A Network Approach to Stroke Systems of Care

FHIR Implementation Guide for Stroke: A dual focus on the patient's clinical pathway and value-based healthcare

BACKGROUND

Stroke management requires a coordinated strategy, adhering to clinical pathways (CP) and value-based healthcare (VBHC) principles from onset to rehabilitation. However, the discrepancies between these pathways and actual patient experiences highlight the need for ongoing monitoring and addressing interoperability issues across multiple institutions in stroke care. To address this, the Fast Healthcare Interoperability Resource (FHIR) Implementation Guide (IG) standardizes the information exchange among these systems, considering a specific context of use.

OBJECTIVE

Develop an FHIR IG for stroke care rooted in established stroke CP and VBHC principles.

METHOD

We represented the stroke patient journey by considering the core stroke CP, the International Consortium for Health Outcomes Measurement (ICHOM) dataset for stroke, and a Brazilian case study using the Business Process Model and Notation (BPMN). Next, we developed a data dictionary that aligns variables with existing FHIR resources and adapts profiling from the Brazilian National Health Data Network (BNHDN).

RESULTS

Our BPMN model encompassed three critical phases that represent the entire patient journey from symptom onset to rehabilitation. The stroke data dictionary included 81 variables, which were expressed as questionnaires, profiles, and extensions. The FHIR IG comprised nine pages: Home, Stroke-CP, Data Dictionary, FHIR, ICHOM, Artifacts, Examples, Downloads, and Security. We developed 96 artifacts, including 7 questionnaires, 27 profiles with corresponding example instances, 3 extensions, 18 value sets, and 14 code systems pertinent to ICHOM outcome measures.

CONCLUSION

The FHIR IG for stroke in this study represents a significant advancement in healthcare interoperability, streamlining the tracking of patient outcomes for quality enhancement, facilitating informed treatment choices, and enabling the development of dashboards to promote collaborative excellence in patient care.

Network analysis of stroke systems of care in Korea

Background

The landscape of stroke care has shifted from stand-alone hospitals to cooperative networks among hospitals. Despite the importance of these networks, limited information exists on their characteristics and functional attributes.

Methods

We extracted patient-level data on acute stroke care and hospital connectivity by integrating national stroke audit data with reimbursement claims data. We then used this information to transform interhospital transfers into a network framework, where hospitals were designated as nodes and transfers as edges. Using the Louvain algorithm, we grouped densely connected hospitals into distinct stroke care communities. The quality and characteristics in given stroke communities were analysed, and their distinct types were derived using network parameters. The clinical implications of this network model were also explored.

Results

Over 6 months, 19 113 patients with acute ischaemic stroke initially presented to 1009 hospitals, with 3114 (16.3%) transferred to 246 stroke care hospitals. These connected hospitals formed 93 communities, with a median of 9 hospitals treating a median of 201 patients. Derived communities demonstrated a modularity of 0.904 , indicating a strong community structure, highly centralised around one or two hubs. Three distinct types of structures were identified: single-hub (n=60), double-hub (n=22) and hubless systems (n=11). The endovascular treatment rate was highest in double-hub systems, followed by single-hub systems, and was almost zero in hubless systems. The hubless communities were characterised by lower patient volumes, fewer hospitals, no hub hospital and no stroke unit.

Conclusions

This network analysis could quantify the national stroke care system and point out areas where the organisation and functionality of acute stroke care could be improved.

Racial and ethnic disparities in emergency department transfers to public hospitals

OBJECTIVE

To examine racial/ethnic differences in emergency department (ED) transfers to public hospitals and factors explaining these differences.

DATA SOURCES AND STUDY SETTING

ED and inpatient data from the Healthcare Cost and Utilization Project for Florida (2010-2019); American Hospital Association Annual Survey (2009-2018).

STUDY DESIGN

Logistic regression examined race/ethnicity and payer on the likelihood of transfer to a public hospital among transferred ED patients. The base model was controlled for patient and hospital characteristics and year fixed effects. Models II and III added urbanicity and hospital referral region (HRR), respectively. Model IV used hospital fixed effects, which compares patients within the same hospital. Models V and VI stratified Model IV by payer and condition, respectively. Conditions were classified as emergency care sensitive conditions (ECSCs), where transfer is protocolized, and non-ECSCs. We reported marginal effects at the means.

DATA COLLECTION/EXTRACTION METHODS

We examined 1,265,588 adult ED patients transferred from 187 hospitals.

PRINCIPAL FINDINGS

Black patients were more likely to be transferred to public hospitals compared with White patients in all models except ECSC patients within the same initial hospital (except trauma). Black patients were 0.5-1.3 percentage points (pp) more likely to be transferred to public hospitals than White patients in the same hospital with the same payer. In the base model, Hispanic patients were more likely to be transferred to public hospitals compared with White patients, but this difference reversed after controlling for HRR. Hispanic patients were - 0.6 pp to -1.2 pp less likely to be transferred to public hospitals than White patients in the same hospital with the same payer.

CONCLUSIONS

Large population-level differences in whether ED patients of different races/ethnicities were transferred to public hospitals were largely explained by hospital market and the initial hospital, suggesting that they may play a larger role in explaining differences in transfer to public hospitals, compared with other external factors.

Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization-Lancet Neurology Commission

Stroke is the second leading cause of death worldwide. The burden of disability after a stroke is also large, and is increasing at a faster pace in low-income and middle-income countries than in high-income countries. Alarmingly, the incidence of stroke is increasing in young and middle-aged people (ie, age <55 years) globally. Should these trends continue, Sustainable Development Goal 3.4 (reducing the burden of stroke as part of the general target to reduce the burden of non-communicable diseases by a third by 2030) will not be met.

In this Commission, we forecast the burden of stroke from 2020 to 2050. We project that stroke mortality will increase by 50%—from 6·6 million (95% uncertainty interval [UI] 6·0 million–7·1 million) in 2020, to 9·7 million (8·0 million–11·6 million) in 2050—with disability-adjusted life-years (DALYs) growing over the same period from 144·8 million (133·9 million–156·9 million) in 2020, to 189·3 million (161·8 million–224·9 million) in 2050. These projections prompted us to do a situational analysis across the four pillars of the stroke quadrangle: surveillance, prevention, acute care, and rehabilitation. We have also identified the barriers to, and facilitators for, the achievement of these four pillars. Disability-adjusted life-years (DALYs) The sum of the years of life lost as a result of premature mortality from a disease and the years lived with a disability associated with prevalent cases of the disease in a population. One DALY represents the loss of the equivalent of one year of full health

On the basis of our assessment, we have identified and prioritised several recommendations. For each of the four pillars (surveillance, prevention, acute care, and rehabilitation), we propose pragmatic solutions for the implementation of evidence-based interventions to reduce the global burden of stroke. The estimated direct (ie, treatment and rehabilitation) and indirect (considering productivity loss) costs of stroke globally are in excess of US$891 billion annually. The pragmatic solutions we put forwards for urgent implementation should help to mitigate these losses, reduce the global burden of stroke, and contribute to achievement of Sustainable Development Goal 3.4, the WHO Intersectoral Global Action Plan on epilepsy and other neurological disorders (2022–2031), and the WHO Global Action Plan for prevention and control of non-communicable diseases.

Reduction of the global burden of stroke, particularly in low-income and middle-income countries, by implementing primary and secondary stroke prevention strategies and evidence-based acute care and rehabilitation services is urgently required. Measures to facilitate this goal include: the establishment of a framework to monitor and assess the burden of stroke (and its risk factors) and stroke services at a national level; the implementation of integrated population-level and individual-level prevention strategies for people at any increased risk of cerebrovascular disease, with emphasis on early detection and control of hypertension; planning and delivery of acute stroke care services, including the establishment of stroke units with access to reperfusion therapies for ischaemic stroke and workforce training and capacity building (and monitoring of quality indicators for these services nationally, regionally, and globally); the promotion of interdisciplinary stroke care services, training for caregivers, and capacity building for community health workers and other health-care providers working in stroke rehabilitation; and the creation of a stroke advocacy and implementation ecosystem that includes all relevant communities, organisations, and stakeholders.

The Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.

Pediatric Patient Insurance Status and Regionalization of Admissions

BACKGROUND

Pediatric hospital care is becoming increasingly regionalized, and previous data have suggested that insurance may be associated with transfer. The aims of the study are to describe regionalization of pediatric care and density of the interhospital transfer network and to determine whether these varied by insurance status.

METHODS

Using the New York State ED Database and State Inpatient Database from 2016, we identified all pediatric patients and calculated regionalization indices (RI) and network density, overall and stratified by insurance. Regionalization indices are based on the likelihood of a patient completing care at the initial hospital. Network density is the proportion of actual transfers compared with the number of potential hospital transfer connections. Both were calculated using the standard State ED Database/State Inpatient Database transfer definition and in a sensitivity analysis, excluding the disposition code requirement.

RESULTS

We identified 1,595,566 pediatric visits (emergency department [ED] or inpatient) in New York in 2016; 7548 (0.5%) were transferred and 7374 transferred visits had eligible insurance status (Medicaid, private, uninsured). Of the transfers, 24% were from ED to ED with discharge, 28% from ED to ED with admission, 31% from ED to inpatient, 16% from inpatient to inpatient, and 1.2% from inpatient to ED. The overall RI was 0.25 (95% confidence interval [95% CI], 0.20-0.31). The overall weighted RI was 0.09 (95% CI, 0.06-0.12) and was 0.09 (95% CI, 0.06-0.13) for Medicaid-insured patients, 0.08 (95% CI, 0.05-0.11) for privately insured patients, and 0.08 (95% CI, 0.05-0.11) for patients without insurance. The overall network density was 0.018 (95% CI, 0.017-0.020). Network density was higher, and transfer rates were lower, for patients with Medicaid insurance as compared with private insurance.

CONCLUSIONS

We found significant regionalization of pediatric emergency care. Although there was not material variation by insurance in regionalization, there was variation in network density and transfer rates. Additional work is needed to understand factors affecting transfer decisions and how these patterns might vary by state.

Hearing and sociality: the implications of hearing loss on social life

Hearing is essential to the formation of social relationships and is the principal afferent of social life. Yet hearing loss, which is one of the most prevalent forms of sensory disability worldwide and is critical for social development, has received little attention from the social interventionalist perspective. The purpose of this mini-review is to describe the basic neurobiological principles of hearing and to explore the reciprocal relationships between social support, hearing loss, and its psychosocial comorbidities. We also discuss the role of social enrichment in sensorineural recovery and identify open questions within the fields of hearing physiology and social networks.

Insurance-Based Disparities in Stroke Center Access in California: A Network Science Approach

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.

Six years of the Angels Initiative: Aims, achievements, and future directions to improve stroke care worldwide

The rate of stroke-related death and disability is four times higher in low- and middle-income countries (LMICs) than in high-income countries (HICs), yet stroke units exist in only 18% of LMICs, compared with 91% of HICs. In order to ensure universal and equitable access to timely, guideline-recommended stroke care, multidisciplinary stroke-ready hospitals with coordinated teams of healthcare professionals and appropriate facilities are essential.Established in 2016, the Angels Initiative is an international, not-for-profit, public-private partnership. It is run in collaboration with the World Stroke Organization, European Stroke Organisation, and regional and national stroke societies in over 50 countries. The Angels Initiative aims to increase the global number of stroke-ready hospitals and to optimize the quality of existing stroke units. It does this through the work of dedicated consultants, who help to standardize care procedures and build coordinated, informed communities of stroke professionals. Angels consultants also establish quality monitoring frameworks using online audit platforms such as the Registry of Stroke Care Quality (RES-Q), which forms the basis of the Angels award system (gold/platinum/diamond) for all stroke-ready hospitals across the world.The Angels Initiative has supported over 1700 hospitals (>1000 in LMICs) that did not previously treat stroke patients to become "stroke ready." Since its inception in 2016, the Angels Initiative has impacted the health outcomes of an estimated 7.46 million stroke patients globally (including an estimated 4.68 million patients in LMICs). The Angels Initiative has increased the number of stroke-ready hospitals in many countries (e.g. in South Africa: 5 stroke-ready hospitals in 2015 vs 185 in 2021), reduced "door to treatment time" (e.g. in Egypt: 50% reduction vs baseline), and increased quality monitoring substantially.The focus of the work of the Angels Initiative has now expanded from the hyperacute phase of stroke treatment to the pre-hospital setting, as well as to the early post-acute setting. A continued and coordinated global effort is needed to achieve the target of the Angels Initiative of >10,000 stroke-ready hospitals by 2030, and >7500 of these in LMICs.

Prehospital Stroke Care Part 1: Emergency Medical Services and the Stroke Systems of Care

Acute stroke care begins before hospital arrival, and several prehospital factors are critical in influencing overall patient care and poststroke outcomes. This topical review provides an overview of the state of the science on prehospital components of stroke systems of care and how emergency medical services systems may interact in the system to support acute stroke care. Topics include layperson recognition of stroke, prehospital transport strategies, networked stroke care, systems for data integration and real-time feedback, and inequities that exist within and among systems.

Modular structures and the delivery of inpatient care in hospitals: a Network Science perspective on healthcare function and dysfunction

BACKGROUND

Reinforced by the COVID-19 pandemic, the capacity of health systems to cope with increasing healthcare demands has been an abiding concern of both governments and the public. Health systems are made up from non-identical human and physical components interacting in diverse ways in varying locations. It is challenging to represent the function and dysfunction of such systems in a scientific manner. We describe a Network Science approach to that dilemma. General hospitals with large emergency caseloads are the resource intensive components of health systems. We propose that the care-delivery services in such entities are modular, and that their structure and function can be usefully analysed by contemporary Network Science. We explore that possibility in a study of Australian hospitals during 2019 and 2020.

METHODS

We accessed monthly snapshots of whole of hospital administrative patient level data in two general hospitals during 2019 and 2020. We represented the organisations inpatient services as network graphs and explored their graph structural characteristics using the Louvain algorithm and other methods. We related graph topological features to aspects of observable function and dysfunction in the delivery of care.

RESULTS

We constructed a series of whole of institution bipartite hospital graphs with clinical unit and labelled wards as nodes, and patients treated by units in particular wards as edges. Examples of the graphs are provided. Algorithmic identification of community structures confirmed the modular structure of the graphs. Their functional implications were readily identified by domain experts. Topological graph features could be related to functional and dysfunctional issues such as COVID-19 related service changes and levels of hospital congestion.

DISCUSSION AND CONCLUSIONS

Contemporary Network Science is one of the fastest growing areas of current scientific and technical advance. Network Science confirms the modular nature of healthcare service structures. It holds considerable promise for understanding function and dysfunction in healthcare systems, and for reconceptualising issues such as hospital capacity in new and interesting ways.

Influence of Hospital Characteristics on Hospital Transfer Destinations for Patients With Stroke

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.

The relationship between stroke system organization and disparities in access to stroke center care in California

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.

Impact of Telestroke Implementation on Emergency Department Transfer Rate

BACKGROUND

and Purpose: Telestroke networks are associated with improved outcomes from acute ischemic stroke(AIS) patient and facilitate greater access to care, particularly in underserved regions. These networks also have the potential to influence patient disposition through avoiding unnecessary interhospital transfers. This study examines the impact of implementation of the VA National Telestroke Program (NTSP) on interhospital transfer among Veterans.

METHODS

We analyzed AIS patients presenting to the emergency department 21 VA hospitals before and after telestroke implementation. Transfer rates were determined through review of administrative data and chart review and patient and facility level characteristics were collected to identify predictors of transfer. Comparisons were made using t-test, Wilcoxon rank sum, and chi-square analysis. Multivariable logistic regression with sensitivity analyses were conducted to assess the influence of telestroke implementation on transfer rates.

RESULTS

We analyzed 3,488 stroke encounters (1,056 pre-NTSP and 2,432 post-NTSP). Following implementation, we observed an absolute 14.4% decrease in transfers across all levels of stroke center designation. Younger age, higher stroke severity, and shorter duration from symptom onset were associated with transfer. At the facility level, hospitals with lower annual stroke volume were more likely to transfer although only one hospital actually saw an increase in transfer rates following implementation. After adjusting for patient and facility characteristics, the implementation of VA NTSP resulted in a nearly 60% reduction in odds of transfer (OR = 0.39, [0.19, 0.77]).

CONCLUSIONS

In addition to improving treatment in acute stroke, telestroke networks have the potential to positively impact the efficiency of interhospital networks through disposition optimization and the avoidance of unnecessary transfers.

What Types of Networks Do Professionals Build, and How Are They Affected by the Results of Network Evaluation?

Background: We aimed to explore what kind of social networks characterizable as "consult/be consulted" are built among healthcare professionals in a community and the impact of providing the professionals with these findings. Methods: We adopted mixed methods exploratory study using social network analysis (SNA) and content analysis. SNA can visualize social network structures such as relationships between individuals. The healthcare professionals were asked about the key persons they consulted and were consulted by concerning these healthcare issues: (1) daily work; (2) a person with acute back pain; (3) a garbage-filled house reported by a neighbor; (4) a person with dementia; and (5) a study meeting. We identified the key roles depending on the issues using SNA. After analysis, the analytical findings were shared with the participants. To explore their cognitive responses, an open-ended questionnaire was delivered and a content analysis was implemented. Results: Of 54 healthcare professional participants, the data of 52 were available for analysis. The findings (in the respective order of the five topics above) were as follows: the number of nodes was 165, 95, 85, 82, and 68; clustering coefficient was 0.19, 0.03, 0.02, 0.11, and 0.23; assortativity was -0.043, -0.11, -0.23, -0.17, and -0.23; reciprocity was 0.35, 0.31, 0.39, 0.29, and 0.48. The top three centralities included nurses. Eighty-seven free comments were received, of which 39 were categorized as descriptive, 10 as analytical, and 38 as critical. Discussion: The structure of "consult/be consulted" networks differed by topic. SNA is available to detect the healthcare resources network and it may have helped them to reflect on their own networks.

National Trends in Telestroke Utilization in a US Commercial Platform Prior to the COVID-19 Pandemic

OBJECTIVES

Most data on telestroke utilization come from single academic hub-and-spoke telestroke networks. Our objective was to describe characteristics of telestroke consultations among a national sample of telestroke sites on one of the most commonly used common vendor platforms, prior to the COVID-19 public health emergency.

MATERIALS AND METHODS

A commercial telestroke vendor provided data on all telestroke consultations by two specialist provider groups from 2013-2019. Kendall's τ β nonparametric test was utilized to assess time trends. Generalized linear models were used to assess the association between hospital consult utilization and alteplase use adjusting for hospital characteristics.

RESULTS

Among 67,736 telestroke consultations to 132 spoke sites over the study period, most occurred in the emergency department (90%) and for stroke indications (final clinical diagnoses: TIA 13%, ischemic stroke 39%, hemorrhagic stroke 2%, stroke mimics 46%). Stroke severity was low (median NIHSS 2, IQR 0-6). Alteplase was recommended for 23% of ischemic stroke patients. From 2013 to 2019, times from ED arrival to NIHSS, CT scan, imaging review, consult, and alteplase administration all decreased (p<0.05 for all), while times from consult start to alteplase recommendation and bolus increased (p<0.01 for both). Transfer was recommended for 8% of ischemic stroke patients. Number of patients treated with alteplase per hospital increased with increasing number of consults and hospital size and was also associated with US region in unadjusted and adjusted analyses. Longer duration of hospital participation in the network was associated with shorter hospital median door-to-needle time for alteplase delivery (39 min shorter per year, p=0.04).

CONCLUSIONS

Among spoke sites using a commercial telestroke platform over a seven-year time horizon, times to consult start and alteplase bolus decreased over time. Similar to academic networks, duration of telestroke participation in this commercial network was associated with faster alteplase delivery, suggesting practice improves performance.

Patient Insurance Status Is Associated With Care Received After Transfer Among Pediatric Patients in the Emergency Department

OBJECTIVE

To determine whether frequency of interfacility transfer varied by insurance status among pediatric emergency department (ED) patients. Secondarily, we tested for an association between insurance status and odds of transfer with discharge from the second ED without observation or admission.

METHODS

We used the 2016 New York State ED and Inpatient Databases to identify all patients <18 years. ED and hospital characteristics were from American Hospital Association and National ED Inventory-USA. Among all ED patients, we calculated the proportion transferred stratified by insurance status (private, public, none). Among ED-to-ED transfers, we identified transfers without subsequent observation or admission, and used hierarchical logistic regression modeling (adjusting for patient and transferring ED/hospital characteristics) to determine whether insurance status was associated with odds of discharge from the second ED without observation or admission.

RESULTS

Of 1,303,575 pediatric ED visits, 6086 (0.5%) were transferred. Transfers were less frequent among patients with public or no insurance. Of 3801 ED-to-ED transfers, 1451 (38%) were without subsequent observation or admission. In bivariate and multivariable analysis, transferred patients with public and with no insurance were less likely to be discharged without observation or admission relative to privately insured patients.

CONCLUSION

Among ED-to-ED transfers, pediatric patients with public or without insurance were more often kept for observation or admission at the second hospital after transfer. Differences in disease acuity or in providers' perception of follow-up availability may play a role in explaining these patterns. This disparity merits further investigation.

Telerehabilitation of Post-Stroke Patients as a Therapeutic Solution in the Era of the Covid-19 Pandemic

(1) Background: Due to the pandemic caused by the SARS-CoV-2 virus, rehabilitation centres have become less available for neurological patients. This is the result of efforts to physically distance society, to try to slow the spread of the pathogen. Health care facilities were mainly restricted to urgent cases, while most physiotherapy treatments, mainly for patients with chronic conditions, were suspended. Some countries have seen a reduction in acute stroke hospital admissions of from 50% to 80%. One solution to the above problem is the use of telerehabilitation in the home environment as an alternative to inpatient rehabilitation. (2) Aim of the study: The purpose of this review is to analyse the benefits and limitations of teletherapy in relation to the functional condition of post-stroke patients. (3) Methods: Selected publications from 2019 to 2021 on the telerehabilitation of stroke patients were reviewed. The review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist. (4) Results: Studies have proven that teletherapy significantly improves the functional condition of post-stroke patients, resulting in improved quality of life and faster return to independence (while maintaining maximum possible precautions related to the SARS-CoV-2 virus pandemic). (5) Conclusions: Analysis of the study results showed comparable effectiveness of rehabilitation in the tele system to inpatient therapy. However, it should be emphasised that patients undergoing telerehabilitation must meet strict conditions to be eligible for this type of treatment program. However, the strength of the evidence itself supporting the effectiveness of this method ranks low due to the limited number of randomised control trials (RCT), small number of participants, and heterogeneous trials.

Social Network Structure Is Related to Functional Improvement From Home-Based Telerehabilitation After Stroke

Objective: Telerehabilitation (TR) is now, in the context of COVID-19, more clinically relevant than ever as a major source of outpatient care. The social network of a patient is a critical yet understudied factor in the success of TR that may influence both engagement in therapy programs and post-stroke outcomes. We designed a 12-week home-based TR program for stroke patients and evaluated which social factors might be related to motor gains and reduced depressive symptoms. Methods: Stroke patients (n = 13) with arm motor deficits underwent supervised home-based TR for 12 weeks with routine assessments of motor function and mood. At the 6-week midpoint, we mapped each patient's personal social network and evaluated relationships between social network metrics and functional improvements from TR. Finally, we compared social networks of TR patients with a historical cohort of 176 stroke patients who did not receive any TR to identify social network differences. Results: Both network size and network density were related to walk time improvement (p = 0.025; p = 0.003). Social network density was related to arm motor gains (p = 0.003). Social network size was related to reduced depressive symptoms (p = 0.015). TR patient networks were larger (p = 0.012) and less dense (p = 0.046) than historical stroke control networks. Conclusions: Social network structure is positively related to improvement in motor status and mood from TR. TR patients had larger and more open social networks than stroke patients who did not receive TR. Understanding how social networks intersect with TR outcomes is crucial to maximize effects of virtual rehabilitation.

Only a Minority of Thrombectomy Candidates Are Admitted During Night Shift: A Rationale for Diurnal Stroke Care Planning

Background: Widespread quick access to mechanical thrombectomy (MT) for acute ischemic stroke (AIS) is one of the main challenges in stroke care. It is unclear if newly established MT units are required 24 h/7 d. We explored the diurnal admission rate of patients with AIS potentially eligible for MT to provide a basis for discussion of daytime-adapted stroke care concepts. Methods: Data collected from the Baden-Württemberg Stroke Registry in Germany were assessed (2008-2012). We analyzed the admission rate of patients with AIS stratified by the National Institutes of Health Stroke Scale (NIHSS) score at admission in 3-h intervals. An NIHSS score ≥10 was considered a predictor of large vessel occlusion. The average annual admission number of patients with severe AIS were stratified by stroke service level and calculated for a three-shift model and working/non-working hours. Results: Of 91,864, 22,527 (21%) presented with an NIHSS score ≥10. The average admission rates per year for a hospital without Stroke Unit (SU), with a local SU, with a regional SU and a stroke center were 8, 52, 90 and 178, respectively. Approximately 61% were admitted during working hours, 54% in the early shift, 36% in the late shift and 10% in the night shift. Conclusions: A two-shift model, excluding the night shift, would cover 90% of the patients with severe AIS. A model with coverage during working hours would miss ~40% of the patients with severe AIS. To achieve a quick and area-wide MT, it seems preferable for newly implemented MT-units to offer MT in a two-shift model at a minimum.

Trends in Telestroke Care Delivery: A 15-Year Experience of an Academic Hub and Its Network of Spokes

BACKGROUND

Telestroke provides access to vascular neurology expertise for hospitals lacking stroke coverage, and its use has risen rapidly in the past decade. We aim to characterize consultations, spoke behavior, and the relationship between spoke telestroke utilization (number of telestroke consults per year) and spoke alteplase treatment metrics in an academic telestroke network.

METHODS AND RESULTS

We analyzed prospectively collected data on all telestroke consults from 2003 to 2018. Trends in network performance and spoke characteristics were analyzed using generalized estimating equations and Kendall τβ nonparametric tests as appropriate. Unadjusted and adjusted linear regression models determined associations between telestroke utilization and treatment metrics. The network included 2 hubs and 43 spokes with 12 803 consults performed during the study period. Network growth overall was +1.8 spokes per year, and median duration of spoke participation was 7.9 years. The numbers of consults and alteplase-treated patients increased annually, even after adjusting for the number of spokes in the network (P<0.01 for both). Although times from last seen well to spoke emergency department arrival and to consult request increased, door-to-needle time, time from teleconsult request to callback, and time from teleconsult to alteplase administration all decreased (all P<0.01). With time, the network included more spokes without a Primary Stroke Center designation. In adjusted analyses, for every 10 telestroke consults requested by a spoke, the spoke door-to-needle decreased by 1.8 minutes (P=0.02), number of patients treated with alteplase was an additional 1.7 (P<0.01), and the percent of eligible patients treated with alteplase increased by 8% (P=0.03).

CONCLUSIONS

Telestroke network size and utilization increased over time. Increased use of teleconsults was associated with increased and timely use of alteplase. Over time, the delivery of timely emergency care has improved significantly among emergency departments participating in this telestroke network. Replication of these findings in other networks is warranted.

Hospital Factors Associated With Interhospital Transfer Destination for Stroke in the Northeast United States

Background

We aimed to determine if there is an association between hospital quality and the likelihood of a given hospital being a preferred transfer destination for stroke patients.

Methods and Results

Data from Medicare claims identified acute ischemic stroke transferred between 394 northeast US hospitals from 2007 to 2011. Hospitals were categorized as transferring (n=136), retaining (n=241), or receiving (n=17) hospitals based on the proportion of acute ischemic stroke encounters transferred or received. We identified all 6409 potential dyads of sending and receiving hospitals, and categorized dyads as connected if ≥5 patients were transferred between the hospitals annually (n=82). We used logistic regression to identify hospital characteristics associated with establishing a connected dyad, exploring the effect of adjusting for different quality measures and outcomes. We also adjusted for driving distance between hospitals, receiving hospital stroke volume, and the number of hospitals in the receiving hospital referral region. The odds of establishing a transfer connection increased when rate of alteplase administration increased at the receiving hospital or decreased at the sending hospital, however this finding did not hold after applying a potential strategy to adjust for clustering. Receiving hospital performance on 90‐day home time was not associated with likelihood of transfer connection.

Conclusions

Among northeast US hospitals, we found that differences in hospital quality, specifically higher levels of alteplase administration, may be associated with increased likelihood of being a transfer destination. Further research is needed to better understand acute ischemic stroke transfer patterns to optimize stroke transfer systems.