1
|
Martins FS, Lopes F, Souza J, Freitas A, Santos JV. Perceptions of Portuguese medical coders on the transition to ICD-10-CM/PCS: A national survey. HEALTH INF MANAG J 2024; 53:237-242. [PMID: 37462322 DOI: 10.1177/18333583231180294] [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: 09/14/2024]
Abstract
BACKGROUND In Portugal, trained physicians undertake the clinical coding process, which serves as the basis for hospital reimbursement systems. In 2017, the classification version used for coding of diagnoses and procedures for hospital morbidity changed from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS). OBJECTIVE To assess the perceptions of medical coders on the transition of the clinical coding process from ICD-9-CM to ICD-10-CM/PCS in terms of its impact on data quality, as well as the major differences, advantages, and problems they faced. METHOD We conducted an observational study using a web-based survey submitted to medical coders in Portugal. Survey questions were based on a literature review and from previous focus group studies. RESULTS A total of 103 responses were obtained from medical coders with experience in the two versions of the classification system (i.e. ICD-9-CM and ICD-10-CM/PCS). Of these, 82 (79.6%) medical coders preferred the latest version and 76 (73.8%) considered that ICD-10-CM/PCS guaranteed higher quality of the coded data. However, more than half of the respondents (N = 61; 59.2%) believed that more time for the coding process for each episode was needed. CONCLUSION Quality of clinical coded data is one of the major priorities that must be ensured. According to the medical coders, the use of ICD-10-CM/PCS appeared to achieve higher quality coded data, but also increased the effort. IMPLICATIONS According to medical coders, the change off classification systems should improve the quality of coded data. Nevertheless, the extra time invested in this process might also pose a problem in the future.
Collapse
Affiliation(s)
- Filipa Santos Martins
- Centro Hospitalar Universitário de São João, Portugal
- CINTESIS - Centre for Health Technology and Services Research, Portugal
| | - Fernando Lopes
- CINTESIS - Centre for Health Technology and Services Research, Portugal
- MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Júlio Souza
- CINTESIS - Centre for Health Technology and Services Research, Portugal
- MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Alberto Freitas
- CINTESIS - Centre for Health Technology and Services Research, Portugal
- MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - João Vasco Santos
- CINTESIS - Centre for Health Technology and Services Research, Portugal
- MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Public Health Unit, ACES Grande Porto V - Porto Ocidental, Portugal
| |
Collapse
|
2
|
Xu Y, Ballew SH, Chang AR, Inker LA, Grams ME, Shin JI. Risk of Major Bleeding, Stroke/Systemic Embolism, and Death Associated With Different Oral Anticoagulants in Patients With Atrial Fibrillation and Severe Chronic Kidney Disease. J Am Heart Assoc 2024; 13:e034641. [PMID: 39119973 DOI: 10.1161/jaha.123.034641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 06/20/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Patients with atrial fibrillation and severe chronic kidney disease have higher risks of bleeding, thromboembolism, and mortality. However, optimal anticoagulant choice in these high-risk patients remains unclear. METHODS AND RESULTS Using deidentified electronic health records from the Optum Labs Data Warehouse, adults with atrial fibrillation and severe chronic kidney disease (estimated glomerular filtration rate <30 mL/min per 1.73 m2) initiating warfarin, apixaban, or rivaroxaban between 2011 and 2021 were included. Using inverse probability of treatment weighting, adjusted risks of major bleeding, stroke/systemic embolism, and death were compared among agents. A total of 6794 patients were included (mean age, 78.5 years; mean estimated glomerular filtration rate, 24.7 mL/min per 1.73 m2; 51% women). Apixaban versus warfarin was associated with a lower risk of major bleeding (incidence rate, 1.5 versus 2.9 per 100 person-years; subdistribution hazard ratio [sub-HR], 0.53 [95% CI, 0.39-0.70]), and similar risks for stroke/systemic embolism (incidence rate, 1.9 versus 2.4 per 100 person-years; sub-HR, 0.80 [95% CI, 0.59-1.09]) and death (incidence rate, 4.6 versus 4.5 per 100 person-years; HR, 1.03 [95% CI, 0.82-1.29]). Rivaroxaban versus warfarin was associated with a higher risk of major bleeding (incidence rate, 4.9 versus 2.9 per 100 person-years; sub-HR, 1.65 [95% CI, 1.10-2.48]), with no difference in risks for stroke/systemic embolism and death. Apixaban versus rivaroxaban was associated with a lower risk of major bleeding (sub-HR, 0.53 [95% CI, 0.36-0.78]). CONCLUSIONS These real-world findings are consistent with potential safety advantages of apixaban over warfarin and rivaroxaban for patients with atrial fibrillation and severe chronic kidney disease. Further randomized trials comparing individual oral anticoagulants are warranted.
Collapse
Affiliation(s)
- Yunwen Xu
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD USA
| | - Shoshana H Ballew
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD USA
- Optimal Aging Institute, New York University Grossman School of Medicine and Langone Health New York NY USA
- Department of Population Health New York University Grossman School of Medicine and Langone Health New York NY USA
| | | | - Lesley A Inker
- Division of Nephrology, Department of Internal Medicine Tufts Medical Center Boston MA USA
| | - Morgan E Grams
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD USA
- Department of Population Health New York University Grossman School of Medicine and Langone Health New York NY USA
- Department of Medicine New York University Grossman School of Medicine and Langone Health New York NY USA
| | - Jung-Im Shin
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD USA
| |
Collapse
|
3
|
Simon TG, Singer DE, Zhang Y, Mastrorilli JM, Cervone A, DiCesare E, Lin KJ. Comparative Effectiveness and Safety of Apixaban, Rivaroxaban, and Warfarin in Patients With Cirrhosis and Atrial Fibrillation : A Nationwide Cohort Study. Ann Intern Med 2024; 177:1028-1038. [PMID: 38976880 DOI: 10.7326/m23-3067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND Apixaban, rivaroxaban, and warfarin have shown benefit for preventing major ischemic events, albeit with increased bleeding risk, among patients in the general population with atrial fibrillation (AF). However, data are scarce in patients with cirrhosis and AF. OBJECTIVE To compare the effectiveness and safety of apixaban versus rivaroxaban and versus warfarin in patients with cirrhosis and AF. DESIGN Population-based cohort study. SETTING Two U.S. claims data sets (Medicare and Optum's de-identified Clinformatics Data Mart Database [2013 to 2022]). PARTICIPANTS 1:1 propensity score (PS)-matched patients with cirrhosis and nonvalvular AF initiating use of apixaban, rivaroxaban, or warfarin. MEASUREMENTS Primary outcomes included ischemic stroke or systemic embolism and major hemorrhage (intracranial hemorrhage or major gastrointestinal bleeding). Database-specific and pooled PS-matched rate differences (RDs) per 1000 person-years (PY) and Cox proportional hazard ratios (HRs) with 95% CIs were estimated, controlling for 104 preexposure covariates. RESULTS Rivaroxaban initiators had significantly higher rates of major hemorrhagic events than apixaban initiators (RD, 33.1 per 1000 PY [95% CI, 12.9 to 53.2 per 1000 PY]; HR, 1.47 [CI, 1.11 to 1.94]) but no significant differences in rates of ischemic events or death. Consistently higher rates of major hemorrhage were found with rivaroxaban across subgroup and sensitivity analyses. Warfarin initiators also had significantly higher rates of major hemorrhage than apixaban initiators (RD, 26.1 per 1000 PY [CI, 6.8 to 45.3 per 1000 PY]; HR, 1.38 [CI, 1.03 to 1.84]), particularly hemorrhagic stroke (RD, 9.7 per 1000 PY [CI, 2.2 to 17.2 per 1000 PY]; HR, 2.85 [CI, 1.24 to 6.59]). LIMITATION Nonrandomized treatment selection. CONCLUSION Among patients with cirrhosis and nonvalvular AF, initiators of rivaroxaban versus apixaban had significantly higher rates of major hemorrhage and similar rates of ischemic events and death. Initiation of warfarin versus apixaban also contributed to significantly higher rates of major hemorrhagic events, including hemorrhagic stroke. PRIMARY FUNDING SOURCE National Institutes of Health.
Collapse
Affiliation(s)
- Tracey G Simon
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School; Division of Gastroenterology and Hepatology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School; and Clinical and Translational Epidemiology Unit (CTEU), Massachusetts General Hospital, Boston, Massachusetts (T.G.S.)
| | - Daniel E Singer
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (D.E.S.)
| | - Yichi Zhang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Y.Z., J.M.M., A.C., E.D.)
| | - Julianna M Mastrorilli
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Y.Z., J.M.M., A.C., E.D.)
| | - Alexander Cervone
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Y.Z., J.M.M., A.C., E.D.)
| | - Elyse DiCesare
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Y.Z., J.M.M., A.C., E.D.)
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, and Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (K.J.L.)
| |
Collapse
|
4
|
Chen H, Yang F, Duan Y, Yang L, Li J. A novel higher performance nomogram based on explainable machine learning for predicting mortality risk in stroke patients within 30 days based on clinical features on the first day ICU admission. BMC Med Inform Decis Mak 2024; 24:161. [PMID: 38849903 PMCID: PMC11161998 DOI: 10.1186/s12911-024-02547-7] [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: 06/23/2023] [Accepted: 05/21/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND This study aimed to develop a higher performance nomogram based on explainable machine learning methods, and to predict the risk of death of stroke patients within 30 days based on clinical characteristics on the first day of intensive care units (ICU) admission. METHODS Data relating to stroke patients were extracted from the Medical Information Marketplace of the Intensive Care (MIMIC) IV and III database. The LightGBM machine learning approach together with Shapely additive explanations (termed as explain machine learning, EML) was used to select clinical features and define cut-off points for the selected features. These selected features and cut-off points were then evaluated using the Cox proportional hazards regression model and Kaplan-Meier survival curves. Finally, logistic regression-based nomograms for predicting 30-day mortality of stroke patients were constructed using original variables and variables dichotomized by cut-off points, respectively. The performance of two nomograms were evaluated in overall and individual dimension. RESULTS A total of 2982 stroke patients and 64 clinical features were included, and the 30-day mortality rate was 23.6% in the MIMIC-IV datasets. 10 variables ("sofa (sepsis-related organ failure assessment)", "minimum glucose", "maximum sodium", "age", "mean spo2 (blood oxygen saturation)", "maximum temperature", "maximum heart rate", "minimum bun (blood urea nitrogen)", "minimum wbc (white blood cells)" and "charlson comorbidity index") and respective cut-off points were defined from the EML. In the Cox proportional hazards regression model (Cox regression) and Kaplan-Meier survival curves, after grouping stroke patients according to the cut-off point of each variable, patients belonging to the high-risk subgroup were associated with higher 30-day mortality than those in the low-risk subgroup. The evaluation of nomograms found that the EML-based nomogram not only outperformed the conventional nomogram in NIR (net reclassification index), brier score and clinical net benefits in overall dimension, but also significant improved in individual dimension especially for low "maximum temperature" patients. CONCLUSIONS The 10 selected first-day ICU admission clinical features require greater attention for stroke patients. And the nomogram based on explainable machine learning will have greater clinical application.
Collapse
Affiliation(s)
- Haoran Chen
- Institute of Medical Information/Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100020, China.
- Key Laboratory of Medical Information Intelligent Technology, Chinese Academy of Medical Sciences, Beijing, 100020, China.
| | - Fengchun Yang
- Institute of Medical Information/Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100020, China
- Key Laboratory of Medical Information Intelligent Technology, Chinese Academy of Medical Sciences, Beijing, 100020, China
| | - Yifan Duan
- Institute of Medical Information/Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100020, China
| | - Lin Yang
- Institute of Medical Information/Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100020, China
- Key Laboratory of Medical Information Intelligent Technology, Chinese Academy of Medical Sciences, Beijing, 100020, China
| | - Jiao Li
- Institute of Medical Information/Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100020, China.
- Key Laboratory of Medical Information Intelligent Technology, Chinese Academy of Medical Sciences, Beijing, 100020, China.
| |
Collapse
|
5
|
Otite FO, Patel SD, Aneni E, Lamikanra O, Wee C, Albright KC, Burke D, Latorre JG, Morris NA, Anikpezie N, Singla A, Sonig A, Kamel H, Khandelwal P, Chaturvedi S. Plateauing atrial fibrillation burden in acute ischemic stroke admissions in the United States from 2010 to 2020. Int J Stroke 2024; 19:547-558. [PMID: 38086764 DOI: 10.1177/17474930231222163] [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: 01/03/2024]
Abstract
BACKGROUND Utilization of oral anticoagulants for acute ischemic stroke (AIS) prevention in patients with atrial fibrillation (AF) increased in the United States over the last decade. Whether this increase has been accompanied by any change in AF prevalence in AIS at the population level remains unknown. The aim of this study is to evaluate trends in AF prevalence in AIS hospitalizations in various age, sex, and racial subgroups over the last decade. METHODS We used data contained in the 2010-2020 National Inpatient Sample to conduct a serial cross-sectional study. Primary AIS hospitalizations with and without comorbid AF were identified using International Classification of Diseases Codes. Joinpoint regression was used to compute annualized percentage change (APC) in prevalence and to identify points of change in prevalence over time. RESULTS Of 5,190,148 weighted primary AIS hospitalizations over the study period, 25.1% had comorbid AF. The age- and sex-standardized prevalence of AF in AIS hospitalizations increased across the entire study period 2010-2020 (average APC: 1.3%, 95% confidence interval (CI): 0.8-1.7%). Joinpoint regression showed that prevalence increased in the period 2010-2015 (APC: 2.8%, 95% CI: 1.9-3.9%) but remained stable in the period 2015-2020 (APC: -0.3%, 95% CI: -1.0 to 1.9%). Upon stratification by age and sex, prevalence increased in all age/sex groups from 2010 to 2015 and continued to increase throughout the entire study period in hospitalizations in men 18-39 years (APC: 4.0%, 95% CI: 0.2-7.9%), men 40-59 years (APC: 3.4%, 95% CI: 1.9-4.9%) and women 40-59 years (APC: 4.4%, 95% CI: 2.0-6.8%). In contrast, prevalence declined in hospitalizations in women 60-79 (APC: -1.0%, 95% CI: -0.5 to -1.5%) and women ⩾ 80 years over the period 2015-2020 but plateaued in hospitalizations in similar-aged men over the same period. CONCLUSION AF prevalence in AIS hospitalizations in the United States increased over the period 2010-2015, then plateaued over the period 2015-2020 due to declining prevalence in hospitalizations in women ⩾ 60 years and plateauing prevalence in hospitalizations in men ⩾ 60 years.
Collapse
Affiliation(s)
- Fadar Oliver Otite
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Smit D Patel
- Department of Neurosurgery, University of Connecticut, Hartford, CT, USA
| | - Ehimen Aneni
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | | | - Claribel Wee
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Karen C Albright
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Devin Burke
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Julius Gene Latorre
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Nicholas Allen Morris
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nnabuchi Anikpezie
- Department of Population Health, University of Mississippi Medical Center, Jackson, MS, USA
| | - Amit Singla
- Department of Neurosurgery, Rutgers University, Newark, NJ, USA
| | - Ashish Sonig
- Department of Neurosurgery, Rutgers University, Newark, NJ, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | | | - Seemant Chaturvedi
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
6
|
Ray WA, Chung CP, Stein CM, Smalley W, Zimmerman E, Dupont WD, Hung AM, Daugherty JR, Dickson A, Murray KT. Serious Bleeding in Patients With Atrial Fibrillation Using Diltiazem With Apixaban or Rivaroxaban. JAMA 2024; 331:1565-1575. [PMID: 38619832 PMCID: PMC11019444 DOI: 10.1001/jama.2024.3867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/29/2024] [Indexed: 04/16/2024]
Abstract
Importance Diltiazem, a commonly prescribed ventricular rate-control medication for patients with atrial fibrillation, inhibits apixaban and rivaroxaban elimination, possibly causing overanticoagulation. Objective To compare serious bleeding risk for new users of apixaban or rivaroxaban with atrial fibrillation treated with diltiazem or metoprolol. Design, Setting, and Participants This retrospective cohort study included Medicare beneficiaries aged 65 years or older with atrial fibrillation who initiated apixaban or rivaroxaban use and also began treatment with diltiazem or metoprolol between January 1, 2012, and November 29, 2020. Patients were followed up to 365 days through November 30, 2020. Data were analyzed from August 2023 to February 2024. Exposures Diltiazem and metoprolol. Main Outcomes and Measures The primary outcome was a composite of bleeding-related hospitalization and death with recent evidence of bleeding. Secondary outcomes were ischemic stroke or systemic embolism, major ischemic or hemorrhagic events (ischemic stroke, systemic embolism, intracranial or fatal extracranial bleeding, or death with recent evidence of bleeding), and death without recent evidence of bleeding. Hazard ratios (HRs) and rate differences (RDs) were adjusted for covariate differences with overlap weighting. Results The study included 204 155 US Medicare beneficiaries, of whom 53 275 received diltiazem and 150 880 received metoprolol. Study patients (mean [SD] age, 76.9 [7.0] years; 52.7% female) had 90 927 person-years (PY) of follow-up (median, 120 [IQR, 59-281] days). Patients receiving diltiazem treatment had increased risk for the primary outcome (RD, 10.6 [95% CI, 7.0-14.2] per 1000 PY; HR, 1.21 [95% CI, 1.13-1.29]) and its components of bleeding-related hospitalization (RD, 8.2 [95% CI, 5.1-11.4] per 1000 PY; HR, 1.22 [95% CI, 1.13-1.31]) and death with recent evidence of bleeding (RD, 2.4 [95% CI, 0.6-4.2] per 1000 PY; HR, 1.19 [95% CI, 1.05-1.34]) compared with patients receiving metoprolol. Risk for the primary outcome with initial diltiazem doses exceeding 120 mg/d (RD, 15.1 [95% CI, 10.2-20.1] per 1000 PY; HR, 1.29 [95% CI, 1.19-1.39]) was greater than that for lower doses (RD, 6.7 [95% CI, 2.0-11.4] per 1000 PY; HR, 1.13 [95% CI, 1.04-1.24]). For doses exceeding 120 mg/d, the risk of major ischemic or hemorrhagic events was increased (HR, 1.14 [95% CI, 1.02-1.27]). Neither dose group had significant changes in the risk for ischemic stroke or systemic embolism or death without recent evidence of bleeding. When patients receiving high- and low-dose diltiazem treatment were directly compared, the HR for the primary outcome was 1.14 (95% CI, 1.02-1.26). Conclusions and Relevance In Medicare patients with atrial fibrillation receiving apixaban or rivaroxaban, diltiazem was associated with greater risk of serious bleeding than metoprolol, particularly for diltiazem doses exceeding 120 mg/d.
Collapse
Affiliation(s)
- Wayne A. Ray
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Cecilia P. Chung
- Department of Medicine, University of Miami, Miami, Florida
- Miami VA Healthcare System, Miami, Florida
| | - C. Michael Stein
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Walter Smalley
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Eli Zimmerman
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - William D. Dupont
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Adriana M. Hung
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - James R. Daugherty
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Alyson Dickson
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Katherine T. Murray
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
| |
Collapse
|
7
|
de Havenon A, Zhou LW, Koo AB, Matouk C, Falcone GJ, Sharma R, Ney J, Shu L, Yaghi S, Kamel H, Sheth KN. Endovascular Treatment of Acute Ischemic Stroke After Cardiac Interventions in the United States. JAMA Neurol 2024; 81:264-272. [PMID: 38285452 PMCID: PMC10825786 DOI: 10.1001/jamaneurol.2023.5416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/25/2023] [Indexed: 01/30/2024]
Abstract
Importance Ischemic stroke is a serious complication of cardiac intervention, including surgery and percutaneous procedures. Endovascular thrombectomy (EVT) is an effective treatment for ischemic stroke and may be particularly important for cardiac intervention patients who often cannot receive intravenous thrombolysis. Objective To examine trends in EVT for ischemic stroke during hospitalization of patients with cardiac interventions vs those without in the United States. Design, Setting, and Participants This cohort study involved a retrospective analysis using data for 4888 US hospitals from the 2016-2020 National Inpatient Sample database. Participants included adults (age ≥18 years) with ischemic stroke (per codes from the International Statistical Classification of Diseases, Tenth Revision, Clinical Modification), who were organized into study groups of hospitalized patients with cardiac interventions vs without. Individuals were excluded from the study if they had either procedure prior to admission, EVT prior to cardiac intervention, EVT more than 3 days after admission or cardiac intervention, or endocarditis. Data were analyzed from April 2023 to October 2023. Exposures Cardiac intervention during admission. Main Outcomes and Measures The odds of undergoing EVT by cardiac intervention status were calculated using multivariable logistic regression. Adjustments were made for stroke severity in the subgroup of patients who had a National Institutes of Health Stroke Scale (NIHSS) score documented. As a secondary outcome, the odds of discharge home by EVT status after cardiac intervention were modeled. Results Among 634 407 hospitalizations, the mean (SD) age of the patients was 69.8 (14.1) years, 318 363 patients (50.2%) were male, and 316 044 (49.8%) were female. A total of 12 093 had a cardiac intervention. An NIHSS score was reported in 218 576 admissions, 216 035 (34.7%) without cardiac intervention and 2541 (21.0%) with cardiac intervention (P < .001). EVT was performed in 23 660 patients (3.8%) without cardiac intervention vs 194 (1.6%) of those with cardiac intervention (P < .001). After adjustment for potential confounders, EVT was less likely to be performed in stroke patients with cardiac intervention vs those without (adjusted odds ratio [aOR], 0.27; 95% CI, 0.23-0.31), which remained consistent after adjusting for NIHSS score (aOR, 0.28; 95% CI, 0.22-0.35). Among individuals with a cardiac intervention, receiving EVT was associated with a 2-fold higher chance of discharge home (aOR, 2.21; 95% CI, 1.14-4.29). Conclusions and Relevance In this study, patients hospitalized with ischemic stroke and cardiac intervention may be less than half as likely to receive EVT as those without cardiac intervention. Given the known benefit of EVT, there is a need to better understand the reasons for lower rates of EVT in this patient population.
Collapse
Affiliation(s)
- Adam de Havenon
- Department of Neurology, Center for Brain and Mind Health, Yale University, New Haven, Connecticut
| | - Lily W. Zhou
- Department of Neurology, The University of British Columbia, Vancouver, Canada
| | - Andrew B. Koo
- Department of Neurosurgery, Yale University, New Haven, Connecticut
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, Connecticut
| | - Guido J. Falcone
- Department of Neurology, Center for Brain and Mind Health, Yale University, New Haven, Connecticut
| | - Richa Sharma
- Department of Neurology, Center for Brain and Mind Health, Yale University, New Haven, Connecticut
| | - John Ney
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Liqi Shu
- Department of Neurology, Brown University, Providence, Rhode Island
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, Rhode Island
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, New York
- Deputy Editor, JAMA Neurology
| | - Kevin N. Sheth
- Department of Neurology, Center for Brain and Mind Health, Yale University, New Haven, Connecticut
| |
Collapse
|
8
|
Xu Y, Chang AR, Inker LA, McAdams-DeMarco M, Grams ME, Shin JI. Associations of Apixaban Dose With Safety and Effectiveness Outcomes in Patients With Atrial Fibrillation and Severe Chronic Kidney Disease. Circulation 2023; 148:1445-1454. [PMID: 37681341 PMCID: PMC10840683 DOI: 10.1161/circulationaha.123.065614] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 08/04/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Recommendations for apixaban dosing on the basis of kidney function are inconsistent between the US Food and Drug Administration and European Medicines Agency for patients with atrial fibrillation. Optimal apixaban dosing in chronic kidney disease remains unknown. METHODS With the use of deidentified electronic health record data from the Optum Labs Data Warehouse, patients with atrial fibrillation and chronic kidney disease stage 4/5 initiating apixaban between 2013 and 2021 were identified. Risks of bleeding and stroke/systemic embolism were compared by apixaban dose (5 versus 2.5 mg), adjusted for baseline characteristics by the inverse probability of treatment weighting. The Fine-Gray subdistribution hazard model was used to account for the competing risk of death. Cox regression was used to examine risk of death by apixaban dose. RESULTS Among 4313 apixaban new users, 1705 (40%) received 5 mg and 2608 (60%) received 2.5 mg. Patients treated with 5 mg apixaban were younger (mean age, 72 versus 80 years), with greater weight (95 versus 80 kg) and higher serum creatinine (2.7 versus 2.5 mg/dL). Mean estimated glomerular filtration rate was not different between the groups (24 versus 24 mL·min-1·1.73 m-2). In inverse probability of treatment weighting analysis, apixaban 5 mg was associated with a higher risk of bleeding (incidence rate 4.9 versus 2.9 events per 100 person-years; incidence rate difference, 2.0 [95% CI, 0.6-3.4] events per 100 person-years; subdistribution hazard ratio, 1.63 [95% CI, 1.04-2.54]). There was no difference between apixaban 5 mg and 2.5 mg groups in the risk of stroke/systemic embolism (3.3 versus 3.0 events per 100 person-years; incidence rate difference, 0.2 [95% CI, -1.0 to 1.4] events per 100 person-years; subdistribution hazard ratio, 1.01 [95% CI, 0.59-1.73]), or death (9.9 versus 9.4 events per 100 person-years; incidence rate difference, 0.5 [95% CI, -1.6 to 2.6] events per 100 person-years; hazard ratio, 1.03 [95% CI, 0.77-1.38]). CONCLUSIONS Compared with 2.5 mg, use of 5 mg apixaban was associated with a higher risk of bleeding in patients with atrial fibrillation and severe chronic kidney disease, with no difference in the risk of stroke/systemic embolism or death, supporting the apixaban dosing recommendations on the basis of kidney function by the European Medicines Agency, which differ from those issued by the US Food and Drug Administration.
Collapse
Affiliation(s)
- Yunwen Xu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Alex R. Chang
- Division of Nephrology, Geisinger Health System, Danville, PA
| | - Lesley A Inker
- Division of Nephrology, Department of Internal Medicine, Tufts Medical Center, Boston, MA
| | - Mara McAdams-DeMarco
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, NY
- Department of Population Health, New York University Grossman School of Medicine and Langone Health, New York, NY
| | - Morgan E. Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Population Health, New York University Grossman School of Medicine and Langone Health, New York, NY
- Department of Medicine, New York University Grossman School of Medicine and Langone Health, New York, NY
| | - Jung-Im Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| |
Collapse
|
9
|
Ray WA, Chung CP, Stein CM, Smalley W, Zimmerman E, Dupont WD, Hung AM, Daugherty JR, Dickson AL, Murray KT. Risk for Bleeding-Related Hospitalizations During Use of Amiodarone With Apixaban or Rivaroxaban in Patients With Atrial Fibrillation : A Retrospective Cohort Study. Ann Intern Med 2023; 176:769-778. [PMID: 37216662 DOI: 10.7326/m22-3238] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Amiodarone, the most effective antiarrhythmic drug in atrial fibrillation, inhibits apixaban and rivaroxaban elimination, thus possibly increasing anticoagulant-related risk for bleeding. OBJECTIVE For patients receiving apixaban or rivaroxaban, to compare risk for bleeding-related hospitalizations during treatment with amiodarone versus flecainide or sotalol, antiarrhythmic drugs that do not inhibit these anticoagulants' elimination. DESIGN Retrospective cohort study. SETTING U.S. Medicare beneficiaries aged 65 years or older. PATIENTS Patients with atrial fibrillation began anticoagulant use between 1 January 2012 and 30 November 2018 and subsequently initiated treatment with study antiarrhythmic drugs. MEASUREMENTS Time to event for bleeding-related hospitalizations (primary outcome) and ischemic stroke, systemic embolism, and death with or without recent (past 30 days) evidence of bleeding (secondary outcomes), adjusted with propensity score overlap weighting. RESULTS There were 91 590 patients (mean age, 76.3 years; 52.5% female) initiating use of study anticoagulants and antiarrhythmic drugs, 54 977 with amiodarone and 36 613 with flecainide or sotalol. Risk for bleeding-related hospitalizations increased with amiodarone use (rate difference [RD], 17.5 events [95% CI, 12.0 to 23.0 events] per 1000 person-years; hazard ratio [HR], 1.44 [CI, 1.27 to 1.63]). Incidence of ischemic stroke or systemic embolism did not increase (RD, -2.1 events [CI, -4.7 to 0.4 events] per 1000 person-years; HR, 0.80 [CI, 0.62 to 1.03]). The risk for death with recent evidence of bleeding (RD, 9.1 events [CI, 5.8 to 12.3 events] per 1000 person-years; HR, 1.66 [CI, 1.35 to 2.03]) was greater than that for other deaths (RD, 5.6 events [CI, 0.5 to 10.6 events] per 1000 person-years; HR, 1.15 [CI, 1.00 to 1.31]) (HR comparison: P = 0.003). The increased incidence of bleeding-related hospitalizations for rivaroxaban (RD, 28.0 events [CI, 18.4 to 37.6 events] per 1000 person-years) was greater than that for apixaban (RD, 9.1 events [CI, 2.8 to 15.3 events] per 1000 person-years) (P = 0.001). LIMITATION Possible residual confounding. CONCLUSION In this retrospective cohort study, patients aged 65 years or older with atrial fibrillation treated with amiodarone during apixaban or rivaroxaban use had greater risk for bleeding-related hospitalizations than those treated with flecainide or sotalol. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.
Collapse
Affiliation(s)
- Wayne A Ray
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee (W.A.R., J.R.D.)
| | - Cecilia P Chung
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee (C.P.C., A.M.H., A.L.D.)
| | - C Michael Stein
- Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee (C.M.S., K.T.M.)
| | - Walter Smalley
- Departments of Health Policy and Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee (W.S.)
| | - Eli Zimmerman
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee (E.Z.)
| | - William D Dupont
- Departments of Health Policy and Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (W.D.D.)
| | - Adriana M Hung
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee (C.P.C., A.M.H., A.L.D.)
| | - James R Daugherty
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee (W.A.R., J.R.D.)
| | - Alyson L Dickson
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee (C.P.C., A.M.H., A.L.D.)
| | - Katherine T Murray
- Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee (C.M.S., K.T.M.)
| |
Collapse
|
10
|
Ahmed R, Mhina C, Philip K, Patel SD, Aneni E, Osondu C, Lamikanra O, Akano EO, Anikpezie N, Albright KC, Latorre JG, Chaturvedi S, Otite FO. Age- and Sex-Specific Trends in Medical Complications After Acute Ischemic Stroke in the United States. Neurology 2023; 100:e1282-e1295. [PMID: 36599695 PMCID: PMC10033158 DOI: 10.1212/wnl.0000000000206749] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/15/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To test the hypothesis that the age and sex-specific prevalence of infectious (pneumonia, sepsis, and urinary tract infection [UTI]) and noninfectious (deep venous thrombosis [DVT], pulmonary embolism [PE], acute renal failure [ARF], acute myocardial infarction [AMI], and gastrointestinal bleeding [GIB]) complications increased after acute ischemic stroke (AIS) hospitalization in the United States from 2007 to 2019. METHODS We conducted a serial cross-sectional study using the 2007-2019 National Inpatient Sample. Primary AIS admissions in adults (aged 18 years or older) with and without complications were identified using International Classification of Diseases codes. We quantified the age/sex-specific prevalence of complications and used negative binomial regression models to evaluate trends over time. RESULTS Of 5,751,601 weighted admissions, 51.4% were women. 25.1% had at least 1 complication. UTI (11.8%), ARF (10.1%), pneumonia (3.2%), and AMI (2.5%) were the most common complications, while sepsis (1.7%), GIB (1.1%), DVT (1.2%), and PE (0.5%) were the least prevalent. Marked disparity in complication risk existed by age/sex (UTI: men 18-39 years 2.1%; women 80 years or older 22.5%). Prevalence of UTI (12.9%-9.7%) and pneumonia (3.8%-2.7%) declined, but that of ARF increased by ≈3-fold (4.8%-14%) over the period 2007-2019 (all p < 0.001). AMI (1.9%-3.1%), DVT (1.0%-1.4%), and PE (0.3%-0.8%) prevalence also increased (p < 0.001), but that of sepsis and GIB remained unchanged over time. After multivariable adjustment, risk of all complications increased with increasing NIH Stroke Scale (pneumonia: prevalence rate ratio [PRR] 1.03, 95% CI 1.03-1.04, for each unit increase), but IV thrombolysis was associated with a reduced risk of all complications (pneumonia: PRR 0.80, 85% CI 0.73-0.88; AMI: PRR 0.85, 95% CI 0.78-0.92; and DVT PRR 0.87, 95% CI 0.78-0.98). Mechanical thrombectomy was associated with a reduced risk of UTI, sepsis, and ARF, but DVT and PE were more prevalent in MT hospitalizations compared with those without. All complications except UTI were associated with an increased risk of in-hospital mortality (sepsis: PRR 1.97, 95% CI 1.78-2.19). DISCUSSION Infectious complications declined, but noninfectious complications increased after AIS admissions in the United States in the last decade. Utilization of IV thrombolysis is associated with a reduced risk of all complications.
Collapse
Affiliation(s)
- Rashid Ahmed
- From the Department of Neurology (R.A.), Massachusetts General Hospital/Harvard Medical School, Boston; Department of Population Health Sciences (C.M.), Duke University, Raleigh, NC; Department of Neurology (K.P., K.C.A., J.G.L., F.O.O.), SUNY Upstate Medical University, Syracuse; Department of Neurology (S.D.P.), University of California Los Angeles; Department of Cardiology (E.A.), Yale University, New Haven, CT; Baptist Health South Florida (C.O.), Miami; Department of Critical Care (O.L.), Springfield Clinic, Springfield, IL; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Carl Mhina
- From the Department of Neurology (R.A.), Massachusetts General Hospital/Harvard Medical School, Boston; Department of Population Health Sciences (C.M.), Duke University, Raleigh, NC; Department of Neurology (K.P., K.C.A., J.G.L., F.O.O.), SUNY Upstate Medical University, Syracuse; Department of Neurology (S.D.P.), University of California Los Angeles; Department of Cardiology (E.A.), Yale University, New Haven, CT; Baptist Health South Florida (C.O.), Miami; Department of Critical Care (O.L.), Springfield Clinic, Springfield, IL; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Karan Philip
- From the Department of Neurology (R.A.), Massachusetts General Hospital/Harvard Medical School, Boston; Department of Population Health Sciences (C.M.), Duke University, Raleigh, NC; Department of Neurology (K.P., K.C.A., J.G.L., F.O.O.), SUNY Upstate Medical University, Syracuse; Department of Neurology (S.D.P.), University of California Los Angeles; Department of Cardiology (E.A.), Yale University, New Haven, CT; Baptist Health South Florida (C.O.), Miami; Department of Critical Care (O.L.), Springfield Clinic, Springfield, IL; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Smit D Patel
- From the Department of Neurology (R.A.), Massachusetts General Hospital/Harvard Medical School, Boston; Department of Population Health Sciences (C.M.), Duke University, Raleigh, NC; Department of Neurology (K.P., K.C.A., J.G.L., F.O.O.), SUNY Upstate Medical University, Syracuse; Department of Neurology (S.D.P.), University of California Los Angeles; Department of Cardiology (E.A.), Yale University, New Haven, CT; Baptist Health South Florida (C.O.), Miami; Department of Critical Care (O.L.), Springfield Clinic, Springfield, IL; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Ehimen Aneni
- From the Department of Neurology (R.A.), Massachusetts General Hospital/Harvard Medical School, Boston; Department of Population Health Sciences (C.M.), Duke University, Raleigh, NC; Department of Neurology (K.P., K.C.A., J.G.L., F.O.O.), SUNY Upstate Medical University, Syracuse; Department of Neurology (S.D.P.), University of California Los Angeles; Department of Cardiology (E.A.), Yale University, New Haven, CT; Baptist Health South Florida (C.O.), Miami; Department of Critical Care (O.L.), Springfield Clinic, Springfield, IL; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Chukwuemeka Osondu
- From the Department of Neurology (R.A.), Massachusetts General Hospital/Harvard Medical School, Boston; Department of Population Health Sciences (C.M.), Duke University, Raleigh, NC; Department of Neurology (K.P., K.C.A., J.G.L., F.O.O.), SUNY Upstate Medical University, Syracuse; Department of Neurology (S.D.P.), University of California Los Angeles; Department of Cardiology (E.A.), Yale University, New Haven, CT; Baptist Health South Florida (C.O.), Miami; Department of Critical Care (O.L.), Springfield Clinic, Springfield, IL; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Oluwatomi Lamikanra
- From the Department of Neurology (R.A.), Massachusetts General Hospital/Harvard Medical School, Boston; Department of Population Health Sciences (C.M.), Duke University, Raleigh, NC; Department of Neurology (K.P., K.C.A., J.G.L., F.O.O.), SUNY Upstate Medical University, Syracuse; Department of Neurology (S.D.P.), University of California Los Angeles; Department of Cardiology (E.A.), Yale University, New Haven, CT; Baptist Health South Florida (C.O.), Miami; Department of Critical Care (O.L.), Springfield Clinic, Springfield, IL; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Emmanuel Oladele Akano
- From the Department of Neurology (R.A.), Massachusetts General Hospital/Harvard Medical School, Boston; Department of Population Health Sciences (C.M.), Duke University, Raleigh, NC; Department of Neurology (K.P., K.C.A., J.G.L., F.O.O.), SUNY Upstate Medical University, Syracuse; Department of Neurology (S.D.P.), University of California Los Angeles; Department of Cardiology (E.A.), Yale University, New Haven, CT; Baptist Health South Florida (C.O.), Miami; Department of Critical Care (O.L.), Springfield Clinic, Springfield, IL; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Nnabuchi Anikpezie
- From the Department of Neurology (R.A.), Massachusetts General Hospital/Harvard Medical School, Boston; Department of Population Health Sciences (C.M.), Duke University, Raleigh, NC; Department of Neurology (K.P., K.C.A., J.G.L., F.O.O.), SUNY Upstate Medical University, Syracuse; Department of Neurology (S.D.P.), University of California Los Angeles; Department of Cardiology (E.A.), Yale University, New Haven, CT; Baptist Health South Florida (C.O.), Miami; Department of Critical Care (O.L.), Springfield Clinic, Springfield, IL; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Karen C Albright
- From the Department of Neurology (R.A.), Massachusetts General Hospital/Harvard Medical School, Boston; Department of Population Health Sciences (C.M.), Duke University, Raleigh, NC; Department of Neurology (K.P., K.C.A., J.G.L., F.O.O.), SUNY Upstate Medical University, Syracuse; Department of Neurology (S.D.P.), University of California Los Angeles; Department of Cardiology (E.A.), Yale University, New Haven, CT; Baptist Health South Florida (C.O.), Miami; Department of Critical Care (O.L.), Springfield Clinic, Springfield, IL; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Julius G Latorre
- From the Department of Neurology (R.A.), Massachusetts General Hospital/Harvard Medical School, Boston; Department of Population Health Sciences (C.M.), Duke University, Raleigh, NC; Department of Neurology (K.P., K.C.A., J.G.L., F.O.O.), SUNY Upstate Medical University, Syracuse; Department of Neurology (S.D.P.), University of California Los Angeles; Department of Cardiology (E.A.), Yale University, New Haven, CT; Baptist Health South Florida (C.O.), Miami; Department of Critical Care (O.L.), Springfield Clinic, Springfield, IL; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Seemant Chaturvedi
- From the Department of Neurology (R.A.), Massachusetts General Hospital/Harvard Medical School, Boston; Department of Population Health Sciences (C.M.), Duke University, Raleigh, NC; Department of Neurology (K.P., K.C.A., J.G.L., F.O.O.), SUNY Upstate Medical University, Syracuse; Department of Neurology (S.D.P.), University of California Los Angeles; Department of Cardiology (E.A.), Yale University, New Haven, CT; Baptist Health South Florida (C.O.), Miami; Department of Critical Care (O.L.), Springfield Clinic, Springfield, IL; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Fadar Oliver Otite
- From the Department of Neurology (R.A.), Massachusetts General Hospital/Harvard Medical School, Boston; Department of Population Health Sciences (C.M.), Duke University, Raleigh, NC; Department of Neurology (K.P., K.C.A., J.G.L., F.O.O.), SUNY Upstate Medical University, Syracuse; Department of Neurology (S.D.P.), University of California Los Angeles; Department of Cardiology (E.A.), Yale University, New Haven, CT; Baptist Health South Florida (C.O.), Miami; Department of Critical Care (O.L.), Springfield Clinic, Springfield, IL; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; and Department of Neurology (S.C.), University of Maryland, Baltimore.
| |
Collapse
|
11
|
Vicent L, Martín de la Mota Sanz D, Rosillo N, Peñaloza-Martínez E, Moreno G, Bernal JL, Elola J, Bueno H. Sex differences in temporal trends in main and secondary pulmonary embolism diagnosis and case fatality rates: 2003-2019. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2023; 9:184-193. [PMID: 35533393 DOI: 10.1093/ehjqcco/qcac020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/11/2022] [Accepted: 04/28/2022] [Indexed: 01/01/2023]
Abstract
AIMS There is controversy regarding the incidence and outcomes of pulmonary embolism (PE) according to sex. Our aim was to address sex differences in temporal trends in main and secondary hospital PE diagnoses, management and case fatality rates (CFR). METHODS AND RESULTS Retrospective analysis of Spain´s National Healthcare System hospital database, years 2003-2019, for patients ≥18 years with main or secondary PE diagnosis. Trends by sex in hospital diagnosis, use of procedures, and CFRs were analysed by joinpoint and Poisson regression models. Of 339 469 PE diagnoses, 52% were in women. Sixty-five percent were main diagnosis, 35.2% secondary. Total annual diagnoses and frequentation rates increased similarly in men and women: average annual percent change (AAPC): 2.0% (95% CI, 1.3-2.6; P < 0.005). Secondary PEs were more common in men (37.8% vs. 32.9%, P < 0.001). Men showed greater comorbidity than women (Charlson index 2.22 ± 0.01 vs. 1.74 ± 0.01, P < 0.001), particularly cancer in the secondary diagnosis group (40.9% vs. 31.6%, P < 0.001). CFRs for PE as main diagnosis were comparable and decreased in parallel in men (from 13.8% in 2003 to 7.3% in 2019) and women (from 13.1% in 2003 to 6.9% in 2019). However, for PE as secondary diagnosis, CFRs remained higher (P < 0.001) in men (from 42.5% in 2003 to 26.2% in 2019) than women (from 34.4% in 2003 to 22.8% in 2019). CONCLUSION PE hospital diagnosis increased significantly between 2003 and 2019 in men and women for both main and secondary diagnosis. Although in-hospital CFR decreased one third still remains very high, especially in men with secondary PE diagnosis.
Collapse
Affiliation(s)
- Lourdes Vicent
- Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.,CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain.,Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | | | - Nicolás Rosillo
- CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain.,Department of Preventive Medicine, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Eduardo Peñaloza-Martínez
- Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.,CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Guillermo Moreno
- Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.,CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain.,Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, Madrid, Spain.,Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - José Luis Bernal
- Management Control Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Javier Elola
- Instituto para la Mejora de la Atención Sanitaria (IMAS), Madrid, Spain
| | - Héctor Bueno
- Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.,CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain.,Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| |
Collapse
|
12
|
Association between Mean Arterial Pressure during the First 24 Hours and Clinical Outcome in Critically Ill Stroke Patients: An Analysis of the MIMIC-III Database. J Clin Med 2023; 12:jcm12041556. [PMID: 36836091 PMCID: PMC9961385 DOI: 10.3390/jcm12041556] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/03/2023] [Accepted: 02/07/2023] [Indexed: 02/18/2023] Open
Abstract
Abnormal blood pressure is common in critically ill stroke patients. However, the association between mean arterial pressure (MAP) and mortality of critically ill stroke patients remains unclear. We extracted eligible acute stroke patients from the MIMIC-III database. The patients were divided into three groups: a low MAP group (MAP ≤ 70 mmHg), a normal MAP group (70 mmHg < MAP ≤ 90 mmHg), and a high MAP group (MAP > 90 mmHg). The Cox proportional hazards model and restricted cubic splines were used to assess the association between MAP and mortality. Sensitivity analyses were conducted to investigate whether MAP had different effects on mortality in different subpopulations. A total of 2885 stroke patients were included in this study. The crude 7-day and 28-day mortality was significantly higher in the low MAP group than that in the normal MAP group. By contrast, patients in the high MAP group did not have higher crude 7-day and 28-day mortality than those in the normal MAP group. After multiple adjustments using the Cox regression model, patients with low MAP were consistently associated with higher 7-day and 28-day mortality than those with normal MAP in the following subgroups: age > 60 years, male, those with or without hypertension, those without diabetes, and those without CHD (p < 0.05), but patients with high MAP were not necessarily associated with higher 7-day and 28-day mortality after adjustments (most p > 0.05). Using the restricted cubic splines, an approximately L-shaped relationship was established between MAP and the 7-day and 28-day mortality in acute stroke patients. The findings were robust to multiple sensitivity analyses in stroke patients. In critically ill stroke patients, a low MAP significantly increased the 7-day and 28-day mortality, while a high MAP did not, suggesting that a low MAP is more harmful than a high MAP in critically ill stroke patients.
Collapse
|
13
|
Xia C, Hoffman H, Anikpezie N, Philip K, Wee C, Choudhry R, Albright KC, Masoud H, Beutler T, Schmidt E, Gould G, Patel SD, Akano EO, Morris N, Chaturvedi S, Aneni E, Lamikanra O, Chin L, Latorre JG, Otite FO. Trends in the Incidence of Spontaneous Subarachnoid Hemorrhages in the United States, 2007-2017. Neurology 2023; 100:e123-e132. [PMID: 36289004 PMCID: PMC10499430 DOI: 10.1212/wnl.0000000000201340] [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: 03/15/2022] [Accepted: 08/17/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVE To test the hypothesis that age-specific, sex-specific, and race-specific and ethnicity-specific incidence of nontraumatic subarachnoid hemorrhage (SAH) increased in the United States over the last decade. METHODS In this retrospective cohort study, validated International Classification of Diseases codes were used to identify all new cases of SAH (n = 39,475) in the State Inpatients Databases of New York and Florida (2007-2017). SAH counts were combined with Census data to calculate incidence. Joinpoint regression was used to compute the annual percentage change (APC) in incidence and to compare trends over time between demographic subgroups. RESULTS Across the study period, the average annual age-standardized/sex-standardized incidence of SAH in cases per 100,000 population was 11.4, but incidence was significantly higher in women (13.1) compared with that in men (9.6), p < 0.001. Incidence also increased with age in both sexes (men aged 20-44 years: 3.6; men aged 65 years or older: 22.0). Age-standardized and sex-standardized incidence was greater in Black patients (15.4) compared with that in non-Hispanic White (NHW) patients (9.9) and other races and ethnicities, p < 0.001. On joinpoint regression, incidence increased over time (APC 0.7%, p < 0.001), but most of this increase occurred in men aged 45-64 years (APC 1.1%, p = 0.006), men aged 65 years or older (APC 2.3%, p < 0.001), and women aged 65 years or older (APC 0.7%, p = 0.009). Incidence in women aged 20-44 years declined (APC -0.7%, p = 0.017), while those in other age/sex groups remained unchanged over time. Incidence increased in Black patients (APC 1.8%, p = 0.014), whereas that in Asian, Hispanic, and NHW patients did not change significantly over time. DISCUSSION Nontraumatic SAH incidence in the United States increased over the last decade predominantly in middle-aged men and elderly men and women. Incidence is disproportionately higher and increasing in Black patients, whereas that in other races and ethnicities did not change significantly over time.
Collapse
Affiliation(s)
- Christina Xia
- From the Departments of Neurology (C.X., K.P., C.W., R.C., K.C.A., H.M., E.S., J.G.L., F.O.O.M.), and Neurosurgery (H.H., T.B., G.G., L.C.), SUNY Upstate Medical University, Syracuse, NY; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; Department of Neurology (S.D.P.), University of California Los Angeles; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Neurology (N.M., S.C.), University of Maryland, Baltimore; Department of Cardiology (E.A.), Yale University, New Haven, CT; andDepartment of Critical Care (O.L.), Springfield Clinic, IL
| | - Haydn Hoffman
- From the Departments of Neurology (C.X., K.P., C.W., R.C., K.C.A., H.M., E.S., J.G.L., F.O.O.M.), and Neurosurgery (H.H., T.B., G.G., L.C.), SUNY Upstate Medical University, Syracuse, NY; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; Department of Neurology (S.D.P.), University of California Los Angeles; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Neurology (N.M., S.C.), University of Maryland, Baltimore; Department of Cardiology (E.A.), Yale University, New Haven, CT; andDepartment of Critical Care (O.L.), Springfield Clinic, IL
| | - Nnabuchi Anikpezie
- From the Departments of Neurology (C.X., K.P., C.W., R.C., K.C.A., H.M., E.S., J.G.L., F.O.O.M.), and Neurosurgery (H.H., T.B., G.G., L.C.), SUNY Upstate Medical University, Syracuse, NY; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; Department of Neurology (S.D.P.), University of California Los Angeles; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Neurology (N.M., S.C.), University of Maryland, Baltimore; Department of Cardiology (E.A.), Yale University, New Haven, CT; andDepartment of Critical Care (O.L.), Springfield Clinic, IL
| | - Karan Philip
- From the Departments of Neurology (C.X., K.P., C.W., R.C., K.C.A., H.M., E.S., J.G.L., F.O.O.M.), and Neurosurgery (H.H., T.B., G.G., L.C.), SUNY Upstate Medical University, Syracuse, NY; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; Department of Neurology (S.D.P.), University of California Los Angeles; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Neurology (N.M., S.C.), University of Maryland, Baltimore; Department of Cardiology (E.A.), Yale University, New Haven, CT; andDepartment of Critical Care (O.L.), Springfield Clinic, IL
| | - Claribel Wee
- From the Departments of Neurology (C.X., K.P., C.W., R.C., K.C.A., H.M., E.S., J.G.L., F.O.O.M.), and Neurosurgery (H.H., T.B., G.G., L.C.), SUNY Upstate Medical University, Syracuse, NY; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; Department of Neurology (S.D.P.), University of California Los Angeles; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Neurology (N.M., S.C.), University of Maryland, Baltimore; Department of Cardiology (E.A.), Yale University, New Haven, CT; andDepartment of Critical Care (O.L.), Springfield Clinic, IL
| | - Reema Choudhry
- From the Departments of Neurology (C.X., K.P., C.W., R.C., K.C.A., H.M., E.S., J.G.L., F.O.O.M.), and Neurosurgery (H.H., T.B., G.G., L.C.), SUNY Upstate Medical University, Syracuse, NY; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; Department of Neurology (S.D.P.), University of California Los Angeles; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Neurology (N.M., S.C.), University of Maryland, Baltimore; Department of Cardiology (E.A.), Yale University, New Haven, CT; andDepartment of Critical Care (O.L.), Springfield Clinic, IL
| | - Karen C Albright
- From the Departments of Neurology (C.X., K.P., C.W., R.C., K.C.A., H.M., E.S., J.G.L., F.O.O.M.), and Neurosurgery (H.H., T.B., G.G., L.C.), SUNY Upstate Medical University, Syracuse, NY; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; Department of Neurology (S.D.P.), University of California Los Angeles; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Neurology (N.M., S.C.), University of Maryland, Baltimore; Department of Cardiology (E.A.), Yale University, New Haven, CT; andDepartment of Critical Care (O.L.), Springfield Clinic, IL
| | - Hesham Masoud
- From the Departments of Neurology (C.X., K.P., C.W., R.C., K.C.A., H.M., E.S., J.G.L., F.O.O.M.), and Neurosurgery (H.H., T.B., G.G., L.C.), SUNY Upstate Medical University, Syracuse, NY; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; Department of Neurology (S.D.P.), University of California Los Angeles; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Neurology (N.M., S.C.), University of Maryland, Baltimore; Department of Cardiology (E.A.), Yale University, New Haven, CT; andDepartment of Critical Care (O.L.), Springfield Clinic, IL
| | - Timothy Beutler
- From the Departments of Neurology (C.X., K.P., C.W., R.C., K.C.A., H.M., E.S., J.G.L., F.O.O.M.), and Neurosurgery (H.H., T.B., G.G., L.C.), SUNY Upstate Medical University, Syracuse, NY; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; Department of Neurology (S.D.P.), University of California Los Angeles; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Neurology (N.M., S.C.), University of Maryland, Baltimore; Department of Cardiology (E.A.), Yale University, New Haven, CT; andDepartment of Critical Care (O.L.), Springfield Clinic, IL
| | - Elena Schmidt
- From the Departments of Neurology (C.X., K.P., C.W., R.C., K.C.A., H.M., E.S., J.G.L., F.O.O.M.), and Neurosurgery (H.H., T.B., G.G., L.C.), SUNY Upstate Medical University, Syracuse, NY; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; Department of Neurology (S.D.P.), University of California Los Angeles; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Neurology (N.M., S.C.), University of Maryland, Baltimore; Department of Cardiology (E.A.), Yale University, New Haven, CT; andDepartment of Critical Care (O.L.), Springfield Clinic, IL
| | - Grahame Gould
- From the Departments of Neurology (C.X., K.P., C.W., R.C., K.C.A., H.M., E.S., J.G.L., F.O.O.M.), and Neurosurgery (H.H., T.B., G.G., L.C.), SUNY Upstate Medical University, Syracuse, NY; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; Department of Neurology (S.D.P.), University of California Los Angeles; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Neurology (N.M., S.C.), University of Maryland, Baltimore; Department of Cardiology (E.A.), Yale University, New Haven, CT; andDepartment of Critical Care (O.L.), Springfield Clinic, IL
| | - Smit D Patel
- From the Departments of Neurology (C.X., K.P., C.W., R.C., K.C.A., H.M., E.S., J.G.L., F.O.O.M.), and Neurosurgery (H.H., T.B., G.G., L.C.), SUNY Upstate Medical University, Syracuse, NY; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; Department of Neurology (S.D.P.), University of California Los Angeles; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Neurology (N.M., S.C.), University of Maryland, Baltimore; Department of Cardiology (E.A.), Yale University, New Haven, CT; andDepartment of Critical Care (O.L.), Springfield Clinic, IL
| | - Emmanuel Oladele Akano
- From the Departments of Neurology (C.X., K.P., C.W., R.C., K.C.A., H.M., E.S., J.G.L., F.O.O.M.), and Neurosurgery (H.H., T.B., G.G., L.C.), SUNY Upstate Medical University, Syracuse, NY; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; Department of Neurology (S.D.P.), University of California Los Angeles; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Neurology (N.M., S.C.), University of Maryland, Baltimore; Department of Cardiology (E.A.), Yale University, New Haven, CT; andDepartment of Critical Care (O.L.), Springfield Clinic, IL
| | - Nicholas Morris
- From the Departments of Neurology (C.X., K.P., C.W., R.C., K.C.A., H.M., E.S., J.G.L., F.O.O.M.), and Neurosurgery (H.H., T.B., G.G., L.C.), SUNY Upstate Medical University, Syracuse, NY; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; Department of Neurology (S.D.P.), University of California Los Angeles; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Neurology (N.M., S.C.), University of Maryland, Baltimore; Department of Cardiology (E.A.), Yale University, New Haven, CT; andDepartment of Critical Care (O.L.), Springfield Clinic, IL
| | - Seemant Chaturvedi
- From the Departments of Neurology (C.X., K.P., C.W., R.C., K.C.A., H.M., E.S., J.G.L., F.O.O.M.), and Neurosurgery (H.H., T.B., G.G., L.C.), SUNY Upstate Medical University, Syracuse, NY; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; Department of Neurology (S.D.P.), University of California Los Angeles; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Neurology (N.M., S.C.), University of Maryland, Baltimore; Department of Cardiology (E.A.), Yale University, New Haven, CT; andDepartment of Critical Care (O.L.), Springfield Clinic, IL
| | - Ehimen Aneni
- From the Departments of Neurology (C.X., K.P., C.W., R.C., K.C.A., H.M., E.S., J.G.L., F.O.O.M.), and Neurosurgery (H.H., T.B., G.G., L.C.), SUNY Upstate Medical University, Syracuse, NY; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; Department of Neurology (S.D.P.), University of California Los Angeles; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Neurology (N.M., S.C.), University of Maryland, Baltimore; Department of Cardiology (E.A.), Yale University, New Haven, CT; andDepartment of Critical Care (O.L.), Springfield Clinic, IL
| | - Oluwatomi Lamikanra
- From the Departments of Neurology (C.X., K.P., C.W., R.C., K.C.A., H.M., E.S., J.G.L., F.O.O.M.), and Neurosurgery (H.H., T.B., G.G., L.C.), SUNY Upstate Medical University, Syracuse, NY; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; Department of Neurology (S.D.P.), University of California Los Angeles; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Neurology (N.M., S.C.), University of Maryland, Baltimore; Department of Cardiology (E.A.), Yale University, New Haven, CT; andDepartment of Critical Care (O.L.), Springfield Clinic, IL
| | - Lawrence Chin
- From the Departments of Neurology (C.X., K.P., C.W., R.C., K.C.A., H.M., E.S., J.G.L., F.O.O.M.), and Neurosurgery (H.H., T.B., G.G., L.C.), SUNY Upstate Medical University, Syracuse, NY; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; Department of Neurology (S.D.P.), University of California Los Angeles; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Neurology (N.M., S.C.), University of Maryland, Baltimore; Department of Cardiology (E.A.), Yale University, New Haven, CT; andDepartment of Critical Care (O.L.), Springfield Clinic, IL
| | - Julius G Latorre
- From the Departments of Neurology (C.X., K.P., C.W., R.C., K.C.A., H.M., E.S., J.G.L., F.O.O.M.), and Neurosurgery (H.H., T.B., G.G., L.C.), SUNY Upstate Medical University, Syracuse, NY; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; Department of Neurology (S.D.P.), University of California Los Angeles; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Neurology (N.M., S.C.), University of Maryland, Baltimore; Department of Cardiology (E.A.), Yale University, New Haven, CT; andDepartment of Critical Care (O.L.), Springfield Clinic, IL
| | - Fadar Oliver Otite
- From the Departments of Neurology (C.X., K.P., C.W., R.C., K.C.A., H.M., E.S., J.G.L., F.O.O.M.), and Neurosurgery (H.H., T.B., G.G., L.C.), SUNY Upstate Medical University, Syracuse, NY; Department of Population Health Science (N.A.), University of Mississippi Medical Center, Jackson; Department of Neurology (S.D.P.), University of California Los Angeles; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Neurology (N.M., S.C.), University of Maryland, Baltimore; Department of Cardiology (E.A.), Yale University, New Haven, CT; andDepartment of Critical Care (O.L.), Springfield Clinic, IL.
| |
Collapse
|
14
|
Deshpande A, Chen Y, Boye-Codjoe E, Obi EN. Adoption and Trends in Uptake of Updated ICD-10 Codes for Clostridioides difficile-A Retrospective Observational Study. Open Forum Infect Dis 2022; 9:ofac622. [PMID: 36519119 PMCID: PMC9745779 DOI: 10.1093/ofid/ofac622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 11/12/2022] [Indexed: 08/30/2023] Open
Abstract
BACKGROUND In October 2017, the single International Classification of Diseases, Tenth Revision (ICD-10), code for Clostridioides difficile infection (CDI), A04.7, was replaced with 2 codes delineating "recurrent CDI" (rCDI; A04.71) and "nonrecurrent CDI" (nrCDI; A04.72). METHODS To evaluate and validate use of the updated codes, this retrospective study included inpatient encounters with a CDI-related ICD-10 code from October 2016 to May 2019 in the PINC AITM Healthcare Database (PHD). Encounters after the October 2017 code update were characterized by clinical, facility, and provider variables and whether coding was concordant or discordant to the 8-week recurrence period. Multivariable regression analysis assessed variables associated with concordant coding. RESULTS Widespread adoption of the updated CDI codes across PHD hospitals occurred in October 2017. After October 2017, 21 446 CDI-related encounters met sample selection criteria (concordance in 67% of rCDI and 25% of nrCDI encounters). Higher proportions of rCDI- vs nrCDI-coded encounters (P < .05) had emergency room admission, admission by a gastroenterologist or infectious disease specialist, and were prescribed fidaxomicin, bezlotoxumab, or fecal microbiota transfer (FMT), with no significant difference by coding concordance status. Encounters coded concordantly were significantly more likely to be for rCDI (odds ratio [OR], 5.67; 95% CI, 5.32-6.03), a nonelective admission (OR, 1.35-1.69), or prescribed fidaxomicin (OR, 1.11; 95% CI, 1.01-1.23) or FMT (OR, 1.29; 95% CI, 1.17-1.42). CONCLUSIONS Our study findings suggest no delay in transition to the updated CDI-related codes. Treatment patterns for rCDI vs nrCDI encounters were consistent with Infectious Diseases Society of America guidelines, regardless of concordance status.
Collapse
Affiliation(s)
- Abhishek Deshpande
- Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Infectious Disease, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Yiyun Chen
- Merck & Co., Inc., Rahway, New Jersey, USA
| | | | | |
Collapse
|
15
|
Otite FO, Somani S, Aneni E, Akano E, Patel SD, Anikpezie N, Lamikanra O, Masoud H, Latorre JG, Chaturvedi S, Mehndiratta P. Trends in age and sex-specific prevalence of cancer and cancer subtypes in acute ischemic stroke from 2007-2019. J Stroke Cerebrovasc Dis 2022; 31:106818. [PMID: 36323171 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/29/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To describe age and sex-specific prevalence of cancer in acute ischemic stroke (AIS) hospitalizations in the United States over the last decade. METHODS We conducted a retrospective serial cross-sectional study using all primary AIS discharges (weighted n=5,748,358) with and without cancer in the 2007-2019 National Inpatient Sample. Admissions with primary central nervous system cancers were excluded. Joinpoint regression was used to compute the average annualized percentage change (AAPC) in cancer prevalence over time. RESULTS Across the study period, 12.7% of AIS admissions had previous/active cancer, while 4.4% had active cancer. Of these, 18.8% were hematologic cancers, 47.2% were solid cancers without metastasis and 34.0% were metastatic cancers of any type. Age-adjusted active cancer prevalence differed by sex (males:4.8%; females:4.0%) and increased with age up to age 70-79 years (30-39 years 1.4%; 70-79 years:5.7%). Amongst cancer admissions, lung (18.7%) and prostate (17.8%) were the most common solid cancers in men, while lung (19.6%) and breast (13.7%) were the most prevalent in women. Active cancer prevalence increased over time (AAPC 1.7%, p<0.05) but the pace of increase was significantly faster in women (AAPC 2.8%) compared to men (AAPC 1.1%) (p-comparison =0.003). Fastest pace of increased prevalence was seen for genitourinary cancers in women and for gastrointestinal cancers in both sexes. Genitourinary cancers in men declined over time (AAPC -2.5%, p<0.05). Lung cancer prevalence increased in women (AAPC 1.8%, p<0.05) but remained constant in men. Prevalence of head/neck, skin/bone, gastrointestinal, hematological and metastatic cancers increased over time at similar pace in both sexes. CONCLUSION Prevalence of cancer in AIS admissions increased in the US over the last decade but the pace of this increase was faster in women compared to men. Gastrointestinal cancers in both sexes and genitourinary cancers in women are increasing at the fastest pace. Additional studies are needed to determine whether this increase is from co-occurrence or causation of AIS by cancer.
Collapse
Affiliation(s)
- Fadar Oliver Otite
- Department of Neurology, State University of New York, Upstate Medical University, Syracuse, NY, USA.
| | - Sana Somani
- Department of Neurology, Georgetown University School of Medicine, Washington, D.C., USA
| | - Ehimen Aneni
- Department of Cardiology, Yale University, New Haven, Connecticut, USA
| | - Emmanuel Akano
- Molecular Neuropharmacological Unit, National Institute of Neurological Diseases and Stroke, NINDS, Bethesda, Maryland, USA
| | - Smit D Patel
- Department of Neurosurgery, University of Connecticut, Hartford, Connecticut, USA
| | - Nnabuchi Anikpezie
- Department of Population Health Science, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | | | - Hesham Masoud
- Department of Neurology, State University of New York, Upstate Medical University, Syracuse, NY, USA
| | - Julius Gene Latorre
- Department of Neurology, State University of New York, Upstate Medical University, Syracuse, NY, USA
| | - Seemant Chaturvedi
- Department of Neurology, University of Maryland School of Medicine, Baltimore, USA
| | - Prachi Mehndiratta
- Department of Neurology, University of Maryland School of Medicine, Baltimore, USA
| |
Collapse
|
16
|
Yang Q, Tong X, George MG, Chang A, Merritt RK. COVID-19 and Risk of Acute Ischemic Stroke Among Medicare Beneficiaries Aged 65 Years or Older: Self-Controlled Case Series Study. Neurology 2022; 98:e778-e789. [PMID: 35115387 DOI: 10.1212/wnl.0000000000013184] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 11/30/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Findings of association between COVID-19 and stroke remain inconsistent, ranging from significant association, absence of association to less than expected ischemic stroke among hospitalized patients with COVID-19. The present study examined the association between COVID-19 and risk of acute ischemic stroke (AIS). METHODS We included 37,379 Medicare fee-for-service (FFS) beneficiaries aged ≥65 years diagnosed with COVID-19 from April 1, 2020 through February 28, 2021 and AIS hospitalization from January 1, 2019 through February 28, 2021. We used a self-controlled case series design to examine the association between COVID-19 and AIS and estimated the incident rate ratios (IRR) by comparing incidence of AIS in risk periods (0-3, 4-7, 8-14, 15-28 days after diagnosis of COVID-19) vs. control periods. RESULTS Among 37,379 Medicare FFS beneficiaries with COVID-19 and AIS, the median age at diagnosis of COVID-19 was 80.4 (interquartile range 73.5-87.1) years and 56.7% were women. When AIS at day of exposure (day=0) included in the risk periods, IRRs at 0-3, 4-7, 8-14, and 15-28 days following COVID-19 diagnosis were 10.3 (95% confidence interval 9.86-10.8), 1.61 (1.44-1.80), 1.44 (1.32-1.57), and 1.09 (1.02-1.18); when AIS at day 0 excluded in the risk periods, the corresponding IRRs were 1.77 (1.57-2.01) (day 1-3), 1.60 (1.43-1.79), 1.43 (1.31-1.56), and 1.09 (1.01-1.17), respectively. The association appeared to be stronger among younger beneficiaries and among beneficiaries without prior history of stroke but largely consistent across sex and race/ethnicities. DISCUSSION Risk of AIS among Medicare FFS beneficiaries was ten times (day 0 cases in the risk period) as high during the first 3 days after diagnosis of COVID-19 as during the control period and the risk associated with COVID-19 appeared to be stronger among those aged 65-74 years and those without prior history of stroke. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that SARS-CoV-2 infection, the virus that causes COVID-19, is associated with increased risk of AIS in the first three days after diagnosis in Medicare FFS beneficiaries ≥ 65 years age.
Collapse
Affiliation(s)
- Quanhe Yang
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, USA
| | - Xin Tong
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, USA
| | - Mary G George
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, USA
| | - Anping Chang
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, USA
| | - Robert K Merritt
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, USA
| |
Collapse
|
17
|
Ehsan A, Re A, Rivera Perla K, Aghagoli G, Bellam K, Sellke F. Trends and outcomes of coronary artery bypass grafting in patients with major depressive disorder: A perspective from the national inpatient sample. HEART AND MIND 2022. [DOI: 10.4103/hm.hm_62_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
18
|
Ray WA, Chung CP, Stein CM, Smalley W, Zimmerman E, Dupont WD, Hung AM, Daugherty JR, Dickson A, Murray KT. Association of Rivaroxaban vs Apixaban With Major Ischemic or Hemorrhagic Events in Patients With Atrial Fibrillation. JAMA 2021; 326:2395-2404. [PMID: 34932078 PMCID: PMC8693217 DOI: 10.1001/jama.2021.21222] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE The comparative effectiveness of rivaroxaban and apixaban, the most frequently prescribed oral anticoagulants for ischemic stroke prevention in patients with atrial fibrillation, is uncertain. OBJECTIVE To compare major ischemic and hemorrhagic outcomes in patients with atrial fibrillation treated with rivaroxaban or apixaban. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study using computerized enrollment and claims files for US Medicare beneficiaries 65 years or older. Between January 1, 2013, and November 30, 2018, a total of 581 451 patients with atrial fibrillation began rivaroxaban or apixaban treatment and were followed up for 4 years, through November 30, 2018. EXPOSURES Rivaroxaban (n = 227 572) and apixaban (n = 353 879), either standard or reduced dose. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of major ischemic (stroke/systemic embolism) and hemorrhagic (intracerebral hemorrhage/other intracranial bleeding/fatal extracranial bleeding) events. Secondary outcomes were nonfatal extracranial bleeding and total mortality (fatal ischemic/hemorrhagic event or other death during follow-up). Rates, hazard ratios (HRs), and rate differences (RDs) were adjusted for baseline differences in comorbidity with inverse probability of treatment weighting. RESULTS Study patients (mean age, 77.0 years; 291 966 [50.2%] women; 134 393 [23.1%] receiving reduced dose) had 474 605 person-years of follow-up (median [IQR] of 174 [62-397] days). The adjusted primary outcome rate for rivaroxaban was 16.1 per 1000 person-years vs 13.4 per 1000 person-years for apixaban (RD, 2.7 [95% CI, 1.9-3.5]; HR, 1.18 [95% CI, 1.12-1.24]). The rivaroxaban group had increased risk for both major ischemic events (8.6 vs 7.6 per 1000 person-years; RD, 1.1 [95% CI, 0.5-1.7]; HR, 1.12 [95% CI, 1.04-1.20]) and hemorrhagic events (7.5 vs 5.9 per 1000 person-years; RD, 1.6 [95% CI, 1.1-2.1]; HR, 1.26 [95% CI, 1.16-1.36]), including fatal extracranial bleeding (1.4 vs 1.0 per 1000 person-years; RD, 0.4 [95% CI, 0.2-0.7]; HR, 1.41 [95% CI, 1.18-1.70]). Patients receiving rivaroxaban had increased risk of nonfatal extracranial bleeding (39.7 vs 18.5 per 1000 person-years; RD, 21.1 [95% CI, 20.0-22.3]; HR, 2.07 [95% CI, 1.99-2.15]), fatal ischemic/hemorrhagic events (4.5 vs 3.3 per 1000 person-years; RD, 1.2 [95% CI, 0.8-1.6]; HR, 1.34 [95% CI, 1.21-1.48]), and total mortality (44.2 vs 41.0 per 1000 person-years; RD, 3.1 [95% CI, 1.8-4.5]; HR, 1.06 [95% CI, 1.02-1.09]). The risk of the primary outcome was increased for rivaroxaban in both those receiving the reduced dose (27.4 vs 21.0 per 1000 person-years; RD, 6.4 [95% CI, 4.1-8.7]; HR, 1.28 [95% CI, 1.16-1.40]) and the standard dose (13.2 vs 11.4 per 1000 person-years; RD, 1.8 [95% CI, 1.0-2.6]; HR, 1.13 [95% CI, 1.06-1.21]) groups. CONCLUSIONS AND RELEVANCE Among Medicare beneficiaries 65 years or older with atrial fibrillation, treatment with rivaroxaban compared with apixaban was associated with a significantly increased risk of major ischemic or hemorrhagic events.
Collapse
Affiliation(s)
- Wayne A. Ray
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Cecilia P. Chung
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - C. Michael Stein
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Walter Smalley
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Eli Zimmerman
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - William D. Dupont
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Adriana M. Hung
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
- Veterans Affairs Tennessee Valley Healthcare System, Nashville Campus
| | - James R. Daugherty
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Alyson Dickson
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Katherine T. Murray
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
| |
Collapse
|
19
|
de Havenon A, Sheth K, Johnston KC, Delic A, Stulberg E, Majersik J, Anadani M, Yaghi S, Tirschwell D, Ney J. Acute Ischemic Stroke Interventions in the United States and Racial, Socioeconomic, and Geographic Disparities. Neurology 2021; 97:e2292-e2303. [PMID: 34649872 PMCID: PMC8665433 DOI: 10.1212/wnl.0000000000012943] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/27/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In patients with ischemic stroke (IS), IV alteplase (tissue plasminogen activator [tPA]) and endovascular thrombectomy (EVT) reduce long-term disability, but their utilization has not been fully optimized. Prior research has also demonstrated disparities in the use of tPA and EVT specific to sex, race/ethnicity, socioeconomic status, and geographic location. We sought to determine the utilization of tPA and EVT in the United States from 2016-2018 and if disparities in utilization persist. METHODS This is a retrospective, longitudinal analysis of the 2016-2018 National Inpatient Sample. We included adult patients who had a primary discharge diagnosis of IS. The primary study outcomes were the proportions who received tPA or EVT. We fit a multivariate logistic regression model to our outcomes in the full cohort and also in the subset of patients who had an available baseline National Institutes of Health Stroke Scale (NIHSS) score. RESULTS The full cohort after weighting included 1,439,295 patients with IS. The proportion who received tPA increased from 8.8% in 2016 to 10.2% in 2018 (p < 0.001) and who had EVT from 2.8% in 2016 to 4.9% in 2018 (p < 0.001). Comparing Black to White patients, the odds ratio (OR) of receiving tPA was 0.82 (95% confidence interval [CI] 0.79-0.86) and for having EVT was 0.75 (95% CI 0.70-0.81). Comparing patients with a median income in their zip code of ≤$37,999 to >$64,000, the OR of receiving tPA was 0.81 (95% CI 0.78-0.85) and for having EVT was 0.84 (95% CI 0.77-0.91). Comparing patients living in a rural area to a large metro area, the OR of receiving tPA was 0.48 (95% CI 0.44-0.52) and for having EVT was 0.92 (95% CI 0.81-1.05). These associations were largely maintained after adjustment for NIHSS, although the effect size changed for many of them. Contrary to prior reports with older datasets, sex was not consistently associated with tPA or EVT. DISCUSSION Utilization of tPA and EVT for IS in the United States increased from 2016 to 2018. There are racial, socioeconomic, and geographic disparities in the accessibility of tPA and EVT for patients with IS, with important public health implications that require further study.
Collapse
Affiliation(s)
- Adam de Havenon
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA.
| | - Kevin Sheth
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - Karen C Johnston
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - Alen Delic
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - Eric Stulberg
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - Jennifer Majersik
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - Mohammad Anadani
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - Shadi Yaghi
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - David Tirschwell
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - John Ney
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| |
Collapse
|
20
|
Tong X, King SMC, Asaithambi G, Odom E, Yang Q, Yin X, Merritt RK. COVID-19 Pandemic and Quality of Care and Outcomes of Acute Stroke Hospitalizations: the Paul Coverdell National Acute Stroke Program. Prev Chronic Dis 2021; 18:E82. [PMID: 34410906 PMCID: PMC8388201 DOI: 10.5888/pcd18.210130] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Studies documented significant reductions in emergency department visits and hospitalizations for acute stroke during the COVID-19 pandemic. A limited number of studies assessed the adherence to stroke performance measures during the pandemic. We examined rates of stroke hospitalization and adherence to stroke quality-of-care measures before and during the early phase of pandemic. METHODS We identified hospitalizations with a clinical diagnosis of acute stroke or transient ischemic attack among 406 hospitals who contributed data to the Paul Coverdell National Acute Stroke Program. We used 10 performance measures to examine the effect of the pandemic on stroke quality of care. We compared data from 2 periods: pre-COVID-19 (week 11-24 in 2019) and COVID-19 (week 11-24 in 2020). We used χ2 tests for differences in categorical variables and the Wilcoxon-Mann-Whitney rank test or Kruskal-Wallis test for continuous variables. RESULTS We identified 64,461 hospitalizations. We observed a 20.2% reduction in stroke hospitalizations (from 35,851 to 28,610) from the pre-COVID-19 period to the COVID-19 period. Hospitalizations among patients aged 85 or older, women, and non-Hispanic White patients declined the most. A greater percentage of patients aged 18 to 64 were hospitalized with ischemic stroke during COVID-19 than during pre-COVID-19 (34.4% vs 32.5%, P < .001). Stroke severity was higher during COVID-19 than during pre-COVID-19 for both hemorrhagic stroke and ischemic stroke, and in-hospital death among patients with ischemic stroke increased from 4.3% to 5.0% (P = .003) during the study period. We found no differences in rates of receiving care across stroke type during the study period. CONCLUSION Despite a significant reduction in stroke hospitalizations, more severe stroke among hospitalized patients, and an increase in in-hospital death during the pandemic period, we found no differences in adherence to quality of stroke care measures.
Collapse
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.
| | - Sallyann M Coleman King
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
- US Public Health Service, Atlanta, Georgia
| | | | - Erika Odom
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
- US Public Health Service, 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
| | | | - 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
| |
Collapse
|
21
|
Grandhi R, Ravindra VM, Ney JP, Zaidat O, Taussky P, de Havenon A. Investigating the "Weekend Effect" on Outcomes of Patients Undergoing Endovascular Mechanical Thrombectomy for Ischemic Stroke. J Stroke Cerebrovasc Dis 2021; 30:106013. [PMID: 34375859 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVES With growing evidence of its efficacy for patients with large-vessel occlusion (LVO) ischemic stroke, the use of endovascular thrombectomy (EVT) has increased. The "weekend effect," whereby patients presenting during weekends/off hours have worse clinical outcomes than those presenting during normal working hours, is a critical area of study in acute ischemic stroke (AIS). Our objective was to evaluate whether a "weekend effect" exists in patients undergoing EVT. METHODS This retrospective, cross-sectional analysis of the 2016-2018 Nationwide Inpatient Sample data included patients ≥18 years with documented diagnosis of ischemic stroke (ICD-10 codes I63, I64, and H34.1), procedural code for EVT, and National Institutes of Health Stroke Scale (NIHSS) score; the exposure variable was weekend vs. weekday treatment. The primary outcome was in-hospital death; secondary outcomes were favorable discharge, extended hospital stay (LOS), and cost. Logistic regression models were constructed to determine predictors for outcomes. RESULTS We identified 6052 AIS patients who received EVT (mean age 68.7±14.8 years; 50.8% female; 70.8% White; median (IQR) admission NIHSS 16 (10-21). The primary outcome of in-hospital death occurred in 560 (11.1%); the secondary outcome of favorable discharge occurred in 1039 (20.6%). The mean LOS was 7.8±8.6 days. There were no significant differences in the outcomes or cost based on admission timing. In the mixed-effects models, we found no effect of weekend vs. weekday admission on in-hospital death, favorable discharge, or extended LOS. CONCLUSION These results demonstrate that the "weekend effect" does not impact outcomes or cost for patients who undergo EVT for LVO.
Collapse
Affiliation(s)
- Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT 84132, USA.
| | - Vijay M Ravindra
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT 84132, USA; Department of Neurosurgery, Naval Medical Center San Diego, 34800 Bob Wilson Dr., San Diego, CA 92134, USA.
| | - John P Ney
- Department of Neurology, Boston University, 72 East Concord Street, C-3, MA 02118, USA.
| | - Osama Zaidat
- Department of Neurology, Mercy Health, 2222 Cherry St m200, Toledo, OH 43608, USA.
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT 84132, USA.
| | - Adam de Havenon
- Department of Neurology, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT 84132, USA.
| |
Collapse
|
22
|
Qureshi AI, Baskett WI, Huang W, Shyu D, Myers D, Lobanova I, Naqvi SH, Thompson VS, Shyu CR. Effect of Race and Ethnicity on In-Hospital Mortality in Patients with COVID-19. Ethn Dis 2021; 31:389-398. [PMID: 34295125 PMCID: PMC8288468 DOI: 10.18865/ed.31.3.389] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective To identify differences in short-term outcomes of patients with coronavirus disease 2019 (COVID-19) according to various racial/ethnic groups. Design Analysis of Cerner de-identified COVID-19 dataset. Setting A total of 62 health care facilities. Participants The cohort included 49,277 adult COVID-19 patients who were hospitalized from December 1, 2019 to November 13, 2020. Main Outcome Measures The primary outcome of interest was in-hospital mortality. The secondary outcome was non-routine discharge (discharge to destinations other than home, such as short-term hospitals or other facilities including intermediate care and skilled nursing homes). Methods We compared patients' age, gender, individual components of Charlson and Elixhauser comorbidities, medical complications, use of do-not-resuscitate, use of palliative care, and socioeconomic status between various racial and/or ethnic groups. We further compared the rates of in-hospital mortality and non-routine discharges between various racial and/or ethnic groups. Results Compared with White patients, in-hospital mortality was significantly higher among African American (OR 1.5; 95%CI:1.3-1.6, P<.001), Hispanic (OR1.4; 95%CI:1.3-1.6, P<.001), and Asian or Pacific Islander (OR 1.5; 95%CI: 1.1-1.9, P=.002) patients after adjustment for age and gender, Elixhauser comorbidities, do-not-resuscitate status, palliative care use, and socioeconomic status. Conclusions Our study found that, among hospitalized patients with COVID-2019, African American, Hispanic, and Asian or Pacific Islander patients had increased mortality compared with White patients after adjusting for sociodemographic factors, comorbidities, and do-not-resuscitate/palliative care status. Our findings add additional perspective to other recent studies.
Collapse
Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, MO
| | - William I. Baskett
- Institute for Data Science and Informatics, University of Missouri, Columbia, MO
| | - Wei Huang
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, MO
| | - Daniel Shyu
- Department of Medicine, University of Missouri, Columbia, MO
| | - Danny Myers
- Tiger Institute for Health Innovation, Cerner Corporation, Columbia, MO
| | - Iryna Lobanova
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, MO
| | - S. Hasan Naqvi
- Department of Internal Medicine, University of Missouri, Columbia, MO
| | - Vetta S. Thompson
- Brown School of Public Health Program, Washington University, St. Louis, MO
| | - Chi-Ren Shyu
- Institute for Data Science and Informatics, University of Missouri, Columbia, MO
- Department of Medicine, University of Missouri, Columbia, MO
- Department of Electrical Engineering and Computer Science, University of Missouri, Columbia, MO
| |
Collapse
|
23
|
Otite FO, Saini V, Sur NB, Patel S, Sharma R, Akano EO, Anikpezie N, Albright K, Schmidt E, Hoffman H, Gould G, Khandelwal P, Latorre JG, Malik AM, Sacco RL, Chaturvedi S. Ten-Year Trend in Age, Sex, and Racial Disparity in tPA (Alteplase) and Thrombectomy Use Following Stroke in the United States. Stroke 2021; 52:2562-2570. [PMID: 34078107 DOI: 10.1161/strokeaha.120.032132] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
Collapse
Affiliation(s)
- Fadar Oliver Otite
- Departments of Neurology (F.O.O., K.A., E.S., J.G.L.), State University of New York (SUNY) Upstate Medical University, Syracuse
| | - Vasu Saini
- University of Miami, FL (V.S., N.B.S., A.M.M., R.L.S.)
| | | | - Smit Patel
- University of Connecticut, Hartford (S.P.)
| | | | - Emmanuel O Akano
- Molecular Neuropharmacology Unit, National Institute of Neurological Disorders and Stroke, Bethesda, MD (E.O.A.)
| | - Nnabuchi Anikpezie
- Department of Healthcare Transformation Initiative, University of Texas Health Science Center at Houston (N.A.)
| | - Karen Albright
- Departments of Neurology (F.O.O., K.A., E.S., J.G.L.), State University of New York (SUNY) Upstate Medical University, Syracuse
| | - Elena Schmidt
- Departments of Neurology (F.O.O., K.A., E.S., J.G.L.), State University of New York (SUNY) Upstate Medical University, Syracuse
| | - Haydn Hoffman
- Department of Neurosurgery (H.H., G.G.), State University of New York (SUNY) Upstate Medical University, Syracuse
| | - Grahame Gould
- Department of Neurosurgery (H.H., G.G.), State University of New York (SUNY) Upstate Medical University, Syracuse
| | | | - Julius Gene Latorre
- Departments of Neurology (F.O.O., K.A., E.S., J.G.L.), State University of New York (SUNY) Upstate Medical University, Syracuse
| | - Amer M Malik
- University of Miami, FL (V.S., N.B.S., A.M.M., R.L.S.)
| | - Ralph L Sacco
- University of Miami, FL (V.S., N.B.S., A.M.M., R.L.S.)
| | | |
Collapse
|
24
|
Kamel H, Parikh NS, Chatterjee A, Kim LK, Saver JL, Schwamm LH, Zachrison KS, Nogueira RG, Adeoye O, Díaz I, Ryan AM, Pandya A, Navi BB. Access to Mechanical Thrombectomy for Ischemic Stroke in the United States. Stroke 2021; 52:2554-2561. [PMID: 33980045 DOI: 10.1161/strokeaha.120.033485] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
Collapse
Affiliation(s)
- Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., N.S.P., A.C., B.B.N.), Weill Cornell Medicine, New York, NY
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., N.S.P., A.C., B.B.N.), Weill Cornell Medicine, New York, NY
| | - Abhinaba Chatterjee
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., N.S.P., A.C., B.B.N.), Weill Cornell Medicine, New York, NY
| | - Luke K Kim
- Division of Cardiology (L.K.K.), Weill Cornell Medicine, New York, NY
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles (J.L.S.)
| | - Lee H Schwamm
- Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston
| | - Kori S Zachrison
- Department of Emergency Medicine (K.S.Z.), Massachusetts General Hospital, Boston
| | - Raul G Nogueira
- Departments of Neurology, Neurosurgery, and Radiology, Emory University School of Medicine, Atlanta, GA (R.G.N.)
| | - Opeolu Adeoye
- Department of Emergency Medicine, University of Cincinnati, OH (O.A.)
| | - Iván Díaz
- Division of Biostatistics and Epidemiology (I.D.), Weill Cornell Medicine, New York, NY
| | - Andrew M Ryan
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor (A.M.R.)
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (A.P.)
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., N.S.P., A.C., B.B.N.), Weill Cornell Medicine, New York, NY
| |
Collapse
|
25
|
de Havenon A, Ney JP, Callaghan B, Hohmann S, Shippey E, Yaghi S, Anadani M, Majersik JJ. Characteristics and Outcomes Among US Patients Hospitalized for Ischemic Stroke Before vs During the COVID-19 Pandemic. JAMA Netw Open 2021; 4:e2110314. [PMID: 33999162 PMCID: PMC8129817 DOI: 10.1001/jamanetworkopen.2021.10314] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE After the emergence of COVID-19, studies reported a decrease in hospitalizations of patients with ischemic stroke (IS), but there are little to no data regarding hospitalizations for the remainder of 2020, including outcome data from a large cohort of patients with IS and comorbid COVID-19. OBJECTIVE To assess hospital discharge rates, demographic factors, and outcomes of hospitalization associated with the COVID-19 pandemic among US patients with IS before vs during the COVID-19 pandemic. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from the Vizient Clinical Data Base on 324 013 patients with IS at 478 nonfederal hospitals in 43 US states between January 1, 2019, and December 31, 2020. Patients were eligible if they were admitted to the hospital on a nonelective basis and were not receiving hospice care at the time of admission. A total of 41 166 discharged between January and March 2020 were excluded from the analysis because they had unreliable data on COVID-19 status, leaving 282 847 patients for the study. EXPOSURE Ischemic stroke and laboratory-confirmed COVID-19. MAIN OUTCOMES AND MEASURES Monthly counts of discharges among patients with IS in 2020. Demographic characteristics and outcomes, including in-hospital death, among patients with IS who were discharged in 2019 (control group) were compared with those of patients with IS with or without comorbid COVID-19 (COVID-19 and non-COVID-19 groups, respectively) who were discharged between April and December 2020. RESULTS Of the 282 847 patients included in the study, 165 912 (50.7% male; 63.4% White; 26.3% aged ≥80 years) were allocated to the control group; 111 418 of 116 935 patients (95.3%; 51.9% male; 62.8% White; 24.6% aged ≥80 years) were allocated to the non-COVID-19 group and 5517 of 116 935 patients (4.7%; 58.0% male; 42.5% White; 21.3% aged ≥80 years) to the COVID-19 group. A mean (SD) of 13 846 (553) discharges per month among patients with IS was reported in 2019. Discharges began decreasing in February 2020, reaching a low of 10 846 patients in April 2020 before returning to a prepandemic level of 13 639 patients by July 2020. A mean (SD) of 13 492 (554) discharges per month was recorded for the remainder of 2020. Black and Hispanic patients accounted for 21.4% and 7.0% of IS discharges in 2019, respectively, but accounted for 27.5% and 16.0% of those discharged with IS and comorbid COVID-19 in 2020. Compared with patients in the control and non-COVID-19 groups, those in the COVID-19 group were less likely to smoke (16.0% vs 17.2% vs 6.4%, respectively) and to have hypertension (73.0% vs 73.1% vs 68.2%) or dyslipidemia (61.2% vs 63.2% vs 56.6%) but were more likely to have diabetes (39.8% vs 40.5% vs 53.0%), obesity (16.2% vs 18.4% vs 24.5%), acute coronary syndrome (8.0% vs 9.2% vs 15.8%), or pulmonary embolus (1.9% vs 2.4% vs 6.8%) and to require intubation (11.3% vs 12.3% vs 37.6%). After adjusting for baseline factors, patients with IS and COVID-19 were more likely to die in the hospital than were patients with IS in 2019 (adjusted odds ratio, 5.17; 95% CI, 4.83-5.53; National Institutes of Health Stroke Scale adjusted odds ratio, 3.57; 95% CI, 3.15-4.05). CONCLUSIONS AND RELEVANCE In this cohort study, after the emergence of COVID-19, hospital discharges of patients with IS decreased in the US but returned to prepandemic levels by July 2020. Among patients with IS between April and December 2020, comorbid COVID-19 was relatively common, particularly among Black and Hispanic populations, and morbidity was high.
Collapse
Affiliation(s)
| | - John P. Ney
- Department of Neurology, Boston University, Boston, Massachusetts
| | | | | | | | - Shadi Yaghi
- Department of Neurology, New York University, New York
| | - Mohammad Anadani
- Department of Neurology, Washington University in St Louis, St Louis, Missouri
| | | |
Collapse
|
26
|
de Havenon A, Ney JP, Callaghan B, Delic A, Hohmann S, Shippey E, Esper GJ, Stulberg E, Tirschwell D, Frontera J, Yaghi S, Anadani M, Majersik JJ. Impact of COVID-19 on Outcomes in Ischemic Stroke Patients in the United States. J Stroke Cerebrovasc Dis 2021; 30:105535. [PMID: 33310595 PMCID: PMC7832426 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105535] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Studies have shown worse outcomes in patients with comorbid ischemic stroke (IS) and coronavirus disease 2019 (COVID-19), but have had small sample sizes. METHODS We retrospectively identified patients in the Vizient Clinical Data Base® with IS as a discharge diagnosis. The study outcomes were in-hospital death and favorable discharge (home or acute rehabilitation). In the primary analysis, we compared IS patients with laboratory-confirmed COVID-19 (IS-COVID) discharged April 1-July 31, 2020 to pre-COVID IS patients discharged in 2019 (IS controls). In a secondary analysis, we compared a matched cohort of IS-COVID patients to patients within the IS controls who had pneumonia (IS-PNA), created with inverse-probability-weighting (IPW). RESULTS In the primary analysis, we included 166,586 IS controls and 2086 IS-COVID from 312 hospitals in 46 states. Compared to IS controls, IS-COVID were less likely to have hypertension, dyslipidemia, or be smokers, but more likely to be male, younger, have diabetes, obesity, acute renal failure, acute coronary syndrome, venous thromboembolism, intubation, and comorbid intracerebral or subarachnoid hemorrhage (all p<0.05). Black and Hispanic patients accounted for 21.7% and 7.4% of IS controls, respectively, but 33.7% and 18.5% of IS-COVID (p<0.001). IS-COVID, versus IS controls, were less likely to receive alteplase (1.8% vs 5.6%, p<0.001), mechanical thrombectomy (4.4% vs. 6.7%, p<0.001), to have favorable discharge (33.9% vs. 66.4%, p<0.001), but more likely to die (30.4% vs. 6.5%, p<0.001). In the matched cohort of patients with IS-COVID and IS-PNA, IS-COVID had a higher risk of death (IPW-weighted OR 1.56, 95% CI 1.33-1.82) and lower odds of favorable discharge (IPW-weighted OR 0.63, 95% CI 0.54-0.73). CONCLUSIONS Ischemic stroke patients with COVID-19 are more likely to be male, younger, and Black or Hispanic, with significant increases in morbidity and mortality compared to both ischemic stroke controls from 2019 and to patients with ischemic stroke and pneumonia.
Collapse
Affiliation(s)
- Adam de Havenon
- Department of Neurology, University of Utah, 175 N. Medical Dr, Salt Lake City, UT 84132, United States.
| | - John P Ney
- Department of Neurology, Boston University, United States.
| | - Brian Callaghan
- Department of Neurology, University of Michigan, United States.
| | - Alen Delic
- Department of Neurology, University of Utah, 175 N. Medical Dr, Salt Lake City, UT 84132, United States.
| | | | | | | | - Eric Stulberg
- Department of Neurology, University of Utah, 175 N. Medical Dr, Salt Lake City, UT 84132, United States.
| | - David Tirschwell
- Department of Neurology, University of Washington, United States.
| | | | - Shadi Yaghi
- Department of Neurology, New York University, United States.
| | | | - Jennifer J Majersik
- Department of Neurology, University of Utah, 175 N. Medical Dr, Salt Lake City, UT 84132, United States.
| |
Collapse
|
27
|
Tong X, Yang Q, George MG, Gillespie C, Merritt RK. Trends of risk profile among middle-aged adults hospitalized for acute ischemic stroke in United States 2006-2017. Int J Stroke 2020; 16:855-862. [PMID: 33308104 DOI: 10.1177/1747493020979379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Recent studies reported increasing trends in hospitalization of stroke patients aged 35-64 years. AIM To examine changes in risk factor profiles among patients aged 35-64 years hospitalized with acute ischemic stroke between 2006 and 2017 in the United States. METHODS We used data from the National Inpatient Sample of the Healthcare Cost and Utilization Project from 2006 through 2017. Principal ICD-9-CM/ICD-10-CM codes were used to identify acute ischemic stroke hospitalizations, and secondary codes were used to identify the presence of four major stroke risk factors: hypertension, diabetes, lipid disorders, and tobacco use. We used the relative percent change to assess the changes in the prevalence of risk profile between 2006-2007 and 2016-2017 and linear regression models to obtain the p values for the overall trends across six time periods. RESULTS Approximately 1.5 million acute ischemic stroke hospitalizations occurred during 2006-2017. The prevalence of having all four risk factors increased from 4.1% in 2006-2007 to 9.1% in 2016-2017 (relative percent change 122.0%, p < 0.001 for trend), prevalence of any three risk factors increased from 24.5% to 33.8% (relative percent change 38.0%, p < 0.001). Prevalence of only two risk factors decreased from 36.1% to 32.7% (p < 0.001), only one risk factor decreased from 25.2% to 18.1% (p < 0.001), and absence of risk factors decreased from 10.1% to 6.2% (p < 0.001). The most prevalent triad of risk factors was hypertension, diabetes, and lipid disorders (14.3% in 2006-2007 and 19.8% in 2016-2017), and the most common dyad risk factors was hypertension and lipid disorders (12.6% in 2006-2007 and 11.9% in 2016-2017). CONCLUSIONS The prevalence of hospitalized acute ischemic stroke patients aged 35-64 years with all four or any three of four major stroke risk factors increased by 122% and 38%, while those with only one risk factor or no risk factor has declined by 28% and 39%, respectively, from 2006 to 2017. Younger adults are increasingly at higher risk for stroke from preventable and treatable risk factors. This growing public health problem will require clinicians, healthcare systems, and public health efforts to implement more effective prevention strategies among this population.
Collapse
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, GA, USA
| | - 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, GA, USA
| | - 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, GA, USA
| | - 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, GA, USA
| | - 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, GA, USA
| |
Collapse
|
28
|
Admission serum cholinesterase concentration for prediction of in-hospital mortality in very elderly patients with acute ischemic stroke: a retrospective study. Aging Clin Exp Res 2020; 32:2667-2675. [PMID: 32067216 DOI: 10.1007/s40520-020-01498-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 01/28/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Cholinesterase as a sensitive biomarker for prognosis in a variety of conditions but it is rare in stroke studies. The very elderly (≥ 80 years of age) represent the most susceptible group of ischemic stroke. We aimed to determine whether admission serum cholinesterase concentration had any effect on clinical outcome in very elderly patients (individuals aged ≥ 80 years) with acute ischemic stroke. METHODS A retrospective record review was conducted in two tertiary university hospitals. Elderly patients aged ≥ 80 years admitted with a diagnosis of acute ischemic stroke from January 1, 2014 to November 30, 2019, who had a cholinesterase concentration drawn, were included. The patients were grouped based on the inflection points of the locally weighted regression and smoothing scatterplot (LOESS) curve between cholinesterase levels and in-hospital mortality (study outcome) with lower concentration as reference group. RESULTS A total of 612 patients were admitted with a diagnosis of acute ischemic stroke, and 569 met the inclusion criteria. A threshold effect was identified using regression smoothing scatterplot (LOESS), with one cutoff point of 4.0 KU/L. There was a significant difference in-hospital mortality was observed (P < 0.001). After adjusted demographic and clinical features, the OR of cholinesterase for mortality was 0.43 (95% CI 0.34-0.54, P < 0.001), suggesting that lower admission cholinesterase level was an independent risk factors for all-cause mortality among patients with AIS. CONCLUSIONS We have demonstrated a significant association between admission cholinesterase concentration and in-hospital mortality in very elderly patients with AIS.
Collapse
|
29
|
Ryan OF, Riley M, Cadilhac DA, Andrew NE, Breen S, Paice K, Shehata S, Sundararajan V, Lannin NA, Kim J, Kilkenny MF. Factors Associated with Stroke Coding Quality: A Comparison of Registry and Administrative Data. J Stroke Cerebrovasc Dis 2020; 30:105469. [PMID: 33253990 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105469] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/14/2020] [Accepted: 11/08/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM) codes are commonly used to identify patients with diseases or clinical conditions for epidemiological research. We aimed to determine the diagnostic agreement and factors associated with a clinician-assigned stroke diagnosis in a national registry and the ICD-10-AM codes recorded in government-held administrative data. MATERIALS AND METHODS Data from 39 hospitals (2009-2013) participating in the Australian Stroke Clinical Registry (AuSCR) were linked and merged with person-level administrative data. The AuSCR clinician-assigned stroke diagnosis was the reference standard. Concordance was defined as agreement between the clinician-assigned diagnosis and the ICD-10-AM codes for acute stroke or transient ischemic attack (TIA) (ICD-10-AM codes: I61-I64, G45.9). Multivariable logistic regression was undertaken to assess factors associated with coded diagnostic concordance. RESULTS A total of 14,716 patient admissions were included (46% female, 63% ischemic, 14% intracerebral hemorrhage [ICH], 18% TIA and 5% unspecified stroke based on the reference standard). Principal ICD-10-AM code concordance was ICH: 76.7%; ischemic stroke: 72.2%; TIA: 80.2%; unspecified stroke: 50.8%. Factors associated with a greater odds of ischemic stroke concordance included: treatment in a stroke unit (adjusted Odds Ratio, aOR:1.58; 95% confidence interval (CI) 1.37, 1.82); length of stay >4 days (aOR:1.30; 95% CI 1.17, 1.45); and discharge destination other than home (Residential care aOR:1.57; 95% CI 1.24, 1.96; Inpatient rehabilitation aOR:1.63; 95% CI 1.43, 1.86). CONCLUSIONS Diagnostic concordance varied based on stroke type. Future research to improve the quality of coding for stroke should focus on patients not treated in stroke units or with shorter lengths of stay where documentation in medical records may be limited.
Collapse
Affiliation(s)
- Olivia F Ryan
- Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia.
| | - Merilyn Riley
- Department of Public Health, School of Psychology and Public Health, College of Science, Health and Engineering, La Trobe University, Bundoora, VIC, Australia.
| | - Dominique A Cadilhac
- Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia; Translational Public Health & Evaluation Division, Stroke & Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia.
| | - Nadine E Andrew
- Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia; Peninsula Clinical School, Central Clinical School, Monash University, VIC, Australia.
| | - Sibilah Breen
- Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia.
| | - Kate Paice
- Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia.
| | - Sam Shehata
- Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia.
| | - Vijaya Sundararajan
- Department of Public Health, School of Psychology and Public Health, College of Science, Health and Engineering, La Trobe University, Bundoora, VIC, Australia.
| | - Natasha A Lannin
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Alfred Health, Melbourne, VIC, Australia.
| | - Joosup Kim
- Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia; Translational Public Health & Evaluation Division, Stroke & Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia.
| | - Monique F Kilkenny
- Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia; Translational Public Health & Evaluation Division, Stroke & Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia.
| |
Collapse
|
30
|
Zachrison KS, Li S, Reeves MJ, Adeoye O, Camargo CA, Schwamm LH, Hsia RY. Strategy for reliable identification of ischaemic stroke, thrombolytics and thrombectomy in large administrative databases. Stroke Vasc Neurol 2020; 6:194-200. [PMID: 33177162 PMCID: PMC8258073 DOI: 10.1136/svn-2020-000533] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/28/2020] [Accepted: 10/02/2020] [Indexed: 12/14/2022] Open
Abstract
Background Administrative data are frequently used in stroke research. Ensuring accurate identification of patients who had an ischaemic stroke, and those receiving thrombolysis and endovascular thrombectomy (EVT) is critical to ensure representativeness and generalisability. We examined differences in patient samples based on mode of identification, and propose a strategy for future patient and procedure identification in large administrative databases. Methods We used non-public administrative data from the state of California to identify all patients who had an ischaemic stroke discharged from an emergency department (ED) or inpatient hospitalisation from 2010 to 2017 based on International Classification of Disease (ICD-9) (2010–2015), ICD-10 (2015–2017) and Medicare Severity-Diagnosis-related Group (MS-DRG) discharge codes. We identified patients with interhospital transfers, patients receiving thrombolytics and patients treated with EVT based on ICD, Current Procedural Terminology (CPT) and MS-DRG codes. We determined what proportion of these transfers and procedures would have been identified with ICD versus MS-DRG discharge codes. Results Of 365 099 ischaemic stroke encounters, most (87.70%) had both a stroke-related ICD-9 or ICD-10 code and stroke-related MS-DRG code; 12.28% had only an ICD-9 or ICD-10 code and 0.02% had only an MS-DRG code. Nearly all transfers (99.99%) were identified using ICD codes. We identified 32 433 thrombolytic-treated patients (8.9% of total) using ICD, CPT and MS-DRG codes; the combination of ICD and CPT codes identified nearly all (98%). We identified 7691 patients treated with EVT (2.1% of total) using ICD and MS-DRG codes; both MS-DRG and ICD-9/ICD-10 codes were necessary because ICD codes alone missed 13.2% of EVTs. CPT codes only pertain to outpatient/ED patients and are not useful for EVT identification. Conclusions ICD-9/ICD-10 diagnosis codes capture nearly all ischaemic stroke encounters and transfers, while the combination of ICD-9/ICD-10 and CPT codes are adequate for identifying thrombolytic treatment in administrative datasets. However, MS-DRG codes are necessary in addition to ICD codes for identifying EVT, likely due to favourable reimbursement for EVT-related MS-DRG codes incentivising accurate coding.
Collapse
Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA .,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Sijia Li
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA
| | | | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lee H Schwamm
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
31
|
de Havenon A, Yaghi S, Mistry EA, Delic A, Hohmann S, Shippey E, Stulberg E, Tirschwell D, Frontera JA, Petersen NH, Anadani M. Endovascular thrombectomy in acute ischemic stroke patients with COVID-19: prevalence, demographics, and outcomes. J Neurointerv Surg 2020; 12:1045-1048. [PMID: 32989032 PMCID: PMC7523171 DOI: 10.1136/neurintsurg-2020-016777] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND We aimed to compare the outcome of acute ischemic stroke (AIS) patients who received endovascular thrombectomy (EVT) with confirmed COVID-19 to those without. METHODS We performed a retrospective analysis using the Vizient Clinical Data Base and included hospital discharges from April 1 to July 31 2020 with ICD-10 codes for AIS and EVT. The primary outcome was in-hospital death and the secondary outcome was favorable discharge, defined as discharge home or to acute rehabilitation. We compared patients with laboratory-confirmed COVID-19 to those without. As a sensitivity analysis, we compared COVID-19 AIS patients who did not undergo EVT to those who did, to balance potential adverse events inherent to COVID-19 infection. RESULTS We identified 3165 AIS patients who received EVT during April to July 2020, in which COVID-19 was confirmed in 104 (3.3%). Comorbid COVID-19 infection was associated with younger age, male sex, diabetes, black race, Hispanic ethnicity, intubation, acute coronary syndrome, acute renal failure, and longer hospital and intensive care unit length of stay. The rate of in-hospital death was 12.4% without COVID-19 vs 29.8% with COVID-19 (P<0.001). In mixed-effects logistic regression that accounted for patient clustering by hospital, comorbid COVID-19 increased the odds of in-hospital death over four-fold (OR 4.48, 95% CI 3.02 to 6.165). Comorbid COVID-19 was also associated with lower odds of a favorable discharge (OR 0.43, 95% CI 0.30 to 0.61). In the sensitivity analysis, comparing AIS patients with COVID-19 who did not undergo EVT (n=2139) to the AIS EVT patients with COVID-19, there was no difference in the rate of in-hospital death (30.6% vs 29.8%, P=0.868), and AIS EVT patients had a higher rate of favorable discharge (32.4% vs 47.1%, P=0.002). CONCLUSION In AIS patients treated with EVT, comorbid COVID-19 infection was associated with in-hospital death and a lower odds of favorable discharge compared with patients without COVID-19, but not compared with AIS patients with COVID-19 who did not undergo EVT. AIS EVT patients with COVID-19 were younger, more likely to be male, have systemic complications, and almost twice as likely to be black and over three times as likely to be Hispanic.
Collapse
Affiliation(s)
- Adam de Havenon
- Department of Neurology, University of Utah Health, Salt Lake City, Utah, USA
| | - Shadi Yaghi
- Neurology, NYU School of Medicine, Brooklyn, New York, USA
| | - Eva A Mistry
- Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alen Delic
- Department of Neurology, University of Utah Health, Salt Lake City, Utah, USA
| | | | | | - Eric Stulberg
- Department of Neurology, University of Utah Health, Salt Lake City, Utah, USA
| | | | | | | | - Mohammad Anadani
- Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| |
Collapse
|
32
|
Mekonnen B, Wang G, Rajbhandari-Thapa J, Shi L, Thapa K, Zhang Z, Zhang D. Weekend Effect on in-Hospital Mortality for Ischemic and Hemorrhagic Stroke in US Rural and Urban Hospitals. J Stroke Cerebrovasc Dis 2020; 29:105106. [PMID: 32912515 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105106] [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: 02/28/2020] [Revised: 06/23/2020] [Accepted: 06/26/2020] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Previous studies have reported a "weekend effect" on stroke mortality, whereby stroke patients admitted during weekends have a higher risk of in-hospital death than those admitted during weekdays. AIMS We aimed to investigate whether patients with different types of stroke admitted during weekends have a higher risk of in-hospital mortality in rural and urban hospitals in the US. METHODS We used data from the 2016 National Inpatient Sample and used logistic regression to assess in-hospital mortality for weekday and weekend admissions among stroke patients aged 18 and older by stroke type (ischemic or hemorrhagic) and rural or urban status. RESULTS Crude stroke mortality was higher in weekend admissions (p <0.001). After adjusting for confounding variables, in-hospital mortality among hemorrhagic stroke patients was significantly greater (22.0%) for weekend admissions compared to weekday admissions (20.2%, p = 0.009). Among rural hospitals, the in-hospital mortality among hemorrhagic stroke patients was also greater among weekend admissions (36.9%) compared to weekday admissions (25.7%, p = 0.040). Among urban hospitals, the mortality of hemorrhagic stroke patients was 21.1% for weekend and 19.6% for weekday admissions (p = 0.026). No weekend effect was found among ischemic stroke patients admitted to rural or urban hospitals. CONCLUSIONS Our results help to understand mortality differences in hemorrhagic stroke for weekend vs. weekday admissions in urban and rural hospitals. Factors such as density of care providers, stroke centers, and patient level risky behaviors associated with the weekend effect on hemorrhagic stroke mortality need further investigation to improve stroke care services and reduce weekend effect on hemorrhagic stroke mortality.
Collapse
Affiliation(s)
- Birook Mekonnen
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, United States.
| | - Guijing Wang
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA 30341, United States.
| | - Janani Rajbhandari-Thapa
- Department of Health Policy and Management, College of Public Health, University of Georgia, 100 Foster Road, 205D Wright Hall, Athens, GA 30602, United States.
| | - Lu Shi
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States.
| | - Kiran Thapa
- Department of Health Policy and Management, College of Public Health, University of Georgia, 100 Foster Road, 205D Wright Hall, Athens, GA 30602, United States.
| | - Zheng Zhang
- Department of Neurology, Wenzhou Medical University, Zhejiang, China.
| | - Donglan Zhang
- Department of Health Policy and Management, College of Public Health, University of Georgia, 100 Foster Road, 205D Wright Hall, Athens, GA 30602, United States.
| |
Collapse
|
33
|
Otite FO, Patel S, Sharma R, Khandwala P, Desai D, Latorre JG, Akano EO, Anikpezie N, Izzy S, Malik AM, Yavagal D, Khandelwal P, Chaturvedi S. Trends in incidence and epidemiologic characteristics of cerebral venous thrombosis in the United States. Neurology 2020; 95:e2200-e2213. [PMID: 32847952 DOI: 10.1212/wnl.0000000000010598] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 05/12/2020] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE To test the hypothesis that race-, age-, and sex-specific incidence of cerebral venous thrombosis (CVT) has increased in the United States over the last decade. METHODS In this retrospective cohort study, validated ICD codes were used to identify all new cases of CVT (n = 5,567) in the State Inpatients Databases (SIDs) of New York and Florida (2006-2016). A new CVT case was defined as first hospitalization for CVT in the SID without prior CVT hospitalization. CVT counts were combined with annual Census data to compute incidence. Joinpoint regression was used to evaluate trends in incidence over time. RESULTS From 2006 to 2016, annual age- and sex-standardized incidence of CVT in cases per 1 million population ranged from 13.9 to 20.2, but incidence varied significantly by sex (women 20.3-26.9, men 6.8-16.8) and by age/sex (women 18-44 years of age 24.0-32.6, men 18-44 years of age 5.3-12.8). Incidence also differed by race (Blacks: 18.6-27.2; Whites: 14.3-18.5; Asians: 5.1-13.8). On joinpoint regression, incidence increased across 2006 to 2016, but most of this increase was driven by an increase in all age groups of men (combined annualized percentage change [APC] 9.2%, p < 0.001), women 45 to 64 years of age (APC 7.8%, p < 0.001), and women ≥65 years of age (APC 7.4%, p < 0.001). Incidence in women 18 to 44 years of age remained unchanged over time. CONCLUSION CVT incidence is disproportionately higher in Blacks compared to other races. New CVT hospitalizations increased significantly over the last decade mainly in men and older women. Further studies are needed to determine whether this increase represents a true increase from changing risk factors or an artifactual increase from improved detection.
Collapse
Affiliation(s)
- Fadar Oliver Otite
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore.
| | - Smit Patel
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Richa Sharma
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Pushti Khandwala
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Devashish Desai
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Julius Gene Latorre
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Emmanuel Oladele Akano
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Nnabuchi Anikpezie
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Saef Izzy
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Amer M Malik
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Dileep Yavagal
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Priyank Khandelwal
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Seemant Chaturvedi
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| |
Collapse
|
34
|
Hammond G, Luke AA, Elson L, Towfighi A, Joynt Maddox KE. Urban-Rural Inequities in Acute Stroke Care and In-Hospital Mortality. Stroke 2020; 51:2131-2138. [PMID: 32833593 DOI: 10.1161/strokeaha.120.029318] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The rural-urban life-expectancy gap is widening, but underlying causes are incompletely understood. Prior studies suggest stroke care may be worse for individuals in more rural areas, and technological advancements in stroke care may disproportionately impact individuals in more rural areas. We sought to examine differences and 5-year trends in the care and outcomes of patients hospitalized for stroke across rural-urban strata. METHODS Retrospective cohort study using National Inpatient Sample data from 2012 to 2017. Rurality was classified by county of residence according to the 6-strata National Center for Health Statistics classification scheme. RESULTS There were 792 054 hospitalizations for acute stroke in our sample. Rural patients were more often white (78% versus 49%), older than 75 (44% versus 40%), and in the lowest quartile of income (59% versus 32%) compared with urban patients. Among patients with acute ischemic stroke, intravenous thrombolysis and endovascular therapy use were lower for rural compared with urban patients (intravenous thrombolysis: 4.2% versus 9.2%, adjusted odds ratio, 0.55 [95% CI, 0.51-0.59], P<0.001; endovascular therapy: 1.63% versus 2.41%, adjusted odds ratio, 0.64 [0.57-0.73], P<0.001). Urban-rural gaps in both therapies persisted from 2012 to 2017. Overall, stroke mortality was higher in rural than urban areas (6.87% versus 5.82%, P<0.001). Adjusted in-patient mortality rates increased across categories of increasing rurality (suburban, 0.97 [0.94-1.0], P=0.086; large towns, 1.05 [1.01-1.09], P=0.009; small towns, 1.10 [1.06-1.15], P<0.001; micropolitan rural, 1.16 [1.11-1.21], P<0.001; and remote rural 1.21 [1.15-1.27], P<0.001 compared with urban patients. Mortality for rural patients compared with urban patients did not improve from 2012 (adjusted odds ratio, 1.12 [1.00-1.26], P<0.001) to 2017 (adjusted odds ratio, 1.27 [1.13-1.42], P<0.001). CONCLUSIONS Rural patients with stroke were less likely to receive intravenous thrombolysis or endovascular therapy and had higher in-hospital mortality than their urban counterparts. These gaps did not improve over time. Enhancing access to evidence-based stroke care may be a target for reducing rural-urban disparities.
Collapse
Affiliation(s)
| | - Alina A Luke
- Washington University School of Medicine, St Louis, MO (A.A.L., L.E.)
| | - Lauren Elson
- Washington University School of Medicine, St Louis, MO (A.A.L., L.E.)
| | - Amytis Towfighi
- Department of Neurology, University of Southern California Keck School of Medicine (A.T.)
| | - Karen E Joynt Maddox
- Division of Cardiology (G.H., K.E.J.M.).,Institute for Public Health at Washington University, St Louis, MO (K.E.J.M.)
| |
Collapse
|