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Reeves MJ, Fonarow GC, Smith EE, Sheth KN, Messe SR, Schwamm LH. Twenty Years of Get With The Guidelines-Stroke: Celebrating Past Successes, Lessons Learned, and Future Challenges. Stroke 2024; 55:1689-1698. [PMID: 38738376 PMCID: PMC11208062 DOI: 10.1161/strokeaha.124.046527] [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] [Indexed: 05/14/2024]
Abstract
The Get With The Guidelines-Stroke program which, began 20 years ago, is one of the largest and most important nationally representative disease registries in the United States. Its importance to the stroke community can be gauged by its sustained growth and widespread dissemination of findings that demonstrate sustained increases in both the quality of care and patient outcomes over time. The objectives of this narrative review are to provide a brief history of Get With The Guidelines-Stroke, summarize its major successes and impact, and highlight lessons learned. Looking to the next 20 years, we discuss potential challenges and opportunities for the program.
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Affiliation(s)
- Mathew J. Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
| | - Gregg C. Fonarow
- Division of Cardiology, Geffen School of Medicine, University of California Los Angeles (G.C.F.)
| | - Eric E. Smith
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada (E.E.S.)
| | - Kevin N. Sheth
- Center for Brain & Mind Health, Departments of Neurology & Neurosurgery (K.N.S.), Yale School of Medicine, New Haven, CT
| | - Steven R. Messe
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia (S.R.M.)
| | - Lee H. Schwamm
- Department of Neurology and Bioinformatics and Data Sciences (L.H.S.), Yale School of Medicine, New Haven, CT
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Gordon Perue GL, Southerland AM. Law and Disorder in the Wild West of Stroke Certification: Is It Time to Standardize the Designation Processes? Stroke 2024; 55:1059-1061. [PMID: 38469727 DOI: 10.1161/strokeaha.124.046275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Affiliation(s)
| | - Andrew M Southerland
- Departments of Neurology and Public Health Sciences, University of Virginia, Charlottesville (A.M.S.)
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Feldmeier M, Kim AS, Zachrison KS, Alberts MJ, Shen YC, Hsia RY. Heterogeneity of State Stroke Center Certification and Designation Processes. Stroke 2024; 55:1051-1058. [PMID: 38469729 DOI: 10.1161/strokeaha.123.045368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/04/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Stroke centers are critical for the timely diagnosis and treatment of acute stroke and have been associated with improved treatment and outcomes; however, variability exists in the definitions and processes used to certify and designate these centers. Our study categorizes state stroke center certification and designation processes and provides examples of state processes across the United States, specifically in states with independent designation processes that do not rely on national certification. METHODS In this cross-sectional study from September 2022 to April 2023, we used peer-reviewed literature, primary source documents from states, and communication with state officials in all 50 states to capture each state's process for stroke center certification and designation. We categorized this information and outlined examples of processes in each category. RESULTS Our cross-sectional study of state-level stroke center certification and designation processes across states reveals significant heterogeneity in the terminology used to describe state processes and the processes themselves. We identify 3 main categories of state processes: No State Certification or Designation Process (category A; n=12), State Designation Reliant on National Certification Only (category B; n=24), and State Has Option for Self-Certification or Independent Designation (category C; n=14). Furthermore, we describe 3 subcategories of self-certification or independent state designation processes: State Relies on Self-Certification or Independent Designation for Acute Stroke Ready Hospital or Equivalent (category C1; n=3), State Has Hybrid Model for Acute Stroke Ready Hospital or Equivalent (category C2; n=5), and State Has Hybrid Model for Primary Stroke Center and Above (category C3; n=6). CONCLUSIONS Our study found significant heterogeneity in state-level processes. A better understanding of how these differences may impact the rigor of each process and clinical performance of stroke centers is worthy of further investigation.
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Affiliation(s)
- Madeline Feldmeier
- Department of Emergency Medicine, University of California, San Francisco. (M.F., R.Y.H.)
| | - Anthony S Kim
- Department of Neurology, UCSF Weill Institute of Neurosciences, University of California, San Francisco. (A.S.K.)
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston (K.S.Z.)
- Harvard Medical School, Boston, MA (K.S.Z.)
| | - Mark J Alberts
- Ayer Neuroscience Institute, Hartford HealthCare, CT (M.J.A.)
| | - Yu-Chu Shen
- Department of Defense Management, Naval Postgraduate School, Monterey, CA (Y.-C.S.)
- National Bureau of Economic Research, Cambridge, MA (Y.-C.S.)
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California, San Francisco. (M.F., R.Y.H.)
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. (R.Y.H.)
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Stein LK, Maillie L, Erdman J, Loebel E, Mayman N, Sharma A, Wolmer S, Tuhrim S, Fifi JT, Jette N, Mocco J, Dhamoon MS. Variation in US acute ischemic stroke treatment by hospital regions: limited endovascular access despite evidence. J Neurointerv Surg 2024; 16:151-155. [PMID: 37068938 PMCID: PMC11192062 DOI: 10.1136/jnis-2023-020128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/02/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Although national organizations recognize the importance of regionalized acute ischemic stroke (AIS) care, data informing expansion are sparse. We assessed real-world regional variation in emergent AIS treatment, including growth in revascularization therapies and stroke center certification. We hypothesized that we would observe overall growth in revascularization therapy utilization, but observed differences would vary greatly regionally. METHODS A retrospective cross-sectional analysis was carried out of de-identified national inpatient Medicare Fee-for-Service datasets from 2016 to 2019. We identified AIS admissions and treatment with thrombolysis and endovascular thrombectomy (ET) with International Classification of Diseases, 10th Revision, Clinical Modification codes. We grouped hospitals in Dartmouth Atlas of Healthcare Hospital Referral Regions (HRR) and calculated hospital, demographic, and acute stroke treatment characteristics for each HRR. We calculated the percent of hospitals with stroke certification and AIS cases treated with thrombolysis or ET per HRR. RESULTS There were 957 958 AIS admissions. Relative mean (SD) growth in percent of AIS admissions receiving revascularization therapy per HRR from 2016 to 2019 was 13.4 (31.7)% (IQR -6.1-31.7%) for thrombolysis and 28.0 (72.0)% (IQR 0-56.0%) for ET. The proportion of HRRs with decreased or no difference in ET utilization was 38.9% and the proportion of HRRs with decreased or no difference in thrombolysis utilization was 32.7%. Mean (SD) stroke center certification proportion across HRRs was 45.3 (31.5)% and this varied widely (IQR 18.3-73.4%). CONCLUSIONS Overall growth in AIS treatment has been modest and, within HRRs, growth in AIS treatment and the proportion of centers with stroke certification varies dramatically.
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Affiliation(s)
- Laura K Stein
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Luke Maillie
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Erdman
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Emma Loebel
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Naomi Mayman
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Akarsh Sharma
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Stanley Tuhrim
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Johanna T Fifi
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nathalie Jette
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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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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De Luca L, D'Errigo P, Rosato S, Badoni G, Giordani B, Mureddu GF, Tavilla A, Seccareccia F, Baglio G. Impact of COVID-19 Diagnosis on Mortality in Patients with Ischemic Stroke Admitted during the 2020 Pandemic in Italy. J Clin Med 2023; 12:4560. [PMID: 37510675 PMCID: PMC10380878 DOI: 10.3390/jcm12144560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/29/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023] Open
Abstract
AIMS The impact of the COVID-19 pandemic on the event rate of patients with ischemic stroke has been poorly investigated. We sought to evaluate the impact of the COVID-19 infection on mortality in patients with ischemic stroke admitted during the 2020 pandemic in Italy. METHODS We analyzed a nationwide, comprehensive, and universal administrative database of patients who were admitted for ischemic stroke during and after the national lockdown for the COVID-19 infection in 2020, and the equivalent periods over the previous 5 years in Italy. The 2020 observed hospitalization and mortality rates of stroke patients with and without COVID-19 infection were compared with the expected rates, in accordance with the trend of the previous 5 years. RESULTS During the period of observation, 300,890 hospitalizations for ischemic stroke occurred in Italy. In 2020, 41,302 stroke patients (1102 with concomitant COVID-19 infection) were admitted at 771 centers. The rate of admissions for ischemic stroke during the 2020 pandemic was markedly reduced compared with previous years (percentage change vs. 2015: -23.5). Based on the 5 year trend, the 2020 expected 30 day and 1 year mortality rates were 9.8% and 23.9%, respectively, and the observed incidence of death rates were 12.2% and 26.7%, respectively (both p < 0.001). After multiple corrections, higher rates of mortality were observed among patients admitted for stroke with a concomitant COVID-19 diagnosis. CONCLUSIONS During the COVID-19 pandemic in 2020 in Italy, the rate of hospitalizations for ischemic stroke was dramatically reduced, although both the 30 day and 1 year mortality rates increased compared with the previous 5 year trend.
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Affiliation(s)
- Leonardo De Luca
- Department of Cardio-Thoracic and Vascular Medicine and Surgery, Division of Cardiology, A.O. San Camillo-Forlanini, 00152 Rome, Italy
- Faculty of Medicine and Dentistry, UniCamillus-Saint Camillus International University of Health Sciences, 00131 Rome, Italy
| | - Paola D'Errigo
- National Centre for Global Health, Italian National Institute of Health, 00161 Rome, Italy
| | - Stefano Rosato
- National Centre for Global Health, Italian National Institute of Health, 00161 Rome, Italy
| | - Gabriella Badoni
- National Centre for Global Health, Italian National Institute of Health, 00161 Rome, Italy
| | - Barbara Giordani
- Italian National Agency for Regional Healthcare Services, 00187 Rome, Italy
| | | | - Andrea Tavilla
- National Center for Disease Prevention and Health Promotion, Italian National Institute of Health, 00161 Rome, Italy
| | - Fulvia Seccareccia
- National Centre for Global Health, Italian National Institute of Health, 00161 Rome, Italy
| | - Giovanni Baglio
- Italian National Agency for Regional Healthcare Services, 00187 Rome, Italy
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7
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McCarthy L, Daniel D, Santos D, Dhamoon MS. Relationships among hospital acute ischemic stroke volumes, hospital characteristics, and outcomes in the US. J Stroke Cerebrovasc Dis 2023; 32:107170. [PMID: 37148626 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107170] [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: 01/13/2023] [Revised: 04/28/2023] [Accepted: 05/01/2023] [Indexed: 05/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Prior research on volume-based patient outcomes related to acute ischemic stroke (AIS) have demonstrated contradictory results and fail to reflect recent advances in stroke care. We sought to examine contemporary relationships between hospital AIS volumes and outcomes. METHODS We used complete Medicare datasets in a retrospective cohort study using validated International Classification of Diseases Tenth Revision codes to identify patients admitted with AIS from January 1, 2016 through December 31, 2019. AIS volume was calculated as the total number of AIS admissions per hospital during the study period. We examined several hospital characteristics by AIS volume quartile. We performed adjusted logistic regressions testing associations of AIS volume quartiles with: inpatient mortality, receipt of tissue plasminogen activator (tPA) and endovascular therapy (ET), discharge home, and 30-day outpatient visit. We adjusted for sex, age, Charlson comorbidity score, teaching hospital status, MDI, hospital urban-rural designation, stroke certification status and ICU and neurologist availability at the hospital. RESULTS There were 952400 AIS admissions among 5084 US hospitals; AIS 4-year volume quartiles were: 1st: 1-8 AIS admissions; 2nd: 9-44; 3rd: 45-237; 4th: 238+. Highest quartile hospitals more often were stroke-certified (49.1% vs 8.7% in lowest quartile, p<0.0001), with ICU bed availability (19.8% vs 4.1%, p<0.0001) and with neurologist expertise (91.1% vs 3%, p<0.0001). In the highest AIS quartile (compared to the lowest quartile), there was lower inpatient mortality (odds ratio [OR] 0.71 [95%CI 0.57-0.87, p<0.0001]), lower 30-day mortality (0.55 [0.49-0.62], p<0.0001), greater receipt of tPA (6.60 [3.19-13.65], p<0.0001) and ET (16.43 [10.64-25.37], p<0.0001, and greater likelihood of discharge home (1.38 [1.22-1.56], p<0.0001). However, when the highest quartile hospitals were examined separately, higher volumes were associated with higher mortality despite higher rates of tPA and ET receipt. CONCLUSIONS High AIS-volume hospitals have greater utilization of acute stroke interventions, stroke certification and availability of neurologist and ICU care. These features likely play a role in the better outcomes observed at such centers, including inpatient and 30-day mortality and discharge home. However, the highest volume centers had higher mortality despite greater receipt of interventions. Further research is needed to better understand volume-outcome relationships in AIS to improve care at lower volume centers.
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Affiliation(s)
- Louise McCarthy
- Department of Neurology, Mount Sinai Downtown, New York, NY, United States
| | - David Daniel
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Daniel Santos
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
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Zachrison KS, Nielsen VM, de la Ossa NP, Madsen TE, Cash RE, Crowe RP, Odom EC, Jauch EC, Adeoye OM, Richards CT. Prehospital Stroke Care Part 1: Emergency Medical Services and the Stroke Systems of Care. Stroke 2023; 54:1138-1147. [PMID: 36444720 PMCID: PMC11050637 DOI: 10.1161/strokeaha.122.039586] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (K.S.Z., R.E.C.)
| | | | - Natalia Perez de la Ossa
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias I Pujol, Badalona, Spain and Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain (N.P.d.l.O)
| | - Tracy E Madsen
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI (T.E.M.)
| | - Rebecca E Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (K.S.Z., R.E.C.)
| | | | - Erika C Odom
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (E.C.O.)
| | - Edward C Jauch
- Department of Research, University of North Carolina Health Sciences at Mountain Area Health Education Center, Asheville, NC (E.C.J.)
| | - Opeolu M Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO (O.M.A.)
| | - Christopher T Richards
- Division of EMS, Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH (C.T.R.)
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Marulanda E, Bustillo A, Gutierrez CM, Rose DZ, Jameson A, Gardener H, Alkhachroum A, Zhou L, Ying H, Dong C, Foster D, Hanel R, Mehta B, Mokin M, Mueller-Kronast N, Landreth M, Sand C, Romano JG, Rundek T, Asdaghi N, Sacco RL. Nationally Certified Stroke Centers Outperform Self-Attested Stroke Centers in the Florida Stroke Registry. Stroke 2023; 54:840-847. [PMID: 36655557 DOI: 10.1161/strokeaha.122.038869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The Florida Stroke Act, signed into law in 2004, set criteria for Comprehensive Stroke Centers (CSC). For a set time period, Florida hospitals were permitted to either receive national certification (NC) or could self-attest (SA) as fulfilling CSC criteria. The aim of this project was to evaluate the quality of ischemic stroke care in NC versus SA stroke centers in Florida, using well-known, guideline-driven ischemic stroke outcome metrics. METHODS A total of 37 CSCs (74% of Florida CSCs) in the Florida Stroke Registry from January 2013 through December 2018 were analyzed, including 19 SA CSCs and 18 NC (13 CSCs and 5 Thrombectomy-Capable Stroke Center). Hospital- and patient-level characteristics and stroke metrics were evaluated, adjusting for demographics, medical comorbidities, and stroke severity. RESULTS A total of 78 424 acute ischemic stroke cases, 36 089 from SA CSCs and 42 335 from NC CSC/Thrombectomy-Capable Stroke Centers were analyzed. NC centers had older patients (73 [61-83] versus 71 [60-81]; P<0.001) with more severe strokes (median National Institutes of Health Stroke Scale score of 5 versus 4; P<0.001). NC had higher intravenous tissue-type plasminogen activator utilization (15% versus 13%; P<0.001), endovascular treatment (10% versus 7%; P<0.001) and faster median door-to-computed tomography (23 minutes [11-73] versus 31 [12-78]; P<0.001), door-to-needle (37 minutes [26-50] versus 45 [34-58]; P<0.001) and door-to-puncture times (77 minutes [50-113] versus 93 [62-140]; P<0.001). In adjusted analysis, patients arriving to NC hospitals by 3 hours were more likely to get intravenous tissue-type plasminogen activator in the 3- to 4.5-hour window (adjusted odds ratio, 1.87 [95% CI, 1.30-2.68]; P=0.001) and more likely to be treated with intravenous tissue-type plasminogen activator within 45 minutes (adjusted odds ratio, 1.61 [95% CI, 1.04-2.50]; P=0.04) compared with SA CSCs. CONCLUSIONS Among Florida-Stroke Registry CSCs, acute ischemic stroke performance and treatment measures at NC centers are superior to SA CSCs. These findings have implications for stroke systems of care in Florida and support legislation updates requiring NC and removal of SA claims.
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Affiliation(s)
- Erika Marulanda
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | - Antonio Bustillo
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | - Carolina M Gutierrez
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | - David Z Rose
- University of South Florida Morsani College of Medicine, Tampa (D.Z.R., A.J., M.M.)
| | - Angus Jameson
- University of South Florida Morsani College of Medicine, Tampa (D.Z.R., A.J., M.M.)
| | - Hannah Gardener
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | - Ayham Alkhachroum
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | - Lili Zhou
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | - Hao Ying
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | - Chuanhui Dong
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | | | - Ricardo Hanel
- Baptist Neurological Institute, Jacksonville, FL (R.H.)
| | - Brijesh Mehta
- Memorial Neuroscience Institute, Hollywood, FL (B.M.)
| | - Maxim Mokin
- University of South Florida Morsani College of Medicine, Tampa (D.Z.R., A.J., M.M.)
| | | | | | - Charles Sand
- St Joseph's Hospital Medical Center, Tampa, FL (C.S.)
| | - Jose G Romano
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | - Tatjana Rundek
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | - Negar Asdaghi
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | - Ralph L Sacco
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
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Zhang R, Liu G, Pan Y, Zhou M, Wang Y. Association between hospital volume, processes of care and outcomes after acute ischaemic stroke: a prospective observational study. BMJ Open 2022; 12:e060015. [PMID: 35680259 PMCID: PMC9185595 DOI: 10.1136/bmjopen-2021-060015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES There is uncertainty with respect to the hospital volume and clinical outcomes for patients with stroke. This study aimed to assess the association between hospital volume, processes of care and outcomes after ischaemic stroke. DESIGN A multicentre prospective cohort study. SETTING Two hundred and seventeen secondary or tertiary public hospitals from China. PARTICIPANTS A total of 17 550 patients within 7 days of acute ischaemic stroke were included. MAIN OUTCOME MEASURES The outcomes included all-cause mortality, poor outcome, recurrent stroke, and combined vascular events at 3 months and 1 year. The patients were divided into four groups based on quartiles of the hospital volume. We compared the difference in the process of care across the groups and estimated the effects of hospital volume on mortality, poor outcome, recurrent stroke, and combined vascular events at 3 months and 1 year. Restricted cubic splines were used to illustrate the association between hospital volume and clinical outcomes. RESULTS There were no significant differences in the process of care across the four groups. When adjusted for confounders, the effect of hospital volume on mortality, recurrent stroke and combined vascular events was not significant. However, compared with the highest quartile, the patients in the lowest quartile of hospital volume tend to have poor outcome at 1 year (OR=1.29, 95% CI 1.01 to 1.64, p=0.0393). The restricted cubic spline analyses suggested a non-linear relationship between hospital volume and 1-year combined vascular events and poor outcome at 3 months and 1 year. CONCLUSIONS We found no significant associations between hospital volume, processes of care at the hospital, and mortality, recurrent stroke, and combined vascular events in patients with ischaemic stroke. However, hospital volume may be associated with poor outcome at 1 year.
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Affiliation(s)
- Runhua Zhang
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gaifen Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Maigeng Zhou
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
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11
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Boggs KM, Vogel BT, Zachrison KS, Espinola JA, Faridi MK, Cash RE, Sullivan AF, Camargo CA. An inventory of stroke centers in the United States. J Am Coll Emerg Physicians Open 2022; 3:e12673. [PMID: 35252972 PMCID: PMC8886184 DOI: 10.1002/emp2.12673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/05/2022] [Accepted: 01/12/2022] [Indexed: 11/15/2022] Open
Abstract
Objectives Stroke centers are essential for the optimal care of patients with acute stroke. However, there is no universally applied standard for stroke center certification/designation and no unified list of confirmed US stroke centers. Multiple national organizations, and some state governments, certify/designate hospitals as stroke centers of various levels, but discrepancies exist between these systems. We aimed to create a unified, easily accessible, national stroke center database. Methods Lists of confirmed stroke centers were obtained from national certifying bodies (The Joint Commission [TJC], Det Norske Veritas, and Healthcare Facilities Accreditation Program) and each state government. Lists were reconciled to a common standard based on TJC requirements and incorporated into the 2018 National Emergency Department Inventory–USA database, which includes all emergency departments (EDs). Results Among 5533 US EDs, we confirmed 2446 (44%) as stroke centers, including 297 Comprehensive Stroke Centers, 14 Thrombectomy‐capable Stroke Centers, 1459 Primary Stroke Centers, and 678 Acute Stroke Ready Hospitals. Compared with EDs without stroke centers, EDs with stroke centers had higher annual visit volumes, were more often academic, and were more often located in hospitals that had trauma or burn centers. Conclusion We report the consolidation of multiple stroke center designation groups with varying criteria into a unified list of all confirmed US stroke centers linked to a comprehensive, national ED database. This data set will be valuable for future stroke systems research and improving access to emergency stroke care for patients. These data have the potential to further optimize the emergency care of patients with stroke.
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Affiliation(s)
- Krislyn M. Boggs
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
| | - Brian T. Vogel
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
| | - Kori S. Zachrison
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
| | - Janice A. Espinola
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
| | - Mohammad K. Faridi
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
| | - Rebecca E. Cash
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
| | - Ashley F. Sullivan
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
| | - Carlos A. Camargo
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
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12
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Bulwa Z, Chen M. Stroke Center Designations, Neurointerventionalist Demand, and the Finances of Stroke Thrombectomy in the United States. Neurology 2021; 97:S17-S24. [PMID: 34785600 DOI: 10.1212/wnl.0000000000012780] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 11/24/2020] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW This article aims to provide an update on the designation of stroke centers, neurointerventionalist demand, and cost-effectiveness of stroke thrombectomy in the United States. RECENT FINDINGS There are now more than 1,660 stroke centers certified by national accrediting bodies in the United States, 306 of which are designated as thrombectomy-capable or comprehensive stroke centers. Considering the amount of nationally certified centers and the number of patients with acute stroke eligible for thrombectomy, each center would be responsible for 64 to 104 thrombectomies per year. As a result, there is a growing demand placed on neurointerventionalists, who have the ability to alter the trajectory of large vessel occlusive strokes. Numbers needed to achieve functional independence after stroke thrombectomy at 90 days range from 3.2 to 7.4 patients in the early time window and 2.8 to 3.6 patients in the extended time window in appropriately selected candidates. With the low number needed to treat, in a variety of valued-based calculations and cost-effectiveness analyses, stroke thrombectomy has proved to be both clinically effective and cost-effective. SUMMARY Advancements in the early recognition and treatment of stroke have been paralleled by a remodeling of health care systems to ensure best practices in a timely manner. Stroke center-accrediting bodies provide oversight to safeguard these standards. As successful trial data from high volume centers transform into real-world experience, we must continue to re-evaluate cost-effectiveness, strike a balance between sufficient case volumes to maintain clinical excellence vs the burden and burnout associated with call responsibilities, and improve access to care for all.
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Affiliation(s)
- Zachary Bulwa
- From the Departments of Neurology (Z.B.) and Neurosurgery (M.C.), Rush University Medical Center, Chicago, IL.
| | - Michael Chen
- From the Departments of Neurology (Z.B.) and Neurosurgery (M.C.), Rush University Medical Center, Chicago, IL
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13
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Zachrison KS, Richard JV, Wilcock A, Zubizaretta JR, Schwamm LH, Uscher-Pines L, Mehrotra A. Association of Hospital Telestroke Adoption With Changes in Initial Hospital Presentation and Transfers Among Patients With Stroke and Transient Ischemic Attacks. JAMA Netw Open 2021; 4:e2126612. [PMID: 34554236 PMCID: PMC8461501 DOI: 10.1001/jamanetworkopen.2021.26612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
IMPORTANCE It has been proposed that the implementation of telestroke services (a web-based approach to using video telecommunication to treat patients with stroke before hospital admission) changes where patients with stroke symptoms receive care, but this proposal has not been rigorously assessed. OBJECTIVE To assess whether the implementation of telestroke services is associated with changes in where and how patients initially present with stroke symptoms, in their decision to be transferred to another hospital, and which hospitals they are transferred to. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study compared changes in stroke systems of care between a sample of 593 US hospitals that adopted telestroke during the period from 2009 to 2016 but were not comprehensive stroke centers, major teaching hospitals, or thrombectomy-capable hospitals vs 593 matched control hospitals without telestroke based on rural location, critical access hospital status, bed size, primary stroke center status, presence of hospital alternatives in the community, hospital stroke volume, census region, and ownership. With the use of data on 100% of Medicare fee-for-service beneficiaries, all stroke and transient ischemic attack admissions from 2008 to 2018 were identified. EXPOSURES For each hospital pair (telestroke plus matched control), the telestroke hospital's implementation date and difference-in-differences approach were used to quantify the association between telestroke implementation and changes in care from 2 years before implementation to 2 years after implementation. Models also controlled for differences in observed patient characteristics. MAIN OUTCOMES AND MEASURES Hospital stroke volume, patients' ambulance transport distance to initial hospital, hospital case mix, interhospital transfer proportion, and size of the receiving hospital for transferred patients. RESULTS Of the 669 telestroke hospitals and 2143 potential control hospitals, 593 hospital pairs were matched; in each category, 261 hospitals (44.0%) were located in a rural area, 179 (30.2%) were primary stroke centers, and 130 (21.9%) were critical access hospitals. The changes in the preimplementation to postimplementation period were similar at telestroke and control hospitals in mean annual stroke volume (telestroke hospitals, decreased from 79.6 to 76.3 patients; control hospitals, decreased from 78.8 to 75.5 patients [-3.3 patients per year for both; difference-in-differences, 0.009; P ≥ .99]). Similarly, no differences were seen in ambulance transport distance, case mix, interhospital transfers, or bed size of receiving hospitals among transferred patients. CONCLUSIONS AND RELEVANCE This study suggests that, across a national sample of hospitals implementing telestroke, no association between telestroke adoption and changes in stroke systems of care were found.
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Affiliation(s)
- Kori S. Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | - Jessica V. Richard
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Andrew Wilcock
- Department of Family Medicine, University of Vermont College of Medicine, Burlington
| | - Jose R. Zubizaretta
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston
| | | | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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14
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Mikulik R, Bar M, Cernik D, Herzig R, Jura R, Jurak L, Neumann J, Sanak D, Ostry S, Sevcik P, Skoda O, Skoloudik D, Vaclavik D, Tomek A. Stroke 20 20: Implementation goals for intravenous thrombolysis. Eur Stroke J 2021; 6:151-159. [PMID: 34414290 DOI: 10.1177/23969873211007684] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/16/2021] [Indexed: 01/01/2023] Open
Abstract
Introduction Knowledge of the implementation gap would facilitate the use of intravenous thrombolysis in stroke, which is still low in many countries. The study was conducted to identify national implementation targets for the utilisation and logistics of intravenous thrombolysis. Material and Method Multicomponent interventions by stakeholders in health care to optimise prehospital and hospital management with the goal of fast and accessible intravenous thrombolysis for every candidate. Implementation results were documented from prospectively collected cases in all 45 stroke centres nationally. The thrombolytic rate was calculated from the total number of all ischemic strokes in the population of the Czech Republic since 2004. Results Thrombolytic rates of 1.3 (95%CI 1.1 to 1.4), 5.4 (95%CI 5.1 to 5.7), 13.6 (95%CI 13.1 to 14.0), 23.3 (95%CI 22.8 to 23.9), and 23.5% (95%CI 23.0 to 24.1%) were achieved in 2005, 2009, 2014, 2017, and 2018, respectively. National median door-to-needle times were 60-70 minutes before 2012 and then decreased progressively every year to 25 minutes (IQR 17 to 36) in 2018. In 2018, 33% of both university and non-university hospitals achieved median door-to-needle time ≤20 minutes. In 2018, door-to-needle times ≤20, ≤45, and ≤60 minutes were achieved in 39, 85, and 93% of patients. Discussion Thrombolysis can be provided to ≥ 20% of all ischemic strokes nationwide and it is realistic to achieve median door-to-needle time 20 minutes. Conclusion Stroke 20-20 could serve as national implementation target for intravenous thrombolysis and country specific implementation policies should be applied to achieve such target.
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Affiliation(s)
- Robert Mikulik
- International Clinical Research Center and Department of Neurology, St. Anne's University Hospital Brno, Brno, Czech Republic.,Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Michal Bar
- Department of Neurology, University Faculty Hospital Ostrava and Faculty of Medicine, University Ostrava, Ostrava, Czech Republic
| | - David Cernik
- Department of Neurology, Masaryk Hospital Usti nad Labem - KZ a.s., Comprehensive Stroke Center, Usti nad Labem, Czech Republic
| | - Roman Herzig
- Comprehensive Stroke Center, University Hospital Hradec Kralove and Charles University Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Rene Jura
- Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Neurology, University Hospital Brno, Brno, Czech Republic
| | - Lubomir Jurak
- Neurocenter, Regional Hospital Liberec, Liberec, Czech Republic
| | - Jiri Neumann
- Department of Neurology, County Hospital Chomutov, Chomutov, Czech Republic
| | - Daniel Sanak
- Department of Neurology, Comprehensive Stroke Center, Palacký University Medical School and Hospital, Olomouc, Czech Republic
| | - Svatopluk Ostry
- Department of Neurology, Hospital Ceske Budejovice, a.s., Ceske Budejovice, Czech Republic.,Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University in Prague and Military University Hospital Prague, Prague, Czech Republic
| | - Petr Sevcik
- Department of Neurology, Charles University Faculty of Medicine in Pilsen, Pilsen, Czech Republic.,Department of Neurology, University Hospital Pilsen, Pilsen, Czech Republic
| | - Ondrej Skoda
- Department of Neurology, Hospital Jihlava, Jihlava, Czech Republic.,Department of Neurology, 3rd Medical School of Charles University and Vinohrady University Hospital, Prague, Czech Republic
| | - David Skoloudik
- Department of Nursing, Faculty of Health Science, Palacký University Olomouc, Olomouc, Czech Republic
| | - Daniel Vaclavik
- Department of Neurology and AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Ostrava, Czech Republic
| | - Ales Tomek
- Department of Neurology, 2nd Medical School of Charles University and Motol University Hospital, Prague, Czech Republic
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15
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Overwyk KJ, Yin X, Tong X, King SMC, Wiltz JL. Defect-free care trends in the Paul Coverdell National Acute Stroke Program, 2008-2018. Am Heart J 2020; 232:177-184. [PMID: 33253677 DOI: 10.1016/j.ahj.2020.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 11/16/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND In an effort to improve stroke quality of care and patient outcomes, quality of care metrics are monitored to assess utilization of evidence-based stroke care processes as part of the Paul Coverdell National Acute Stroke Program (PCNASP). We aimed to assess temporal trends in defect-free care (DFC) received by stroke patients in the PCNASP between 2008 and 2018. METHODS Quality of care data for 10 performance measures were available for 849,793 patients aged ≥18 years who were admitted to a participating hospital with a clinical diagnosis of stroke between 2008 and 2018. A patient who receives care according to all performance measures for which they are eligible, receives "defect-free care" (DFC) (eg, appropriate medications, assessments, and education). Generalized estimating equations were used to examine the factors associated with receipt of DFC. RESULTS DFC among ischemic stroke patients increased from 38.0% in 2008 to 80.8% in 2018 (P < .0001), with the largest improvement seen in receipt of stroke education (relative percent change, RPC = 64%). Similarly, DFC for hemorrhagic stroke and transient ischemic attack patients increased from 46.7% to 82.6% (RPC = 76.9%) and 39.9% to 85.0% (RPC = 113.0%) (P < .001), respectively. Among ischemic stroke patients, the adjusted odds for receiving DFC were lower for women, patients aged 18 to 54 years, Medicaid or Medicare participants, and patients with atrial fibrillation (P < .05). CONCLUSIONS From 2008 to 2018, receipt of DFC by ischemic stroke patients significantly increased in the PCNASP; however certain subgroups were less likely to receive this level of care. Targeted quality improvement initiatives could result in even further improvements among all stroke patients and help reduce disparities in care.
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16
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Dandapat S, Kasab SA, Zevallos CB, Farooqui M, Dai B, Quispe-Orozco D, Dajles A, Hasan D, Samaniego EA, Derdeyn CP, Ortega-Gutierrez S. In-House Anesthesia and Interventional Radiology Technologist Support Optimize Mechanical Thrombectomy Workflow after Hours. J Stroke Cerebrovasc Dis 2020; 29:105246. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105246] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/04/2020] [Accepted: 08/08/2020] [Indexed: 10/23/2022] Open
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17
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Langhorne P, Audebert HJ, Cadilhac DA, Kim J, Lindsay P. Stroke systems of care in high-income countries: what is optimal? Lancet 2020; 396:1433-1442. [PMID: 33129394 DOI: 10.1016/s0140-6736(20)31363-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/31/2020] [Accepted: 06/09/2020] [Indexed: 01/19/2023]
Abstract
Stroke is a complex, time-sensitive, medical emergency that requires well functioning systems of care to optimise treatment and improve patient outcomes. Education and training campaigns are needed to improve both the recognition of stroke among the general public and the response of emergency medical services. Specialised stroke ambulances (mobile stroke units) have been piloted in many cities to speed up the diagnosis, triage, and emergency treatment of people with acute stroke symptoms. Hospital-based interdisciplinary stroke units remain the central feature of a modern stroke service. Many have now developed a role in the very early phase (hyperacute units) plus outreach for patients who return home (early supported discharge services). Different levels (comprehensive and primary) of stroke centre and telemedicine networks have been developed to coordinate the various service components with specialist investigations and interventions including rehabilitation. Major challenges include the harmonisation of resources for stroke across the whole patient journey (including the rapid, accurate triage of patients who require highly specialised treatment in comprehensive stroke centres) and the development of technology to improve communication across different parts of a service.
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Affiliation(s)
- Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Royal Infirmary, Glasgow, UK.
| | - Heinrich J Audebert
- Department of Neurology and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Dominique A Cadilhac
- Monash University, Department of Medicine, School of Clinical Sciences at Monash Health, Clayton, VIC, Australia
| | - Joosup Kim
- Monash University, Department of Medicine, School of Clinical Sciences at Monash Health, Clayton, VIC, Australia
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18
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Man S, Fonarow GC. Door-to-Needle Time and Long-term Outcomes in Patients With Stroke-Reply. JAMA 2020; 324:1467-1468. [PMID: 33048151 DOI: 10.1001/jama.2020.15188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Shumei Man
- Department of Neurology, Cleveland Clinic, Cleveland, Ohio
| | - Gregg C Fonarow
- Associate Editor, JAMA Cardiology
- Division of Cardiology, University of California, Los Angeles
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19
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Zhao J, Li H, Kung D, Fisher M, Shen Y, Liu R. Impact of the COVID-19 Epidemic on Stroke Care and Potential Solutions. Stroke 2020; 51:1996-2001. [PMID: 32432997 PMCID: PMC7258753 DOI: 10.1161/strokeaha.120.030225] [Citation(s) in RCA: 235] [Impact Index Per Article: 58.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 04/30/2020] [Accepted: 05/05/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE When the coronavirus disease 2019 (COVID-19) outbreak became paramount, medical care for other devastating diseases was negatively impacted. In this study, we investigated the impact of the COVID-19 outbreak on stroke care across China. METHODS Data from the Big Data Observatory Platform for Stroke of China consisting of 280 hospitals across China demonstrated a significant drop in the number of cases of thrombolysis and thrombectomy. We designed a survey to investigate the major changes during the COVID-19 outbreak and potential causes of these changes. The survey was distributed to the leaders of stroke centers in these 280 hospitals. RESULTS From the data of Big Data Observatory Platform for Stroke of China, the total number of thrombolysis and thrombectomy cases dropped 26.7% (P<0.0001) and 25.3% (P<0.0001), respectively, in February 2020 as compared with February 2019. We retrieved 227 valid complete datasets from the 280 stroke centers. Nearly 50% of these hospitals were designated hospitals for COVID-19. The capacity for stroke care was reduced in the majority of the hospitals. Most of the stroke centers stopped or reduced their efforts in stroke education for the public. Hospital admissions related to stroke dropped ≈40%; thrombolysis and thrombectomy cases dropped ≈25%, which is similar to the results from the Big Data Observatory Platform for Stroke of China as compared with the same period in 2019. Many factors contributed to the reduced admissions and prehospital delays; lack of stroke knowledge and proper transportation were significant limiting factors. Patients not coming to the hospital for fear of virus infection was also a likely key factor. CONCLUSIONS The COVID-19 outbreak impacted stroke care significantly in China, including prehospital and in-hospital care, resulting in a significant drop in admissions, thrombolysis, and thrombectomy. Although many factors contributed, patients not coming to the hospital was probably the major limiting factor. Recommendations based on the data are provided.
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Affiliation(s)
- Jing Zhao
- From the Department of Neurology, Minhang Hospital, Fudan University, Shanghai, China (J.Z.)
| | - Hang Li
- Department of Cerebrovascular Disease, Henan Provincial People’s Hospital, Zhengzhou, China (H.L.)
| | - David Kung
- Department of Neurosurgery and Interventional Neuroradiology (D.K.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.)
| | - Ying Shen
- Department of Traditional Chinese Medicine, Xuanwu Hospital Capital Medical University, Beijing, China (Y.S.)
| | - Renyu Liu
- Department of Anesthesiology and Critical Care (R.L.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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20
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Hospital Volume and Mortality in Acute Ischemic Stroke Patients: Effect of Adjustment for Stroke Severity. J Stroke Cerebrovasc Dis 2020; 29:104753. [PMID: 32151475 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104753] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/29/2020] [Accepted: 02/10/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Stroke severity of 1 hospital is a crucial information when assessing hospital performance. We aimed to determine the effect of stroke severity in the association between hospital patient volume and outcome after acute ischemic stroke. METHODS Data from National Acute Stroke Quality Assessment in 2013 and 2014 were analyzed. Hospital patient volume was defined as the annual number of acute ischemic stroke patients who admitted to each hospital. Comparisons among hospital patient volume quartiles before and after adjusting age, sex, onset to arrival and stroke severity were made to determine the associations between hospital patient volume and mortality at 30 days, 90 days and 1 year. Assessments for the nonlinear associations, with treating hospital patient volume as a continuous variable, and the associations between hospital patient volume and quality of care were also made. RESULTS A total of 14,666 acute ischemic stroke patients admitted to 202 hospitals were analyzed. In the crude analysis, patients admitted to hospitals with lower patient volume showed higher mortality with a non-linear inverse association with a cut-off value of 227 patients/year. While the associations remained significant after adjusting age, sex and onset to arrival time (P's < .05), they disappeared when stroke severity was further adjusted (P's > .05). In contrary, hospital patient volume showed a nonlinear positive association with a plateau for summary measures of quality indicators even after adjustments for covariates including stroke severity (P < .001). CONCLUSIONS Our study implicates that stroke severity should be considered when assessing hospital performance regarding outcomes of acute stroke care.
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21
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Zachrison KS, Onnela JP, Reeves MJ, Hernandez A, Camargo CA, Zhao X, Matsouaka RA, Goldstein JN, Metlay JP, Schwamm LH. Hospital Factors Associated With Interhospital Transfer Destination for Stroke in the Northeast United States. J Am Heart Assoc 2019; 9:e011575. [PMID: 31888430 PMCID: PMC6988147 DOI: 10.1161/jaha.118.011575] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine Massachusetts General Hospital Boston MA
| | - Jukka-Pekka Onnela
- Department of Biostatistics Harvard T.H. Chan School of Public Health Boston MA
| | - Mathew J Reeves
- Department of Epidemiology Michigan State University Lansing MI
| | | | - Carlos A Camargo
- Department of Emergency Medicine Massachusetts General Hospital Boston MA
| | - Xin Zhao
- Duke Clinical Research Institute Durham NC
| | - Roland A Matsouaka
- Duke Clinical Research Institute Durham NC.,Department of Biostatistics and Bioinformatics Duke University Durham NC
| | - Joshua N Goldstein
- Department of Emergency Medicine Massachusetts General Hospital Boston MA
| | - Joshua P Metlay
- Division of General Internal Medicine Massachusetts General Hospital Boston MA
| | - Lee H Schwamm
- Department of Neurology Massachusetts General Hospital Boston MA
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Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O'Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Circulation 2019; 139:e56-e528. [PMID: 30700139 DOI: 10.1161/cir.0000000000000659] [Citation(s) in RCA: 5324] [Impact Index Per Article: 1064.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
BACKGROUND Prehospital delay remains an important reason for low intravenous tissue plasminogen activator administration rates. Study of ischemic stroke patients' responses to stroke onset may be hampered by lack of a questionnaire designed specifically to examine their cognitive, emotional, and behavioral responses to symptoms. METHODS We provide evidence for content validity and reliability for the Responses to Ischemic Stroke Symptoms Questionnaire (RISQ) through, expert panel review and calculation of a content validity index and a study to examine stability reliability among hospitalized acute ischemic stroke patients. RESULTS Expert panel review demonstrated agreement on the relevance of questionnaire items and an overall content validity index of 0.97. The study to examine stability reliability demonstrated acceptable stability of the items on the RISQ over the short term in a sample of white and black stroke patients. CONCLUSION Preliminary evidence was gathered to support the content validity and stability reliability of the RISQ. Study of the RISQ with other population groups is needed.
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Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50:e344-e418. [PMID: 31662037 DOI: 10.1161/str.0000000000000211] [Citation(s) in RCA: 3302] [Impact Index Per Article: 660.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.
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Kada A, Ogasawara K, Kitazono T, Nishimura K, Sakai N, Onozuka D, Shiokawa Y, Miyachi S, Nagata I, Toyoda K, Hashimoto Y, Hasegawa Y, Hoshino H, Yoshimura S, Suzuki M, Tsujino A, Matsuda S, Kurogi R, Kurogi A, Ren N, Nishimura A, Arimura K, Hagihara A, Tominaga T, Kayama T, Arai H, Suzuki N, Miyamoto S, Ogawa A, Iihara K. National trends in outcomes of ischemic stroke and prognostic influence of stroke center capability in Japan, 2010-2016. Int J Stroke 2019:1747493019884526. [PMID: 31653178 DOI: 10.1177/1747493019884526] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND Limited national-level information on temporal trends in comprehensive stroke center capabilities and their effects on acute ischemic stroke patients exists. AIMS To examine trends in in-hospital outcomes of acute ischemic stroke patients and the prognostic influence of temporal changes in comprehensive stroke center capabilities in Japan. METHODS This retrospective study used the J-ASPECT Diagnosis Procedure Combination database and identified 372,978 acute ischemic stroke patients hospitalized in 650 institutions between 2010 and 2016. Temporal trends in patient outcomes and recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy usage were examined. Facility comprehensive stroke center capabilities were assessed using a validated scoring system (comprehensive stroke center score: 1-25 points) in 2010 and 2014. The prognostic influence of temporal comprehensive stroke center score changes on in-hospital mortality and poor outcomes (modified Rankin Scale: 3-6) at discharge were examined using hierarchical logistic regression models. RESULTS Over time, stroke severity at admission decreased, whereas median age, sex ratio, and comorbidities remained stable. The median comprehensive stroke center score increased from 16 to 17 points. After adjusting for age, sex, comorbidities, consciousness level, and facility comprehensive stroke center score, proportion of in-hospital mortality and poor outcomes at discharge decreased (from 7.6% to 5.0%, and from 48.7% to 43.1%, respectively). The preceding comprehensive stroke center score increase (in 2010-2014) was independently associated with reduced in-hospital mortality and poor outcomes, and increased rt-PA and mechanical thrombectomy use (odds ratio (95% confidence interval): 0.97 (0.95-0.99), 0.97 (0.95-0.998), 1.07 (1.04-1.10), and 1.21 (1.14-1.28), respectively). CONCLUSIONS This nationwide study revealed six-year trends in better patient outcomes and increased use of rt-PA and mechanical thrombectomy in acute ischemic stroke. In addition to lesser stroke severity, preceding improvement of comprehensive stroke center capabilities was an independent factor associated with such trends, suggesting importance of comprehensive stroke center capabilities as a prognostic indicator of acute stroke care.
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Affiliation(s)
- Akiko Kada
- Department of Clinical Research Management, Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City General Hospital, Kobe, Japan
| | - Daisuke Onozuka
- Department of Health Communication, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | - Shigeru Miyachi
- Department of Neurosurgery, Neuroendovascular Therapy Center, Aichi Medical University, Nagakute, Japan
| | - Izumi Nagata
- Department of Neurosurgery, Kokura Memorial Hospital, Kita-Kyushu, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | | | - Yasuhiro Hasegawa
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Haruhiko Hoshino
- Department of Neurology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Michiyasu Suzuki
- Department of Neurosurgery, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Akira Tsujino
- Department of Neurology and Strokology, Nagasaki University Hospital, Nagasaki, Japan
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health School of Medicine, Kitakyushu, Japan
| | - Ryota Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ai Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nice Ren
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ataru Nishimura
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koichi Arimura
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akihito Hagihara
- Department of Health Communication, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takamasa Kayama
- Department of Advanced Medicine, Yamagata University School of Medicine, Yamagata, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Norihiro Suzuki
- Department of Neurology, Shonan Keiiku Hospital, Fujisawa, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akira Ogawa
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Fan F, Li Y, Zhang Y, Li J, Liu J, Hao Y, Smith SC, Fonarow GC, Taubert KA, Ge J, Zhao D, Huo Y. Chest Pain Center Accreditation Is Associated With Improved In-Hospital Outcomes of Acute Myocardial Infarction Patients in China: Findings From the CCC-ACS Project. J Am Heart Assoc 2019; 8:e013384. [PMID: 31630594 PMCID: PMC6898834 DOI: 10.1161/jaha.119.013384] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Chest pain center (CPC) accreditation plays an important role in the management of acute myocardial infarction (AMI). However, no evidence shows whether the outcomes of AMI patients are improved with CPC accreditation in China. Methods and Results This retrospective analysis is based on a predesigned nationwide registry, CCC‐ACS (Improving Care for Cardiovascular Disease in China‐Acute Coronary Syndrome). The primary outcome was major adverse cardiovascular events (MACE), including all‐cause death, reinfarction, stent thrombosis, stroke, and heart failure. A total of 15 344 AMI patients, from 40 CPC‐accredited hospitals, were enrolled, including 7544 admitted before and 7800 after accreditation. In propensity score matching, 6700 patients in each group were matched. The incidence of 7‐day MACE (6.7% versus 8.0%; P=0.003) and all‐cause death (1.1% versus 1.6%; P=0.021) was lower after accreditation. In multivariate adjusted mixed‐effects Cox proportional hazards models, CPC accreditation was associated with significantly decreased risk of MACE (hazard ratio: 0.78; 95% CI, 0.68–0.91) and all‐cause death (hazard ratio: 0.71; 95% CI, 0.51–0.99). The risk of MACE and all‐cause death both followed a reverse J‐shaped trend: the risk of MACE and all‐cause death decreased gradually after achieving CPC accreditation, with minimal risk occurring in the first year, but increased in the second year and after. Conclusions Based on a large‐scale national registry data set, CPC accreditation was associated with better in‐hospital outcomes for AMI patients. However, the benefits seemed to attenuate over time, and reaccreditation may be essential for maintaining AMI care quality and outcomes.
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Affiliation(s)
- Fangfang Fan
- Department of Cardiology Peking University First Hospital Beijing China
| | - Yuxi Li
- Department of Cardiology Peking University First Hospital Beijing China
| | - Yan Zhang
- Department of Cardiology Peking University First Hospital Beijing China
| | - Jianping Li
- Department of Cardiology Peking University First Hospital Beijing China
| | - Jing Liu
- Department of Epidemiology Capital Medical University Beijing Anzhen Hospital Beijing Institute of Heart, Lung & Blood Vessel Diseases Beijing China
| | - Yongchen Hao
- Department of Epidemiology Capital Medical University Beijing Anzhen Hospital Beijing Institute of Heart, Lung & Blood Vessel Diseases Beijing China
| | - Sidney C Smith
- Division of Cardiology University of North Carolina Chapel Hill NC
| | - Gregg C Fonarow
- Division of Cardiology Geffen School of Medicine at University of California Los Angeles CA
| | - Kathryn A Taubert
- Department of International Science American Heart Association Basel Switzerland
| | - Junbo Ge
- Department of Cardiology Shanghai Institute of Cardiovascular Diseases Zhongshan Hospital Fudan University Shanghai China
| | - Dong Zhao
- Department of Epidemiology Capital Medical University Beijing Anzhen Hospital Beijing Institute of Heart, Lung & Blood Vessel Diseases Beijing China
| | - Yong Huo
- Department of Cardiology Peking University First Hospital Beijing China
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Stroke Center Care and Outcome: Results from the CSPPC Stroke Program. Transl Stroke Res 2019; 11:377-386. [PMID: 31494833 DOI: 10.1007/s12975-019-00727-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/16/2019] [Accepted: 08/19/2019] [Indexed: 10/26/2022]
Abstract
The aim of this study was to assess the association between admission to stroke centers for acute ischemic stroke and complications and mortality during hospitalization in a Chinese population by means of an observational study using data from the China Stroke Center Data-Sharing Platform. We compared in-hospital complications and mortality for patients admitted with acute ischemic stroke (N = 13,236) between November 1, 2018 and December 31, 2018 at stroke center (SH) and non-stroke center (CH) hospitals using distance to hospitals as an instrumental variable to adjust for potential prehospital selection bias. The results showed that complication rates during hospitalization among ischemic stroke patients who received thrombolytic therapy (n = 11,203) were lower in the SH group than in the CH group: 11.1% vs 15.7% (absolute difference, - 5.11% [95% CI, - 6.05 to - 3.99%], odds ratio [OR] 0.85 [95% CI, 0.74 to 0.92]). The incidence of intracranial hemorrhage was reduced from 4.2 to 3.2%: SH group vs CH group, 3.2% vs 4.2% (absolute difference, - 1.24% [95% CI, - 1.65 to - 0.82%], OR 0.83 [95% CI, 0.69 to 0.0.98]). Furthermore, the total mortality rate in the SH group was also lower than in the CH group: SH group vs CH group, 2.2% vs 3.0% (absolute difference, - 0.92% [95% CI, - 1.48 to - 0.53%], OR 0.85 [95% CI, 0.73 to 0.96]). The data showed that admission to SH hospitals was associated with a lower risk of treatment complications and death for patients with an acute ischemic stroke receiving thrombolytic therapy.
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Astudillo C, Ankrom C, Trevino A, Malazarte RM, Bambhroliya AB, Savitz S, Topel CH, Milling TJ, Wu TC. Rationale and design of a statewide telestroke registry: Lone Star Stroke Consortium Telestroke Registry (LeSteR). BMJ Open 2019; 9:e026496. [PMID: 31488463 PMCID: PMC6731890 DOI: 10.1136/bmjopen-2018-026496] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION The Lone Star Stroke Consortium Telestroke Registry (LeSteR) currently consisting of 3 academic hub centres and 27 partner spokes is a statewide initiative organised by leading academic health centres in the State of Texas to understand practice patterns of acute stroke management via telestroke (TS) in Texas, a state with one of the largest rural populations in the USA. METHODS AND ANALYSIS All patients who had presumed stroke for whom a TS consultation has been obtained in the network are entered into a web-based, Health Insurance Portability and Accountability Act-compliant database from September 2013 to present. Spokes were enrolled into LeSteR in a staggered approach in two data collection phases: a retrospective phase and a prospective phase. Basic clinical, demographic data and relevant time metrics are collected in the retrospective phase. Starting 1 September 2015, additional outcome data including 90-day modified Rankin score, readmission and 90-day disposition are obtained by a standard phone interview. From the registry initiation to 31 December 2017, there are 8089 patients who had suspected stroke in the registry. Over 60% of patients enrolled after 1 September 2015 have reported outcome data. Enrolment is still active for this registry. ETHICS AND DISSEMINATION LeSteR is a statewide TS registry organised by academic health centres that will provide significant insight regarding the impact of TS in the State of Texas. Findings from LeSteR will provide data that can be analysed to improve the allocation of healthcare resources using TS to treat stroke in a state with one of the largest rural populations.
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Affiliation(s)
- Cesar Astudillo
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Christy Ankrom
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Alyssa Trevino
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Rene M Malazarte
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Arvind B Bambhroliya
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Sean Savitz
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Christopher H Topel
- Department of Neurology, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Truman J Milling
- Department of Neurology, Dell Medical School, University of Texas, Austin, Texas, USA
| | - Tzu-Ching Wu
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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Jayaraman MV, Hemendinger ML, Baird GL, Yaghi S, Cutting S, Saad A, Siket M, Madsen TE, Williams K, Rhodes J, Haas RA, Furie KL, McTaggart RA. Field triage for endovascular stroke therapy: a population-based comparison. J Neurointerv Surg 2019; 12:233-239. [DOI: 10.1136/neurintsurg-2019-015033] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 06/27/2019] [Accepted: 06/29/2019] [Indexed: 11/04/2022]
Abstract
BackgroundEndovascular therapy (EVT) for stroke improves outcomes but is time sensitive.ObjectiveTo compare times to treatment and outcomes between patients taken to the closest primary stroke center (PSC) with those triaged in the field to a more distant comprehensive stroke center (CSC).MethodsDuring the study, a portion of our region allowed field triage of patients who met severity criteria to a more distant CSC than the closest PSC. The remaining patients were transported to the closest PSC. We compared times to treatment and clinical outcomes between those two groups. Additionally, we performed a matched-pairs analysis of patients from both groups on stroke severity and distance to CSC.ResultsOver 2 years, 232 patients met inclusion criteria and were closest from the field to a PSC; 144 were taken to the closest PSC and 88 to the more distant CSC. The median additional transport time to the CSC was 7 min. Times from scene departure to alteplase and arterial puncture were faster in the direct group (50 vs 62 min; 93 vs 152 min; p<0.001 for both). Among patients who were independent before the stroke, the OR for less disability in the direct group was 1.47 (95% CI 1.13 to 1.93, p=0.003), and 2.06 (95% CI 1.10 to 3.89, p=0.01) for the matched pairs.ConclusionsIn a densely populated setting, for patients with stroke who are EVT candidates and closest to a PSC from the field, triage to a slightly more distant CSC is associated with faster time to EVT, no delay to alteplase, and less disability at 90 days.
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Man S, Zhao X, Uchino K, Hussain MS, Smith EE, Bhatt DL, Xian Y, Schwamm LH, Shah S, Khan Y, Fonarow GC. Comparison of Acute Ischemic Stroke Care and Outcomes Between Comprehensive Stroke Centers and Primary Stroke Centers in the United States. Circ Cardiovasc Qual Outcomes 2019; 11:e004512. [PMID: 29794035 DOI: 10.1161/circoutcomes.117.004512] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 04/27/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND To improve stroke care, the Brain Attack Coalition recommended establishing primary stroke center (PSC) and comprehensive stroke center (CSC) certification. This study aimed to compare ischemic stroke care and in-hospital outcomes between CSCs and PSCs. METHODS AND RESULTS We analyzed patients with acute ischemic stroke who were hospitalized at stroke centers participating in Get With The Guidelines-Stroke from 2013 to 2015. Multivariable logistic regression models were generated to examine the association between stroke center certification (CSC versus PSC) and performances and outcomes. This study included 722 941 patients who were admitted to 134 CSCs and 1047 PSCs. Both CSCs and PSCs had good conformity to 7 performance measures and the summary defect-free care measure. Among emergency department admissions, CSCs had higher intravenous tPA (tissue-type plasminogen activator) and endovascular thrombectomy rates than PSCs (14.3% versus 10.3%, 4.1% versus 1.0%, respectively). Door to intravenous tPA time was shorter at CSCs (median, 52 versus 61 minutes; adjusted risk ratio, 0.92; 95% confidence interval, 0.89-0.95). More patients at CSCs had door to intravenous tPA time ≤60 minutes (79.7% versus 65.1%; adjusted odds ratio, 1.48; 95% confidence interval, 1.25-1.75). For transferred patients, CSCs and PSCs had comparable overall performance in defect-free care, except higher endovascular thrombectomy therapy rates. The overall in-hospital mortality was higher at CSCs in both emergency department admissions (4.6% versus 3.8%; adjusted odds ratio, 1.14; 95% confidence interval, 1.01-1.29) and transferred patients (7.7% versus 6.8%; adjusted odds ratio, 1.17; 95% confidence interval, 1.05-1.32). In-hospital outcomes were comparable between CSCs and PSCs in patients who received intravenous tPA or endovascular thrombectomy. CONCLUSIONS CSCs and PSCs achieved similar overall care quality for patients with acute ischemic stroke. CSCs exceeded PSCs in timely acute reperfusion therapy for emergency department admissions, whereas PSCs had lower risk-adjusted in-hospital mortality. This information may be important for acute stroke triage and targeted quality improvement.
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Affiliation(s)
- Shumei Man
- Department of Neurology, Miami Valley Hospital, Wright State University Boonshoft School of Medicine, Dayton, OH (S.M.).,Cerebrovascular Center, Neurological Institute, Cleveland Clinic, OH (S.M., K.U., M.S.H.)
| | - Xin Zhao
- Duke Clinical Research Center, Durham, NC (X.Z., Y.X.)
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, OH (S.M., K.U., M.S.H.)
| | - M Shazam Hussain
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, OH (S.M., K.U., M.S.H.)
| | - Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.)
| | - Ying Xian
- Duke Clinical Research Center, Durham, NC (X.Z., Y.X.).,Department of Neurology, Duke University Medical Center, Duke University School of Medicine, Durham, NC (S.S., Y.X.)
| | - Lee H Schwamm
- Division of Neurology, Massachusetts General Hospital, Boston (L.H.S.)
| | - Shreyansh Shah
- Department of Neurology, Duke University Medical Center, Duke University School of Medicine, Durham, NC (S.S., Y.X.)
| | - Yosef Khan
- Department of Quality and HIT, National Center, American Heart Association, Dallas, TX (Y.K.)
| | - Gregg C Fonarow
- Division of Cardiology, University of California, Los Angeles (G.C.F.).
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Kamel H, Okin PM, Merkler AE, Navi BB, Campion TR, Devereux RB, Díaz I, Weinsaft JW, Kim J. Relationship between left atrial volume and ischemic stroke subtype. Ann Clin Transl Neurol 2019; 6:1480-1486. [PMID: 31402612 PMCID: PMC6689681 DOI: 10.1002/acn3.50841] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/19/2019] [Accepted: 06/19/2019] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE Atrial cardiopathy without atrial fibrillation (AF) may be a potential cardiac source of embolic strokes of undetermined source (ESUS). Atrial volume is a feature of atrial cardiopathy, but the relationship between atrial volume and ESUS remains unclear. METHODS We compared left atrial volume among ischemic stroke subtypes in the Cornell Acute Stroke Academic Registry (CAESAR), which includes all patients with acute ischemic stroke at our hospital since 2011. Stroke subtype was determined by neurologists per the TOAST classification and consensus ESUS definition. Left atrial volume index (LAVI) was obtained directly from our echocardiography image system (Xcelera, Philips Healthcare). We used t-tests and analysis of variance for unadjusted comparisons and targeted minimum loss-based estimation for comparisons adjusted for demographics and comorbidities. RESULTS Among 2116 patients in CAESAR from 2011 to 2016, 1293 had LAVI measurements. LAVI varied across subtypes (P < 0.001) from 48.8 (±30.0) mL/m2 in cardioembolic strokes to 30.3 (±10.5) mL/m2 in small-vessel strokes. LAVI was larger in ESUS (33.3 ± 13.6 mL/m2 ) than in small- or large-vessel stroke (30.9 ± 10.7 mL/m2 ) (P = 0.01). The association between LAVI and ESUS persisted after the adjustment for demographics and comorbidities: a 10 mL/m2 increase in LAVI was associated with a 4.4% increase in ESUS probability (95% CI, 2.3%-6.4%). Results were similar after excluding patients with AF during post-discharge heart-rhythm monitoring. INTERPRETATION We found larger left atria among patients with ESUS versus non-cardioembolic stroke. There was significant overlap in left atrial size between ESUS and non-cardioembolic stroke, highlighting that many ESUS cases are not cardioembolic.
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Affiliation(s)
- Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medical College, New York, New York
| | - Peter M Okin
- Division of Cardiology, Weill Cornell Medical College, New York, New York
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medical College, New York, New York
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medical College, New York, New York
| | - Thomas R Campion
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Richard B Devereux
- Division of Cardiology, Weill Cornell Medical College, New York, New York
| | - Iván Díaz
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | | | - Jiwon Kim
- Division of Cardiology, Weill Cornell Medical College, New York, New York
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Shen YC, Chen G, Hsia RY. Community and Hospital Factors Associated With Stroke Center Certification in the United States, 2009 to 2017. JAMA Netw Open 2019; 2:e197855. [PMID: 31348507 PMCID: PMC6661722 DOI: 10.1001/jamanetworkopen.2019.7855] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The increased number of stroke centers in the United States may not be equitably distributed across all populations. Anecdotal reports suggest there may be differential proliferation in wealthier and urban communities. OBJECTIVE To examine hospital characteristics and economic conditions of communities surrounding hospitals with and without stroke centers. DESIGN, SETTING, AND PARTICIPANTS This cohort study included all general, short-term, acute hospitals in the continental United States and used merged data from the Joint Commission, Det Norske Veritas, Healthcare Facilities Accreditation Program, state health departments, the Centers for Medicare & Medicaid Services, the American Hospital Association, the Dartmouth Atlas of Health Care, and the US Census Bureau from January 1, 2009, to September 30, 2017, to compare hospital and community characteristics of stroke-certified and non-stroke-certified hospitals and assessed characteristics of early and late adopters of stroke certification. MAIN OUTCOMES AND MEASURES Stroke center certification was the primary outcome. Risk factors were grouped into 3 categories: economic and financial, hospital, and community characteristics. Survival analyses were performed using a Cox proportional hazards regression model. RESULTS The study included 4546 US hospitals. During the study period, 1689 hospitals (37.2%) were stroke certified (961 adopted certification on or before January 1, 2009, 728 afterward). After controlling for other area and hospital characteristics, hospitals in low-income hospital service areas and the lower tertile of profit-margin distribution were less likely to adopt stroke certification (hazard ratio [HR], 0.62; 95% CI, 0.52-0.74 and HR, 0.87; 95% CI, 0.78-0.98, respectively). Urban hospitals had a higher likelihood of stroke certification than rural hospitals (HR, 12.79; 95% CI, 10.64-15.37). CONCLUSIONS AND RELEVANCE This study found that stroke centers have proliferated unevenly across geographic localities, where hospitals in high-income hospital service areas and with higher profit margins have a greater likelihood of being stroke certified. These findings suggest that market-driven factors may be associated with stroke center certification.
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Affiliation(s)
- Yu-Chu Shen
- Graduate School of Business and Public Policy, Naval Postgraduate School, Monterey, California
- National Bureau of Economic Research, Cambridge, Massachusetts
| | | | - Renee Y. Hsia
- Department of Emergency Medicine, University of California at San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco
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Adeoye O, Nyström KV, Yavagal DR, Luciano J, Nogueira RG, Zorowitz RD, Khalessi AA, Bushnell C, Barsan WG, Panagos P, Alberts MJ, Tiner AC, Schwamm LH, Jauch EC. Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update. Stroke 2019; 50:e187-e210. [PMID: 31104615 DOI: 10.1161/str.0000000000000173] [Citation(s) in RCA: 222] [Impact Index Per Article: 44.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In 2005, the American Stroke Association published recommendations for the establishment of stroke systems of care and in 2013 expanded on them with a statement on interactions within stroke systems of care. The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating stroke systems of care to date and to update the American Stroke Association recommendations on the basis of improvements in stroke systems of care. Over the past decade, stroke systems of care have seen vast improvements in endovascular therapy, neurocritical care, and stroke center certification, in addition to the advent of innovations, such as telestroke and mobile stroke units, in the context of significant changes in the organization of healthcare policy in the United States. This statement provides an update to prior publications to help guide policymakers and public healthcare agencies in continually updating their stroke systems of care in light of these changes. This statement and its recommendations span primordial and primary prevention, acute stroke recognition and activation of emergency medical services, triage to appropriate facilities, designation of and treatment at stroke centers, secondary prevention at hospital discharge, and rehabilitation and recovery.
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Ischemic Stroke Transfer Patterns in the Northeast United States. J Stroke Cerebrovasc Dis 2018; 28:295-304. [PMID: 30389376 DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 08/29/2018] [Accepted: 09/28/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Little is known about how hospitals are connected in the transfer of ischemic stroke (IS) patients. We aimed to describe differences in characteristics of transferred versus nontransferred patients and between transferring and receiving hospitals in the Northeastern United States, and to describe changes over time. METHODS We used Medicare claims data, and a subset linked with the Get with the Guidelines-Stroke registry from 2007 to 2011. Receiving hospitals were those with annual IS volume greater than or equal to 120 and greater than or equal to 15% received as transfers, and transferring hospitals were nonaccepting hospitals that transferred greater than or equal to 15% of their total (ED plus inpatient) IS patient discharges. A transferring-to-receiving hospital connection was identified if greater than or equal to 5 patients per year were shared. ArcGIS 10.3.1 was used for network visualization. RESULTS Among 177,270 admissions to 402 Northeast hospitals, 6906 (3.9%) patients were transferred. Transferred patients were younger with more severe strokes (78 versus 81 years, P < .001; National Institutes of Health Stroke Severity 7 versus 5, P < .001), and were as likely to receive tissue plasminogen activator as nontransferred (P = .29). From 2007 to 2011, there were more patients transferred (960 [3%] to 1777 [6%], P < .001), and more transferring hospitals (46 [12%] to 91 [24%], P < .001), and receiving hospitals (6 [2%] to 16 [4%], P < .001). Most transferring hospitals were exclusively connected to a single receiving hospital. CONCLUSIONS From 2007 to 2011, hospitals in the United States Northeast became more connected in the care of IS patients, with increasing patient transfers and hospital connections. Yet most hospitals remained unconnected. Further characterization of this transfer network will be important for understanding and improving regional stroke systems of care.
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Ortega J, Gonzalez JM, de Tantillo L, Gattamorta K. Implementation of an in-hospital stroke simulation protocol. Int J Health Care Qual Assur 2018; 31:552-562. [PMID: 29954272 DOI: 10.1108/ijhcqa-08-2017-0149] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose A major component of hospital stroke care involves prompt identification of stroke in admitted patients. Delays in recognizing stroke symptoms and initiating treatment for in-hospital stroke can adversely impact patient outcomes. This quality improvement intervention used simulation together with a traditional lecture to instruct nurses at a university hospital about a new stroke protocol being implemented to increase rapid recognition of stroke and meet Joint Commission National Hospital Inpatient Quality Measures. The paper aims to discuss these issues. Design/methodology/approach In total, 86 registered nurses from the neurology and cardiology units attended a lecture and participated in a simulation scenario with a standardized patient exhibiting stroke symptoms. Participants completed a ten-item pre-test to measure their knowledge of stroke care prior to the lecture; they repeated the test pre-simulation and once again post-simulation to evaluate changes in knowledge. Findings Overall mean stroke knowledge scores increased significantly from pre-lecture to pre-simulation, and from pre-simulation to post-simulation. Simulation plus lecture was more effective than lecture alone in increasing knowledge about hospital stroke protocol despite assigned unit (cardiology or neurology), years of experience, or previous exposure to simulation. Research limitations/implications All eligible nurses who agreed to participate received training, making it impossible to compare improvements in knowledge to those who did not receive the training. Originality/value A diverse array of nursing professionals and their patients may benefit from simulation training. This quality improvement intervention provides a feasible model for establishing new care protocols in a hospital setting.
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Affiliation(s)
- Johis Ortega
- School of Nursing and Health Studies, University of Miami , Florida, USA
| | - Juan M Gonzalez
- School of Nursing and Health Studies, University of Miami , Florida, USA
| | - Lila de Tantillo
- School of Nursing and Health Studies, University of Miami , Florida, USA
| | - Karina Gattamorta
- School of Nursing and Health Studies, University of Miami , Florida, USA
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Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, Chiuve SE, Cushman M, Delling FN, Deo R, de Ferranti SD, Ferguson JF, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Lutsey PL, Mackey JS, Matchar DB, Matsushita K, Mussolino ME, Nasir K, O'Flaherty M, Palaniappan LP, Pandey A, Pandey DK, Reeves MJ, Ritchey MD, Rodriguez CJ, Roth GA, Rosamond WD, Sampson UKA, Satou GM, Shah SH, Spartano NL, Tirschwell DL, Tsao CW, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P. Heart Disease and Stroke Statistics-2018 Update: A Report From the American Heart Association. Circulation 2018; 137:e67-e492. [PMID: 29386200 DOI: 10.1161/cir.0000000000000558] [Citation(s) in RCA: 4508] [Impact Index Per Article: 751.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Miller EC, Blum C, Rostanski SK. Developing a Stroke Center. Stroke 2017; 48:e155-e156. [PMID: 28611086 DOI: 10.1161/strokeaha.117.017745] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 05/08/2017] [Accepted: 05/10/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Eliza C Miller
- From the Department of Neurology, Columbia University Medical Center, New York, NY (E.C.M.); Department of Neurology, Brown University, Miriam Hospital, Providence, RI (C.B.); Department of Neurology, New York University School of Medicine, NY (S.K.R.); and Department of Neurology, Bellevue Hospital Center, New York, NY (S.K.R.).
| | - Christina Blum
- From the Department of Neurology, Columbia University Medical Center, New York, NY (E.C.M.); Department of Neurology, Brown University, Miriam Hospital, Providence, RI (C.B.); Department of Neurology, New York University School of Medicine, NY (S.K.R.); and Department of Neurology, Bellevue Hospital Center, New York, NY (S.K.R.)
| | - Sara K Rostanski
- From the Department of Neurology, Columbia University Medical Center, New York, NY (E.C.M.); Department of Neurology, Brown University, Miriam Hospital, Providence, RI (C.B.); Department of Neurology, New York University School of Medicine, NY (S.K.R.); and Department of Neurology, Bellevue Hospital Center, New York, NY (S.K.R.)
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Ormseth CH, Sheth KN, Saver JL, Fonarow GC, Schwamm LH. The American Heart Association's Get With the Guidelines (GWTG)-Stroke development and impact on stroke care. Stroke Vasc Neurol 2017; 2:94-105. [PMID: 28959497 PMCID: PMC5600018 DOI: 10.1136/svn-2017-000092] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 04/26/2017] [Indexed: 01/06/2023] Open
Abstract
The American Heart Association’s Get With the Guidelines (GWTG)-Stroke programme has changed stroke care delivery in the USA since its establishment in 2003. GWTG is a voluntary registry and continuous quality improvement initiative that collects data on patient characteristics, hospital adherence to guidelines and inpatient outcomes. Implementation of the programme saw increased provision of evidence-based care and improved patient outcomes. This review will describe the development of the programme and discuss the impact on stroke outcomes and transformation of stroke care delivery that followed its implementation.
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Affiliation(s)
- Cora H Ormseth
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kevin N Sheth
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jeffrey L Saver
- Department of Neurology, UCLA Medical Center, Los Angeles, California, USA
| | - Gregg C Fonarow
- Department of Cardiology, UCLA Medical Center, Los Angeles, California, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
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