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Man S, Bruckman D, Uchino K, Schold JD, Dalton J. Racial, Ethnic, and Regional Disparities of Post-Acute Service Utilization After Stroke in the United States. Neurol Clin Pract 2024; 14:e200329. [PMID: 39036785 PMCID: PMC11259533 DOI: 10.1212/cpj.0000000000200329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 04/02/2024] [Indexed: 07/23/2024]
Abstract
Background and Objectives Post-acute care is critical for patient functional recovery and successful community transition. This study aimed to understand the current racial, ethnic, and regional disparities in post-acute service utilization after stroke. Methods This retrospective cross-sectional study included patients hospitalized for ischemic stroke and intracerebral hemorrhage in 2017-2018 using the National Inpatient Sample. Discharge destinations were classified as follows: (1) facility including inpatient rehabilitation, skilled nursing facility, and facility hospice; (2) home health care (HHC), including home health and home hospice; and (3) home without HHC. Multinomial logistic regression was used to study the odds of discharge to a facility over home and HHC over home without HHC by race, ethnicity, insurance, and census division, adjusting for clinical factors and survey design. Results Among the 1,000,980 weighted ischemic stroke admissions, 66.9% were White, 17.6% Black, 9.5% Hispanic, 3.1% Asian American/Pacific Islander, and 0.4% Native American. Relative to private insurance, uninsured patients had the lowest adjusted odds of facility over home discharge (0.44; 95% CI 0.40-0.48) and HHC discharge over home without HHC (0.79; 95% CI 0.71-0.88). Compared with White patients, only Hispanic patients with Medicare/Medicaid insurance or self-pay had lower odds of facility over home discharge (adjusted OR 0.80 and 0.75, respectively; 95% CI 0.76-0.84 and 0.63-0.93). Uninsured Hispanic patients also had lower odds of HHC discharge over home without HHC than White patients (0.74; 95% CI 0.57-0.97). Facility discharge rate was the highest in East North Central (39.2%) and lowest in Pacific (31.2%). HHC discharge rate was the highest in New England (20.2%) and lowest in West North Central (10.3%), which had the highest home without HHC discharge (46.1%). Compared with New England, other census divisions had lower odds of facility over any home discharge with Pacific being the lowest (adjusted OR, 0.66; 95% CI 0.60-0.71) and HHC over home without HHC discharge with West North Central being the lowest (adjusted OR, 0.33; 95% CI 0.29-0.38). Similar patterns were observed in intracerebral hemorrhage. Discussion Significant insurance-dependent racial and ethnic disparities and regional variations were evident in post-acute service utilization after stroke. Targeted efforts are needed to improve post-acute service access for uninsured patients especially Hispanic patients and people in certain regions.
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Affiliation(s)
- Shumei Man
- Department of Neurology and Cerebrovascular Center (SM, KU), Neurological Institute, Cleveland Clinic, OH; Center for Population Health Research (DB, JDS, JD), Department of Quantitative Health Sciences, Cleveland Clinic, OH
| | - David Bruckman
- Department of Neurology and Cerebrovascular Center (SM, KU), Neurological Institute, Cleveland Clinic, OH; Center for Population Health Research (DB, JDS, JD), Department of Quantitative Health Sciences, Cleveland Clinic, OH
| | - Ken Uchino
- Department of Neurology and Cerebrovascular Center (SM, KU), Neurological Institute, Cleveland Clinic, OH; Center for Population Health Research (DB, JDS, JD), Department of Quantitative Health Sciences, Cleveland Clinic, OH
| | - Jesse D Schold
- Department of Neurology and Cerebrovascular Center (SM, KU), Neurological Institute, Cleveland Clinic, OH; Center for Population Health Research (DB, JDS, JD), Department of Quantitative Health Sciences, Cleveland Clinic, OH
| | - Jarrod Dalton
- Department of Neurology and Cerebrovascular Center (SM, KU), Neurological Institute, Cleveland Clinic, OH; Center for Population Health Research (DB, JDS, JD), Department of Quantitative Health Sciences, Cleveland Clinic, OH
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Dunkley R, Omeaku N, Trickey AW, Tandel MD, Garcia A, Govindarajan P. Growth of Statewide Emergency Medical Services Bypass Policies for Acute Stroke. JAMA HEALTH FORUM 2024; 5:e241752. [PMID: 38967951 PMCID: PMC11227071 DOI: 10.1001/jamahealthforum.2024.1752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 05/03/2024] [Indexed: 07/06/2024] Open
Abstract
This cross-sectional study evaluates growth of transport policies and policy components that directed emergency medical services (EMS) to bypass local emergency departments for the closest certified stroke centers as a proven treatment for stroke.
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Affiliation(s)
| | | | - Amber W. Trickey
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford Medicine, Stanford University, Palo Alto, California
| | - Megha D. Tandel
- Quantitative Sciences Unit, Department of Medicine, Stanford Medicine, Stanford University, Palo Alto, California
| | - Ariadna Garcia
- Quantitative Sciences Unit, Department of Medicine, Stanford Medicine, Stanford University, Palo Alto, California
| | - Prasanthi Govindarajan
- Department of Emergency Medicine, Stanford Medicine, Stanford University, Palo Alto, California
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Chen Y, Lei Q, Li J, Li J, He Y, Li J, Xing S, Fan Y, Zeng J. Certification of stroke centers at primary hospitals and the improvement of thrombolysis n South China during 2020-2022. Eur Stroke J 2024; 9:477-485. [PMID: 38189301 PMCID: PMC11318416 DOI: 10.1177/23969873231223062] [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: 10/15/2023] [Accepted: 12/04/2023] [Indexed: 01/09/2024] Open
Abstract
INTRODUCTION IVT use declined globally in 2020 due to the Corona Virus Disease 2019 (COVID-19) pandemic, but it increased in South China. This study was conducted to evaluate the association of establishing Stroke Prevention Centers (SPCs) at primary hospitals with IVT increase in South China. MATERIALS AND METHODS We conducted a longitudinal observational study across 336 hospitals in 114 areas in South China during 2020-2022. Data regarding certified stroke centers, IVT volumes, and IVT rates were collected. Correlations between IVT rates and the number or density of stroke centers were accessed. IVT use was compared among areas with different levels of stroke centers or on different certification process. RESULTS During 2020-2022, there were 83, 125, and 152 stroke centers, with 26, 65, and 92 SPCs, respectively. IVT therapies were 12,795, 17,266, and 20,411, representing a 29.8% increase/year (all p < 0.001). IVT rates increased from 7.2% in 2020 to 8.8% and 10.4% in 2021 and 2022, demonstrating a 22.2% increase/year (all p < 0.001). IVT rates correlated with the number and density of SPCs (all p < 0.05). IVT rates were higher in areas equipped with SPCs than in those without stroke centers (all p < 0.05). IVT rates consistently increased during the SPC certification process from 1 year before through the certification and subsequent maintenance (both p < 0.05). DISCUSSION AND CONCLUSION Well-organised SPCs and IVT therapy demonstrated substantial increase during the 3-year period. Certification of SPCs at primary hospitals is associated with improved IVT therapy in South China even with city lockdown during COVID-19 pandemic.
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Affiliation(s)
- Yicong Chen
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Qingfeng Lei
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
- Department of Neurology, The Sixth Affiliated Hospital, Sun Yat-sen University, Yuancun, Guangzhou, China
| | - Jiaoxing Li
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Jianle Li
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Yinxin He
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Jingjing Li
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Shihui Xing
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Yuhua Fan
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Jinsheng Zeng
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
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Wolcott ZC, English SW. Artificial intelligence to enhance prehospital stroke diagnosis and triage: a perspective. Front Neurol 2024; 15:1389056. [PMID: 38756217 PMCID: PMC11096539 DOI: 10.3389/fneur.2024.1389056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/22/2024] [Indexed: 05/18/2024] Open
Abstract
As health systems organize to deliver the highest quality stroke care to their patients, there is increasing emphasis being placed on prehospital stroke recognition, accurate diagnosis, and efficient triage to improve outcomes after stroke. Emergency medical services (EMS) personnel currently rely heavily on dispatch accuracy, stroke screening tools, bypass protocols and prehospital notification to care for patients with suspected stroke, but novel tools including mobile stroke units and telemedicine-enabled ambulances are already changing the landscape of prehospital stroke care. Herein, the authors provide our perspective on the current state of prehospital stroke diagnosis and triage including several of these emerging trends. Then, we provide commentary to highlight potential artificial intelligence (AI) applications to improve stroke detection, improve accurate and timely dispatch, enhance EMS training and performance, and develop novel stroke diagnostic tools for prehospital use.
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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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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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Fox C. Pediatric Ischemic Stroke. Continuum (Minneap Minn) 2023; 29:566-583. [PMID: 37039410 DOI: 10.1212/con.0000000000001239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Pediatric cerebrovascular disease is one of the leading causes of death and disability in children. Survivors of childhood stroke and their families are often left to cope with long-lasting sequelae, such as barriers to school reentry and long-term challenges in attaining independence as adults. Because childhood stroke is rare and providers may not be familiar with the disorder, this article reviews the risk factors, acute management, and sequelae of ischemic stroke in children. LATEST DEVELOPMENTS High-quality evidence has resulted in an organized approach to emergent treatment of ischemic stroke in adults, but most front-line providers are less prepared for emergent stroke management in children. The level of evidence for reperfusion therapies in children remains low but is growing. Thrombolysis and thrombectomy are sometimes considered for hyperacute treatment of stroke in children. Readiness for pediatric stroke at regional centers should include an organized approach to pediatric stroke triage and management based on extrapolation from adult stroke trials, expert consensus, and emerging pediatric studies. ESSENTIAL POINTS This review provides up-to-date information about ischemic stroke risk factors and management in children. Preparation for rapid stroke diagnosis and management in children may improve outcomes.
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Erben Y, Brott TG. The Challenge of Preventing Carotid Artery Stroke in Properly Medically Managed Patients: Lessons From SPACE-2. J Vasc Surg 2023; 77:1575-1577. [PMID: 36893947 DOI: 10.1016/j.jvs.2023.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 02/23/2023] [Indexed: 03/09/2023]
Affiliation(s)
- Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL.
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Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Beaton AZ, Boehme AK, Buxton AE, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Fugar S, Generoso G, Heard DG, Hiremath S, Ho JE, Kalani R, Kazi DS, Ko D, Levine DA, Liu J, Ma J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Virani SS, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation 2023; 147:e93-e621. [PMID: 36695182 DOI: 10.1161/cir.0000000000001123] [Citation(s) in RCA: 1258] [Impact Index Per Article: 1258.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Moody KA, Maillie L, Dhamoon MS. National Patterns and Outcomes of Neurologist Care in Acute Ischemic Stroke. Neurohospitalist 2023; 13:13-21. [PMID: 36531857 PMCID: PMC9755618 DOI: 10.1177/19418744221129428] [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: 01/03/2024] Open
Abstract
Background & Purpose Specialist care of acute ischemic stroke patients has been associated with improved outcomes but is not well-characterized. We sought to elucidate the involvement and influence of neurologists on acute ischemic stroke care. Methods Using 100% Medicare datasets, index acute ischemic stroke admissions from 2016-2018 were identified with International Classification of Diseases, 10th Revision codes. Neurologists were identified by NPI code. Neurologist involvement in care was defined as: "neurologist involved in care"; "hospital with a neurologist"; and "percent of acute ischemic stroke treated by neurologist." Adjusted logistic regression models summarized exposure to neurologists and their association with outcomes (inpatient mortality, good outcome, and 30-day readmission). Results Among 647838 index AIS admissions from 2016-2018, 15.6% included a neurologist involved in care, associated with receiving intravenous thrombolysis (19.1% vs 6.5%), endovascular thrombectomy (13.2% vs 1.4%), treatment at a teaching hospital (87.7% vs 55.5%), and treatment at a hospital in the highest volume quartile (95.3% vs 75.6%). Of 4797 hospitals, 36.1% had a neurologist, among which the mean percent of admissions treated by a neurologist was 14.7% (SD 24.4). Neurologist involvement was associated with increased inpatient mortality (OR 1.81; 95% CI 1.75-1.86), decreased odds of a good outcome (OR .92; 95% CI .90-.93), and increased 30-day readmission (OR 1.04; 95% C: 1.01-1.06). Conclusions The minority of acute ischemic stroke admissions among the elderly in the US are treated by neurologists. Neurologist involvement in care is associated with worse outcomes, possibly from the allocation of severe cases to neurologists.
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Affiliation(s)
- Kate A. Moody
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Luke Maillie
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mandip S. Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Shen YC, Sarkar N, Hsia RY. Structural Inequities for Historically Underserved Communities in the Adoption of Stroke Certification in the United States. JAMA Neurol 2022; 79:777-786. [PMID: 35759253 PMCID: PMC9237804 DOI: 10.1001/jamaneurol.2022.1621] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/28/2022] [Indexed: 12/22/2022]
Abstract
Importance Stroke centers are associated with better outcomes. There is substantial literature surrounding disparities in stroke outcomes for underserved populations. However, the existing literature has focused primarily on discrimination at the individual or institutional level, and studies of structural discrimination in stroke care are scant. Objective To examine differences in hospitals' likelihood of adopting stroke care certification between historically underserved and general communities. Design, Setting, and Participants This study combined a data set of hospital stroke certification from all general acute nonfederal hospitals in the continental US from January 1, 2009, to December 31, 2019, with national, hospital, and census data to define historically underserved communities by racial and ethnic composition, income distribution, and rurality. For all categories except rurality, communities were categorized by the composition and degree of segregation of each characteristic. Cox proportional hazard models were then estimated to compare the hazard of adopting stroke care certification between historically underserved and general communities, adjusting for population size and hospital bed capacity. Data were analyzed from June 2021 to April 2022. Main Outcomes and Measures Hospitals' likelihood of adopting stroke care certification. Results A total of 4984 hospitals were included. From 2009 to 2019, the total number of hospitals with stroke certification grew from 961 to 1763. Hospitals serving Black, racially segregated communities had the highest hazard of adopting stroke care certification (hazard ratio [HR], 1.67; 95% CI, 1.41-1.97) in models not accounting for population size, but their hazard was 26% lower than among those serving non-Black, racially segregated communities (HR, 0.74; 95% CI, 0.62-0.89) in models controlling for population and hospital size. Adoption hazard was lower in low-income communities compared with high-income communities, regardless of their level of economic segregation, and rural hospitals were much less likely to adopt any level of stroke care certification relative to urban hospitals (HR, 0.43; 95% CI, 0.35-0.51). Conclusions and Relevance In this analysis of stroke certification adoption across acute care hospitals in the US from 2009 to 2019, hospitals in low-income and rural communities had a lower likelihood of receiving stroke certification than hospitals in general communities. Hospitals operating in Black, racially segregated communities had the highest likelihood of adopting stroke care, but because these communities had the largest population, patients in these communities had the lowest likelihood of access to stroke-certified hospitals when the model controlled for population size. These findings provide empirical evidence that the provision of acute neurological services is structurally inequitable across historically underserved communities.
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Affiliation(s)
- Yu-Chu Shen
- Naval Postgraduate School, Monterey, California
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Nandita Sarkar
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Renee Y. Hsia
- Department of Emergency Medicine, University of California, San Francisco
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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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13
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Tsao CW, Aday AW, Almarzooq ZI, Alonso A, Beaton AZ, Bittencourt MS, Boehme AK, Buxton AE, Carson AP, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Ferguson JF, Generoso G, Ho JE, Kalani R, Khan SS, Kissela BM, Knutson KL, Levine DA, Lewis TT, Liu J, Loop MS, Ma J, Mussolino ME, Navaneethan SD, Perak AM, Poudel R, Rezk-Hanna M, Roth GA, Schroeder EB, Shah SH, Thacker EL, VanWagner LB, Virani SS, Voecks JH, Wang NY, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association. Circulation 2022; 145:e153-e639. [PMID: 35078371 DOI: 10.1161/cir.0000000000001052] [Citation(s) in RCA: 2468] [Impact Index Per Article: 1234.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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14
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Abstract
BACKGROUND Racial minorities are disproportionately affected by stroke, with Black patients experiencing worse poststroke outcomes than White patients. A modifiable aspect of acute stroke care delivery not yet examined is whether disparities in stroke outcomes are related to hospital nurse staffing levels. OBJECTIVES The aim of this study was to determine whether 7- and 30-day readmission disparities between Black and White patients were associated with nurse staffing levels. METHODS We conducted a secondary analysis of 542 hospitals in four states. Risk-adjusted, logistic regression models were used to determine the association of nurse staffing with 7- and 30-day all-cause readmissions for Black and White ischemic stroke patients. RESULTS Our sample included 98,150 ischemic stroke patients (87% White, 13% Black). Thirty-day readmission rates were 10.4% (12.7% for Black patients, 10.0% for White patients). In models accounting for hospital and patient characteristics, the odds of 30-day readmissions were higher for Black than White patients. A significant interaction was found between race and nurse staffing, with Black patients experiencing higher odds of 30- and 7-day readmissions for each additional patient cared for by a nurse. In the best-staffed hospitals (less than three patients per nurse), Black and White stroke patients' disparities were no longer significant. DISCUSSION Disparities in readmissions between Black and White stroke patients may be linked to the level of nurse staffing in the hospitals where they receive care. Tailoring nurse staffing levels to meet the needs of Black ischemic stroke patients represents a promising intervention to address systemic inequities linked to readmission disparities among minority stroke patients.
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15
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Flowers AM, Chan W, Meyer BI, Bruce BB, Newman NJ, Biousse V. Referral Patterns of Central Retinal Artery Occlusion to an Academic Center Affiliated With a Stroke Center. J Neuroophthalmol 2021; 41:480-487. [PMID: 34788238 PMCID: PMC9546636 DOI: 10.1097/wno.0000000000001409] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Central retinal artery occlusion (CRAO) is a medical emergency, and patients who present acutely should be immediately referred to the nearest stroke center. We evaluated practice patterns for CRAO management at one academic center over the last decade. METHODS This was a retrospective study on all adult patients diagnosed with a CRAO seen at one tertiary hospital and outpatient clinic affiliated with a comprehensive stroke center ("our institution") from 2010 to 2020. Our electronic medical records were searched for CRAO diagnoses, and patient medical records were reviewed. The exclusion criteria were incorrect diagnosis, unclear diagnosis, historical CRAO, or satellite clinic location. Demographics, distance and time to presentation to our institution, number and type of prior providers seen, diagnostic tests performed, and treatments provided were collected. Summary statistics of median, mean, and frequency were calculated and reported with measures of variance (interquartile range [IQR], ranges). F, Tukey, and Fisher exact tests were used for comparisons. RESULTS We included 181 patients with a diagnosis of CRAO (80 [44.2%] women; median age 69 years [range 20-101]). The median distance from patient's home to our institution was 27.8 miles (IQR 15.5-57.4; range 2.4-930). The median time from visual loss to presentation at our institution was 144 hours (IQR 23-442 hours, range 0.5-2,920) from 2010 to 2013, 72 hours (IQR 10.5-372 hours, range 0-13,140) from 2014 to 2016, and 48 hours (IQR 7-180 hours, range 0-8,030) from 2017 to 2020 (P = 0.07). 91/181 (50%) patients presented to an outpatient provider. 73/181 (40%) presented to an emergency department. Eighty-six percent presented within 1 week of visual loss onset, and rates of comprehensive inpatient evaluation for acute CRAO improved from 44% in 2010-2013 to 82% in 2017-2020 (P < 0.01). CONCLUSIONS Patients with CRAO often present late and only after evaluation by multiple outpatient providers. Improvement has occurred over the past decade, but delays underscore the barriers to performing clinical trials evaluating very acute treatments for CRAO. Educational interventions for healthcare providers and patients are necessary.
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Affiliation(s)
- Alexis M Flowers
- Department of Ophthalmology, Emory University, Atlanta, GA 30322
| | - Wesley Chan
- Department of Ophthalmology, Emory University, Atlanta, GA 30322
| | | | - Beau B. Bruce
- Department of Ophthalmology, Emory University, Atlanta, GA 30322
- Department of Neurology, Emory University, Atlanta, GA 30322
- Department of Epidemiology, Emory University, Atlanta, GA 30322
| | - Nancy J. Newman
- Department of Ophthalmology, Emory University, Atlanta, GA 30322
- Department of Neurology, Emory University, Atlanta, GA 30322
- Department of Neurological Surgery, Emory University, Atlanta, GA 30322
| | - Valérie Biousse
- Department of Ophthalmology, Emory University, Atlanta, GA 30322
- Department of Neurology, Emory University, Atlanta, GA 30322
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16
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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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17
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Zhang M, Rodrigues A, Zhou Q, Li G. Focused ultrasound: growth potential and future directions in neurosurgery. J Neurooncol 2021; 156:23-32. [PMID: 34410576 DOI: 10.1007/s11060-021-03820-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/31/2021] [Indexed: 12/18/2022]
Abstract
Over the past two decades, vast improvements in focused ultrasound (FUS) technology have made the therapy an exciting addition to the neurosurgical armamentarium. In this time period, FUS has gained US Food and Drug Administration (FDA) approval for the treatment of two neurological disorders, and ongoing efforts seek to expand the lesion profile that is amenable to ultrasonic intervention. In the following review, we highlight future applications for FUS therapy and compare its potential role against established technologies, including deep brain stimulation and stereotactic radiosurgery. Particular attention is paid to tissue ablation, blood-brain-barrier opening, and gene therapy. We also address technical and infrastructural challenges involved with FUS use and summarize the hurdles that must be overcome before FUS becomes widely accepted in the neurosurgical community.
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Affiliation(s)
- Michael Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA. .,Center for Academic Medicine, Neurosurgery, Stanford University School of Medicine, MC 5327, 453 Quarry Road, Palo Alto, CA, 94304, USA.
| | - Adrian Rodrigues
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Quan Zhou
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA.,Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Gordon Li
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
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18
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Chen Y, Li J, Dang C, Tan S, Ouyang F, Li J, Yu J, Zeng J, Fan Y. Impact of stroke center certification on rt-PA thrombolysis after acute ischemic stroke in South China from 2015 to 2020. Int J Stroke 2021; 17:559-565. [PMID: 34235984 DOI: 10.1177/17474930211031440] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE In China, stroke center certification was launched in 2015, but little is known about its impact on intravenous thrombolysis. This study aimed to evaluate the effects of stroke center certification on the use of intravenous thrombolysis during a five-year period in South China. METHODS We retrospectively collected data regarding the use of recombinant tissue plasminogen activator (rt-PA) in 21 cities of Guangdong from 2015 to 2020. The annual thrombolysis rate was defined as the number of patients who underwent intravenous rt-PA therapy divided by the number of those who had acute ischemic stroke within the same year. The density of stroke centers was calculated as the number of stroke centers divided by the corresponding residents. Spearman's correlation analysis was used to determine the correlations between the annual thrombolysis rates and the number/density of stroke centers. Paired t-test was used to compare differences in growth in annual thrombolysis rates before and after having stroke centers. RESULTS From 2015 to 2020, the annual rt-PA thrombolysis rates of Guangdong increased from 1.4% to 7.2%, which was accompanied by an increase in the number of stroke centers from 0 to 82 and density of stroke centers from 0.00 to 0.71 per million population. The average annual rt-PA use in stroke centers was higher than that in non-stroke centers from 2016 to 2020 (all P < 0.05). There was a positive correlation of annual thrombolysis rates with the number of stroke centers (r = 1.00, P = 0.0028) and with the density of stroke centers in the 21 cities from 2018 to 2020 (all P < 0.05). The growth in annual thrombolysis rates significantly accelerated at the city-level after having stroke centers (1.55%/y vs. 0.77%/y, P < 0.001). CONCLUSIONS Stroke center certification may partially drive the increased use of rt-PA thrombolysis. Stroke center certification should be continually promoted to facilitate access to intravenous thrombolysis for patients with acute ischemic stroke.
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Affiliation(s)
- Yicong Chen
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Jiaoxing Li
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Chao Dang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Shuangquan Tan
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Fubing Ouyang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Jianle Li
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Jian Yu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Jinsheng Zeng
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Yuhua Fan
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
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19
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Nagaraja N, Kubilis PS, Hoh BL, Wilson CA, Khanna AY, Kelly AG. Trends of Acute Ischemic Stroke Reperfusion Therapies from 2012 to 2016 in the United States. World Neurosurg 2021; 150:e621-e630. [PMID: 33757890 DOI: 10.1016/j.wneu.2021.03.073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/14/2021] [Accepted: 03/15/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND American Heart Association/American Stroke Association guidelines recommend endovascular stroke therapy (EST) with recombinant tissue plasminogen activator (rt-PA) for eligible patients in acute ischemic stroke (AIS). Using the National Inpatient Sample database, we evaluated trends in treatment with rt-PA and EST for AIS and their outcomes. METHODS This is a cross-sectional observational study of patients with AIS admitted in US hospitals from 2012 to 2016. Patients were grouped into those who received rt-PA alone, EST alone, and rtPA+EST. Survey statistical procedures were performed. Multivariable regression analysis with pairwise comparisons of each treatment group with no treatment group was performed for discharge outcomes. RESULTS The study included 2,290,520 patients with AIS with the mean age of 70.46 years. Treatment rates increased from 2012 to 2016 for rt-PA by 7% per year (5.86%-7.67%, odds ratio [OR] = 1.07, 95% confidence interval [CI]: 1.05-1.08) and EST by 38% per year (0.55%-1.75%, OR = 1.38, 95% CI: 1.31-1.45) but not rt-PA+EST (0.54%-0.57%, OR = 1.04, 95% CI: 0.99-1.08). The mean length of stay reduced from 2012 to 2016 for rt-PA (6.07-4.91 days, P < 0.0001) and rt-PA+EST (9.19-7.10 days, P = 0.0067) but not for EST (9.61-8.51 days, P = 0.5074). The odds of patients discharged home increased by 8%, 9%, and 15% among patients who received rt-PA alone, EST alone, and rt-PA+EST, respectively, compared with no treatment group. CONCLUSION The utilization of rt-PA alone and EST alone increased but that of rt-PA+EST remained unchanged from 2012 to 2016 in the National Inpatient Sample.
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Affiliation(s)
- Nandakumar Nagaraja
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, USA.
| | - Paul S Kubilis
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Brian L Hoh
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Christina A Wilson
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Anna Y Khanna
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Adam G Kelly
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, USA; Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
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20
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Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Cheng S, Delling FN, Elkind MSV, Evenson KR, Ferguson JF, Gupta DK, Khan SS, Kissela BM, Knutson KL, Lee CD, Lewis TT, Liu J, Loop MS, Lutsey PL, Ma J, Mackey J, Martin SS, Matchar DB, Mussolino ME, Navaneethan SD, Perak AM, Roth GA, Samad Z, Satou GM, Schroeder EB, Shah SH, Shay CM, Stokes A, VanWagner LB, Wang NY, Tsao CW. Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association. Circulation 2021; 143:e254-e743. [PMID: 33501848 DOI: 10.1161/cir.0000000000000950] [Citation(s) in RCA: 3090] [Impact Index Per Article: 1030.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease. RESULTS Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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21
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Tong X, Schieb L, George MG, Gillespie C, Merritt RK, Yang Q. Racial/Ethnic and Geographic Variations In Long-Term Survival Among Medicare Beneficiaries After Acute Ischemic Stroke. Prev Chronic Dis 2021; 18:E15. [PMID: 33600303 PMCID: PMC7895479 DOI: 10.5888/pcd18.200242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Little information is available about racial/ethnic and geographic variations in long-term survival among older patients (≥65) after acute ischemic stroke (AIS). METHODS We examined data on 1,019,267 Medicare fee-for-service (FFS) beneficiaries aged 66 or older, hospitalized with a primary diagnosis of AIS from 2008 through 2012. Survival was defined as the time from the date of AIS to date of death, or an end of follow-up date of December 31, 2017. We used Cox proportional hazard models to estimate 5-year survival after AIS, adjusted for age, sex, race and Hispanic ethnicity, poverty level, Charlson Comorbidity Index, and state. RESULTS Among 1,019,267 Medicare FFS beneficiaries hospitalized with AIS from 2008 through 2012, we documented 701,718 deaths (68.8%) during a median of 4 years of follow-up with 4.08 million person-years. The overall adjusted 5-year survival was 44%. Non-Hispanic Black men had the lowest 5-year survival, and 5-year survival varied significantly by state, from the highest at 49.1% (North Dakota) to the lowest at 40.5% (Hawaii). The ranges between the highest and lowest 5-year survival rates across states also varied significantly by racial/ethnic groups, with percentage point differences of 9.6 among non-Hispanic White, 11.3 among non-Hispanic Black, 17.7 among Hispanic, and 28.5 among other racial/ethnic beneficiaries. CONCLUSION We identified significant racial/ethnic and geographic variations in 5-year survival rates after AIS among 2008-2012 Medicare FFS beneficiaries. Further study is needed to understand the reasons for these variations and develop prevention strategies to improve survival and racial disparities in survival after AIS.
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Affiliation(s)
- Xin Tong
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.,Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, 4770 Buford Hwy, MS-S107-1, Atlanta, GA 30341.
| | - Linda Schieb
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mary G George
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Cathleen Gillespie
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Robert K Merritt
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Quanhe Yang
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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22
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Holcombe A, Mohr N, Farooqui M, Dandapat S, Dai B, Zevallos CB, Quispe-Orozco D, Siddiqui F, Ortega-Gutierrez S. Patterns of Care and Clinical Outcomes in Patients with Cerebral Sinus Venous Thrombosis. J Stroke Cerebrovasc Dis 2020; 29:105313. [PMID: 32992183 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/04/2020] [Accepted: 09/07/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVES To explore the association between rurality, transfer patterns and level of care with clinical outcomes of CVST patients in a rural Midwestern state. MATERIALS AND METHODS CVST patients admitted to the hospitals between 2005 and 2014 were identified by inpatient diagnosis codes from statewide administrative claims dataset. Records were linked across interhospital transfers using probabilistic linkage. Rurality was defined by Rural-Urban Commuting Areas using the 2-category approximation. Driving distances were estimated using GoogleMaps Application Programming Interface. Hospital stroke certification was defined by the Joint Commission. Severity of CVST was estimated by cost of care corrected for inflation and cost-to-charge ratios. Outcome was discharge disposition and total length of stay (LOS). Wilcoxon rank-sum, Chi-square, Fisher's exact tests and linear and logistic regressions were used. RESULTS 168 CVST patients were identified (79.8% female; median age = 32, IQR = 24.0-45.5). Median LOS was four days (IQR = 2-7) and patients traveled a median of 8.1 miles (IQR = 2.5-28.5) to the first hospital; 42% of patients were transferred to a second hospital, 5% to a third. More than half (58.3%) bypassed the nearest hospital. 86% visit a primary or comprehensive stroke center (CSC) during their acute care. Rurality was not significantly associated with LOS or discharge disposition after adjusting for age, sex and cost of care. Patients in CSC demonstrated greater likelihood of being discharged home compared to at a primary stroke center after adjusting for age and disease severity (p = 0.008). CONCLUSIONS While rurality was not significantly associated with LOS or disposition outcome, care at a CSC increases likelihood of being discharge home.
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Affiliation(s)
- Andrea Holcombe
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Nicholas Mohr
- Department of Emergency Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Sudeepta Dandapat
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Biyue Dai
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Cynthia B Zevallos
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Darko Quispe-Orozco
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Fazeel Siddiqui
- Department of Neuroscience, Metro Health, University of Michigan, Wyoming, MI, United States
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery, and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States.
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Man S, Tang AS, Schold JD, Kolikonda MK, Uchino K. The Patterns and Outcomes of Inter-Hospital Transfer Among Medicare Patients with Ischemic Stroke. J Stroke Cerebrovasc Dis 2020; 29:105331. [PMID: 32992204 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105331] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/03/2020] [Accepted: 09/12/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND AND PURPOSE Inter-hospital transfer for ischemic stroke is an essential part of stroke system of care. This study aimed to understand the national patterns and outcomes of ischemic stroke transfer. METHODS AND RESULTS This retrospective study examined Medicare beneficiaries aged ≥65 years undergoing inter-hospital transfer for ischemic stroke in 2012. Cox proportional hazards model was used to compare 30-day and one-year mortality between transferred patients and direct admissions from the emergency department (ED admissions). Among 312,367 ischemic stroke admissions, 5.7% underwent inter-hospital transfer. Using this value as cut-off, the hospitals were classified into receiving (n = 411), sending (n = 559), and low-transfer (n = 1863) hospitals. Receiving hospitals were larger than low-transfer and sending hospitals as demonstrated by the median bed number (371, 189, and 88, respectively, p < 0.001); more frequently to be certified stroke centers (75%, 47%, and 16%, respectively, p < 0.001); and less commonly located in the rural area (2%, 7%, and 24%, respectively, p < 0.001). For receiving hospitals, transfer-in patients and ED admissions had comparable mortality at 30 days (10% vs 10%; adjusted HR [aHR]=1.07; 95% CI, 0.99-1.14) and 1 year (23% vs 24%; aHR=1.03; 95% CI, 0.99-1.08). For sending hospitals, transfer-out patients, compared to ED admissions, had higher mortality at 30 days (14% vs 11%; aHR=1.63; 95% CI, 1.39-1.91) and 1 year (30% vs 27%; aHR=1.33; 95% CI, 1.20-1.48). For low-transfer hospitals, overall transfer-in and transfer-out patients, compared to ED admissions, had higher mortality at 30 days (13% vs 10%; aHR=1.46; 95% CI, 1.33-1.60) and 1 year (28% vs 25%; aHR=1.27; 95% CI, 1.19-1.36). CONCLUSIONS Hospitals in the US, based on their transfer patterns, could be classified into 3 groups that shared distinct characteristics including hospital size, rural vs urban location, and stroke certification. Transferred patients at sending and low-transfer hospitals had worse outcomes than their ED admission counterpart.
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Affiliation(s)
- Shumei Man
- Department of Neurology & Cerebrovascular Center, Neurological Institute, Cleveland Clinic, United States
| | - Anne S Tang
- Center for Populations Health Research, Department of Quantitative Health Sciences, Cleveland Clinic, United States
| | - Jesse D Schold
- Center for Populations Health Research, Department of Quantitative Health Sciences, Cleveland Clinic, United States
| | - Murali K Kolikonda
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue/S80, Cleveland, OH, United States
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue/S80, Cleveland, OH, United States.
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Kitaji Y, Harashima H, Miyano S. Relationship between first mobilization following the onset of stroke and clinical outcomes in patients with ischemic stroke in the general ward of a hospital: A cohort study. Phys Ther Res 2020; 23:209-215. [PMID: 33489661 PMCID: PMC7814213 DOI: 10.1298/ptr.e10022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 06/25/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The purpose of this study was to compare the effects of first mobilization following a stroke with independently performing the activities of daily living at discharge in acute phase ischemic stroke patients in a general ward of a hospital. METHODS A total of 158 patients with ischemic strokes were admitted to a general ward from June 1, 2014 to March 31, 2015. Of the 158 patients, 53 met the study's eligibility criteria. First mobilization was defined as the transfer of a patient from the bed to a wheelchair by a rehabilitation therapist. A favorable primary outcome at discharge was defined as a modified Rankin Scale score of < 3. The outcome was analyzed using the proportional hazards analysis and receiver operating characteristic curves. RESULTS The age of the participants was 78.2 ± 11.7 years, stroke severity evaluated by the National Institutes of Health Stroke Scale scores on admission was 14.3 ± 10.6 points, and first mobilization of this population was 6.4 ± 5.2 days. Thirteen [25%] patients had a favorable outcome. Hazards analysis showed a favorable outcome due to first mobilization (adjusted hazards ratio 0.80, 95% confidence interval 0.65-0.98; p < 0.05). The cutoff point for first mobilization to produce a favorable outcome was 6.5 days after the stroke onset (area under the curve 0.729; p < 0.05). CONCLUSION As seen in stroke units, early first mobilization is associated with improved clinical outcomes in ischemic stroke patients admitted to a general ward.
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Remick K, Cramer A. Hear Our Voice: Every Child, Every Day; Pediatric Emergency Care Services in the United States. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2020. [DOI: 10.1016/j.cpem.2020.100781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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26
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Catalá-Ripoll JV, Monsalve-Naharro JÁ, Hernández-Fernández F. Incidence and predictive factors of diaphragmatic dysfunction in acute stroke. BMC Neurol 2020; 20:79. [PMID: 32138697 PMCID: PMC7057624 DOI: 10.1186/s12883-020-01664-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 02/27/2020] [Indexed: 12/14/2022] Open
Abstract
Background The most characteristic clinical signs of stroke are motor and/or sensory involvement of one side of the body. Respiratory involvement has also been described, which could be related to diaphragmatic dysfunction contralateral to the brain injury. Our objective is to establish the incidence of diaphragmatic dysfunction in ischaemic stroke and analyse the relationship between this and the main prognostic markers. Methods A prospective study of 60 patients with supratentorial ischaemic stroke in the first 48 h. Demographic and clinical factors were recorded. A diaphragmatic ultrasound was performed for the diagnosis of diaphragmatic dysfunction by means of the thickening fraction, during normal breathing and after forced inspiration. Diaphragmatic dysfunction was considered as a thickening fraction lower than 20%. The appearance of respiratory symptoms, clinical outcomes and mortality were recorded for 6 months. A bivariate and multivariate statistical analysis was designed to relate the incidence of respiratory involvement with the diagnosis of diaphragmatic dysfunction and with the main clinical determinants. Results An incidence of diaphragmatic dysfunction of 51.7% was observed. 70% (23 cases) of these patients developed symptoms of severe respiratory compromise during follow-up. Independent predictors were diaphragmatic dysfunction in basal respiration (p = 0.026), hemiparesis (p = 0.002) and female sex (p = 0.002). The cut-off point of the thickening fraction with greater sensitivity (75.75%) and specificity (62.9%) was 24% (p = 0.003). Conclusions There is a high incidence of diaphragmatic dysfunction in patients with supratentorial ischaemic stroke which can be studied by calculating the thickening fraction on ultrasound. Among these patients we have detected a higher incidence of severe respiratory involvement.
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Affiliation(s)
- José Vicente Catalá-Ripoll
- Department of Anesthesiology and Critical Care Medicine, Complejo Hospitalario Universitario de Albacete, Albacete, Spain.
| | - José Ángel Monsalve-Naharro
- Department of Anesthesiology and Critical Care Medicine, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Francisco Hernández-Fernández
- Department of Neurology, Unit of Interventional Neuroradiology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
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Man S, Schold JD, Uchino K. Case Fatality Decline from 2009 to 2013 among Medicare Beneficiaries with Ischemic Stroke. J Stroke Cerebrovasc Dis 2020; 29:104559. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 11/09/2019] [Accepted: 11/21/2019] [Indexed: 11/25/2022] Open
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Liao HH, Wang PC, Yeh EH, Lin CJ, Chao TH. Impact of disease-specific care certification on clinical outcome and healthcare performance of myocardial infarction in Taiwan. J Chin Med Assoc 2020; 83:156-163. [PMID: 31834024 DOI: 10.1097/jcma.0000000000000237] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The relationship between certification for specific disease care and clinical outcome was not well known. Previous studies regarding the effect of certification for acute stroke centers were limited by their cross-sectional design. This study aimed to investigate the effect of disease-specific care (DSC) certification on healthcare performance and clinical outcome of acute myocardial infarction (AMI). METHODS This retrospective, longitudinal, controlled study was performed by analyzing the nationwide Taiwan Clinical Performance Indicators dataset from 2011 to 2018. Hospitals undergoing DSC certification for coronary care and reporting AMI indicators 1 year before, during, and 1 year after certification were included in group C, whereas hospitals not seeking DSC certification but reporting AMI indicators during the same period were included in group U. The primary endpoint was in-hospital mortality of AMI. RESULTS In total, 20 hospitals (9 in group C and 11 in group U) and up to 16 173 AMI cases were included for analysis. In-hospital mortality was similar between both groups at baseline. However, the in-hospital mortality was significantly improved during and after certification periods in comparison with that at baseline in group C (6.8% vs 8.4%, p = 0.04; 6.7% vs 8.4%, p = 0.02), whereas there was no significant change in group U, resulting in a statistically significant difference between both groups during and after certification periods (odds ratio = 0.74 [95% CI = 0.60-0.91] and 0.78 [95% CI = 0.64-0.96]). Compared with group U, the improvement in healthcare performance indicators, such as door-to-electrocardiography time <10 minutes, blood testing for low-density lipoprotein cholesterol level, prescribing a beta-blockade or a P2Y12 receptor inhibitor during hospitalization, prescribing a statin on discharge, and consultation for cardiac rehabilitation, was significant in group C. CONCLUSION The current study demonstrated the beneficial effect of DSC certification on clinical outcome of AMI probably mediated through quality improvement during the healthcare process.
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Affiliation(s)
- Hsun-Hsiang Liao
- Joint Commission of Taiwan, Chief Executive Officer Office, New Taipei City, Taiwan, ROC
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan, ROC
| | - Pa-Chun Wang
- Joint Commission of Taiwan, Chief Executive Officer Office, New Taipei City, Taiwan, ROC
- Department of Otolaryngology, Cathay General Hospital, Taipei, Taiwan, ROC
- School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan, ROC
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan, ROC
| | - En-Hui Yeh
- Division of Quality Improvement, Joint Commission of Taiwan, New Taipei City, Taiwan, ROC
| | - Chii-Jeng Lin
- Department of Orthopedics, College of Medicine and Hospital, National Cheng Kung University, Tainan, Taiwan, ROC
- President Office, Joint Commission of Taiwan, New Taipei City, Taiwan, ROC
| | - Ting-Hsing Chao
- Department of Internal Medicine, College of Medicine and Hospital, National Cheng Kung University, Tainan, Taiwan, ROC
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Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, 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, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Shay CM, Spartano NL, Stokes A, Tirschwell DL, VanWagner LB, Tsao CW. Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation 2020; 141:e139-e596. [PMID: 31992061 DOI: 10.1161/cir.0000000000000757] [Citation(s) in RCA: 4832] [Impact Index Per Article: 1208.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals. RESULTS Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Gardener H, Leifheit EC, Lichtman JH, Wang Y, Wang K, Gutierrez CM, Ciliberti-Vargas MA, Dong C, Oluwole S, Robichaux M, Romano JG, Rundek T, Sacco RL. Racial/Ethnic Disparities in Mortality Among Medicare Beneficiaries in the FL - PR CR eSD Study. J Am Heart Assoc 2020; 8:e009649. [PMID: 30587062 PMCID: PMC6405703 DOI: 10.1161/jaha.118.009649] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Racial/ethnic disparities in acute stroke care may impact stroke outcomes. We compared outcomes by race/ethnicity among elderly Medicare beneficiaries in hospitals participating in the FL‐PR CReSD (Florida–Puerto Rico Collaboration to Reduce Stroke Disparities) registry with those in hospitals not participating in any quality improvement programs (non‐QI) in Florida and Puerto Rico (PR). Methods and Results The population included fee‐for‐service Medicare beneficiaries age 65+ in Florida and PR, discharged with primary diagnosis of ischemic stroke (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD‐9‐CM], codes 433, 434, 436) in 2010–2013. We used mixed logistic models to assess racial/ethnic differences in outcomes (in‐hospital, 30‐day, and 1‐year mortality, and 30‐day readmission) for CReSD and non‐QI hospitals, adjusted for demographic and clinical characteristics. The study included 62 CReSD hospitals (N=44 013, 84% white, 9% black, 4% Florida Hispanic, 1% PR Hispanic) and 113 non‐QI hospitals (N=14 422, 78% white, 7% black, 5% Florida Hispanic, 8% PR Hispanic). For patients treated at CReSD hospitals, there were no differences in risk‐adjusted in‐hospital mortality by race/ethnicity; blacks had lower 30‐day mortality versus whites (odds ratio, 0.86; 95% confidence interval, 0.77–0.97), but higher 30‐day readmission (hazard ratio, 1.09; 1.00–1.18) and 1‐year mortality (odds ratio, 1.13; 1.04–1.23); Florida Hispanics had lower 30‐day readmission (hazard ratio, 0.87; 0.78–0.98). PR Hispanic and black stroke patients treated at non‐QI hospitals had higher risk‐adjusted in‐hospital, 30‐day and 1‐year mortality, but similar 30‐day readmission versus whites treated in non‐QI hospitals. Conclusions Disparities in outcomes were less common in CReSD than non‐QI hospitals, suggesting the benefits of quality improvement programs, particularly those focusing on racial/ethnic disparities.
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Affiliation(s)
- Hannah Gardener
- 1 Department of Neurology University of Miami Miller School of Medicine Miami FL
| | - Erica C Leifheit
- 2 Department of Epidemiology Yale School of Public Health New Haven CT
| | - Judith H Lichtman
- 2 Department of Epidemiology Yale School of Public Health New Haven CT
| | - Yun Wang
- 2 Department of Epidemiology Yale School of Public Health New Haven CT
| | - Kefeng Wang
- 1 Department of Neurology University of Miami Miller School of Medicine Miami FL
| | - Carolina M Gutierrez
- 1 Department of Neurology University of Miami Miller School of Medicine Miami FL
| | | | - Chuanhui Dong
- 1 Department of Neurology University of Miami Miller School of Medicine Miami FL
| | - Sofia Oluwole
- 1 Department of Neurology University of Miami Miller School of Medicine Miami FL
| | - Mary Robichaux
- 1 Department of Neurology University of Miami Miller School of Medicine Miami FL
| | - Jose G Romano
- 1 Department of Neurology University of Miami Miller School of Medicine Miami FL
| | - Tatjana Rundek
- 1 Department of Neurology University of Miami Miller School of Medicine Miami FL
| | - Ralph L Sacco
- 1 Department of Neurology University of Miami Miller School of Medicine Miami FL
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Bresette LM. What Is Stroke Certification and Does It Matter? Crit Care Nurs Clin North Am 2019; 32:109-119. [PMID: 32014157 DOI: 10.1016/j.cnc.2019.11.002] [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: 11/19/2022]
Abstract
Many academic and community hospitals have obtained, or are considering obtaining, stroke center certification. Participation in structured quality improvement programs that also incorporate an objective assessment has been shown to improve outcomes and foster team building. Although obtaining certification can be challenging and costly, it can provide a framework to ensure hospitals deliver high- level, evidence-based stroke care. For the intensive care unit nurse, awareness and participation in the certification programs process is an important part of professional nursing practice.
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Affiliation(s)
- Linda M Bresette
- Comprehensive Stroke Program, Neurology, Brigham and Women's Hospital, Boston, MA, USA.
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32
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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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Park HK, Kim SE, Cho YJ, Kim JY, Oh H, Kim BJ, Kang J, Lee KJ, Jang MU, Park JM, Park KY, Lee KB, Lee SJ, Lee JS, Lee J, Yang KH, Choi AR, Kang MY, Smith EE, Gorelick PB, Bae HJ. Quality of acute stroke care in Korea (2008-2014): Retrospective analysis of the nationwide and nonselective data for quality of acute stroke care. Eur Stroke J 2019; 4:337-346. [PMID: 31903432 DOI: 10.1177/2396987319849983] [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] [Received: 01/03/2019] [Accepted: 04/19/2019] [Indexed: 11/15/2022] Open
Abstract
Background There is limited information about non-selective and contemporary data on quality of stroke care and its variation among hospitals at a national level. Patients and methods We analysed data of the patients admitted to 258 acute stroke care hospitals covering the entire country from the Acute Stroke Quality Assessment Program, which was performed by the Health Insurance Review and Assessment Service from 2008 to 2014 in South Korea. The primary outcome measure was defect-free stroke care (all-or-none), based on six get with the guidelines-stroke performance measures (except venous thromboembolism prophylaxis). Results Among 43,793 acute stroke patients (mean age, 67 ± 14 years; male, 55%), 31,915 (72.9%) were hospitalised due to ischaemic stroke. At a patient level, defect-free stroke care steadily increased throughout the study period (2008, 80.2% vs. 2014, 92.1%), but there were large disparities among hospitals (mean = 50.7%, SD = 21.7%). Defect-free stroke care was given more frequently in patients being treated in hospitals with 25 or more stroke cases per month (odds ratio [OR] 2.83; 95% confidence interval [CI] 1.69-4.72), delivery of intravenous thrombolysis one or more times per month (OR 2.37; 95% CI 1.44-3.92), or provision of stroke unit care (OR 1.75; 95% CI 1.22-2.52). Discussion This study shows that the quality of stroke care in Korea is improving over time and is higher in centres with a larger volume of stroke or intravenous thrombolysis cases and providing stroke unit care but hospital disparities exist. Conclusion Reducing large differences in defect-free stroke care among acute stroke care hospitals should be continuously pursued.
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Affiliation(s)
- Hong-Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Seong-Eun Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Yong-Jin Cho
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Jun Yup Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyunji Oh
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jihoon Kang
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Keon-Joo Lee
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Min Uk Jang
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Jong-Moo Park
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Kwang-Yeol Park
- Department of Neurology, Chung-Ang University Hospital, Seoul, Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital, Seoul, Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Daejeon, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Ki Hwa Yang
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Ah Rum Choi
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Mi Yeon Kang
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
| | - Philip B Gorelick
- Department of Translational Science and Molecular Medicine, Michigan State University College of Human Medicine, and Mercy Health Hauenstein Neurosciences, Grand Rapids, Michigan
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Anderle P, Rockenbach SP, Goulart BNGD. Reabilitação pós-AVC: identificação de sinais e sintomas fonoaudiológicos por enfermeiros e médicos da Atenção Primária à Saúde. Codas 2019; 31:e20180015. [DOI: 10.1590/2317-1782/20182018015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 10/03/2018] [Indexed: 11/22/2022] Open
Abstract
RESUMO Objetivo O Acidente Vascular Cerebral (AVC) é um agravo comum para a população e um problema para a saúde pública global em termos de mortalidade, deficiência e demanda de custos. O objetivo deste estudo é verificar quais grupos de comorbidades ligados aos distúrbios fonoaudiológicos são identificados por médicos e enfermeiros das equipes de Estratégia de Saúde da Família (ESF) para encaminhamento à reabilitação fonoaudiológica e continuidade do cuidado de pacientes pós-AVC nas Atenções Primária e Secundária à Saúde (APS). Método Participaram 22 médicos e enfermeiros das equipes de ESF apoiadas pelo Núcleo de Apoio à Saúde da Família, no sul do Brasil. Um questionário desenvolvido para este estudo foi respondido, explorando variáveis sociodemográficas, histórico de formação, atuação profissional e condutas ao paciente com AVC. Análise descritiva dos dados (frequências absoluta e relativa) foi realizada no Software SPSS 22. Resultados Dos entrevistados, 77,3% encaminham pacientes pós-AVC para fisioterapia e 54,5%, para reabilitação fonoaudiológica. Nenhum profissional realiza encaminhamento por sequelas cognitivas de compreensão; 90,0% encaminham por distúrbios de linguagem expressiva na fala. Para alterações do sistema estomatognático, 80,0% dos médicos não encaminham para fonoaudiólogo e 83,3% dos enfermeiros o fazem. Conclusão Os profissionais demonstraram dificuldade em identificar distúrbios fonoaudiológicos ligados à cognição e ao sistema estomatognático, não encaminhando para reabilitação fonoaudiológica nas Atenções Primária e Secundária à Saúde. Os resultados apontam para a necessidade de ações que auxiliem no processo de educação permanente e melhorem o conhecimento das equipes de APS, para que as sequelas fonoaudiológicas sejam devidamente identificadas e encaminhadas para reabilitação.
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Wang Y, Li Z, Wang Y, Zhao X, Liu L, Yang X, Wang C, Gu H, Zhang F, Wang C, Xian Y, Wang DZ, Dong Q, Xu A, Zhao J. Chinese Stroke Center Alliance: a national effort to improve healthcare quality for acute stroke and transient ischaemic attack: rationale, design and preliminary findings. Stroke Vasc Neurol 2018; 3:256-262. [PMID: 30637133 PMCID: PMC6312129 DOI: 10.1136/svn-2018-000154] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 07/31/2018] [Accepted: 08/03/2018] [Indexed: 11/03/2022] Open
Abstract
Background In June 2015, the Chinese Stroke Association (CSA) initiated the Chinese Stroke Center Alliance (CSCA) to establish the national hospital-based stroke care quality assessment and improvement platform. This article outlines its objectives, operational structure, patient population, quality improvement (QI) intervention tools, data elements, data collection methodology and current patient and hospital data. Methods The CSCA is a national, hospital-based, multicentre, voluntary, multifaceted intervention and continuous QI initiative. This multifaceted intervention includes stroke centre development, written care protocols, workshops and a monitoring/feedback system of evidence-based performance measures. The data coordinating centre of the CSCA resides at the China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital. Results As of July 2017, 1576 hospitals in China have contributed detailed clinical information to serve as a benchmark for the stroke care quality of 433 264 patients with acute stroke/transient ischaemic attacks (TIA), including 352 572 (81.38%) acute ischaemic stroke, 30 362 (7.01%) TIA, 42 080 (9.71%) spontaneous intracranial haemorrhage, 5505 (1.27%) subarachnoid haemorrhage and 2745 (0.63%) not specified stroke. Conclusion The CSCA programme is designed to establish a continuous national stroke registry and help healthcare providers develop stroke centres and treat patients in a consistent manner in accordance with accepted national guidelines and, ultimately, improve patient outcomes. It supports the CSA mission to reduce stroke burden in China.
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Affiliation(s)
- Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China.,Tiantan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Center for Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Zixiao Li
- China National Clinical Research Center for Neurological Diseases, Beijing, China.,Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China.,Tiantan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- China National Clinical Research Center for Neurological Diseases, Beijing, China.,Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center for Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Neuro-intensive Care Unit, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Yang
- China National Clinical Research Center for Neurological Diseases, Beijing, China.,Tiantan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Caiyun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hongqiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing, China.,Tiantan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fuying Zhang
- Office of Chinese Stroke Center Alliance, Chinese Stroke Association, Beijing, China
| | - Chunjuan Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China.,Tiantan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Center for Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Ying Xian
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - David Z Wang
- INI Stroke Network, OSF Healthcare System, University of Illinois College of Medicine, Peoria, Illinois, USA
| | - Qiang Dong
- Department of Neurology, Shanghai Huashan Hospital, Fudan University, Shanghai, China
| | - Anding Xu
- Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jizong Zhao
- China National Clinical Research Center for Neurological Diseases, Beijing, China.,Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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