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Gallacher PJ, Yeung D, Bell S, Shah ASV, Mills NL, Dhaun N. Kidney replacement therapy: trends in incidence, treatment, and outcomes of myocardial infarction and stroke in a nationwide Scottish study. Eur Heart J 2024; 45:1339-1351. [PMID: 38426727 PMCID: PMC11015953 DOI: 10.1093/eurheartj/ehae080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 12/21/2023] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND AND AIMS Patients with kidney failure have a higher risk of cardiovascular disease compared with the general population. Whilst temporal trends of myocardial infarction and stroke are declining in the general population, these have not been evaluated in patients with kidney failure. This study aimed to describe national trends in the incidence, treatment, and outcomes of myocardial infarction and stroke in patients with kidney failure (i.e. on dialysis or with a kidney transplant) over a 20-year period, stratified by age and sex. METHODS In this retrospective national data linkage study, all patients with kidney failure in Scotland (UK) receiving kidney replacement therapy between January 1996 and December 2016 were linked to national hospitalization, prescribing, and death records. The primary outcomes were the incidence of myocardial infarction and stroke, and subsequent cardiovascular death. Generalized additive models were constructed to estimate age-standardized, sex-stratified incidence rates and trends in cardiovascular and all-cause death. RESULTS Amongst 16 050 patients with kidney failure [52 (SD 15) years; 41.5% women], there were 1992 [66 (SD 12) years; 34.8% women] and 996 [65 (SD 13) years; 45.1% women] incident myocardial infarctions and strokes, respectively, between January 1996 and December 2016. During this period, the age-standardized incidence of myocardial infarction per 100 000 decreased in men {from 4376 [95% confidence interval (CI) 3998-4785] to 1835 (95% CI 1692-1988)} and women [from 3268 (95% CI 2982-3593) to 1369 (95% CI 1257-1491)]. Similarly, the age-standardized incidence of stroke per 100 000 also decreased in men [from 1978 (95% CI 1795-2175) to 799 (95% CI 729-875)] and women [from 2234 (95% CI 2031-2468) to 903 (95% CI 824-990)]. Compared with the general population, the incidence of myocardial infarction was four- to eight-fold higher in patients with kidney failure, whilst for stroke it was two- to four-fold higher. The use of evidence-based cardioprotective treatment increased over the study period, and the predicted probability of cardiovascular death within 1 year of myocardial infarction for a 66-year-old patient with kidney failure (mean age of the cohort) fell in men (76.6% to 38.6%) and women (76.8% to 38.8%), and also decreased in both sexes following stroke (men, from 63.5% to 41.4%; women, from 67.6% to 45.8%). CONCLUSIONS The incidence of myocardial infarction and stroke has halved in patients with kidney failure over the past 20 years but remains significantly higher than in the general population. Despite improvements in treatment and outcomes, the prognosis of these patients following myocardial infarction and stroke remains poor.
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Affiliation(s)
- Peter J Gallacher
- BHF/University Centre for Cardiovascular Science, Little France Crescent, University of Edinburgh, Edinburgh EH16 4SA, UK
| | - David Yeung
- BHF/University Centre for Cardiovascular Science, Little France Crescent, University of Edinburgh, Edinburgh EH16 4SA, UK
| | - Samira Bell
- Division of Population Health and Genomics, University of Dundee, Dundee, UK
- Scottish Renal Registry, Scottish Health Audits, Public Health Scotland, Glasgow, UK
| | - Anoop S V Shah
- Department of Non-Communicable Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Nicholas L Mills
- BHF/University Centre for Cardiovascular Science, Little France Crescent, University of Edinburgh, Edinburgh EH16 4SA, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Neeraj Dhaun
- BHF/University Centre for Cardiovascular Science, Little France Crescent, University of Edinburgh, Edinburgh EH16 4SA, UK
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
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Reddy KM, Lee P, Gor PJ, Cheesman A, Al-Hammadi N, Westrich DJ, Taylor J. Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality, complications, or outcomes. World J Gastrointest Pharmacol Ther 2022; 13:77-87. [PMID: 36157266 PMCID: PMC9453443 DOI: 10.4292/wjgpt.v13.i5.77] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 01/22/2022] [Accepted: 08/18/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Percutaneous Endoscopic Gastrostomy (PEG) tubes are often placed for dysphagia following a stroke in order to maintain sufficient caloric intake. The 2011 ASGE guidelines recommend delaying PEG tube placement for two weeks, as half of patients with dysphagia improve within 2 wk. There are few studies comparing outcomes based on timing of PEG tube placement, and there is increasing demand for early PEG tube placement to meet requirements for timely discharge to rehab and skilled nursing facilities.
AIM To assess the safety of early (≤ 7 d post stroke) vs late (> 7 d post stroke) PEG tube placement and evaluate whether pre-procedural risk factors could predict mortality or complications.
METHODS We performed a retrospective study of patients undergoing PEG tube placement for dysphagia following a stroke at two hospitals in Saint Louis, MO between January 2011 and December 2017. Patients were identified by keyword search of endoscopy reports. Mortality, peri-procedural complication rates, and post-procedural complication rates were compared in both groups. Predictors of morbidity and mortality such as protein-calorie malnutrition, presence of an independent cardiovascular risk equivalent, and presence of Systemic inflammatory response syndrome (SIRS) criteria or documented infection were evaluated by multivariate logistic regression.
RESULTS 154 patients had a PEG tube placed for dysphagia following a stroke, 92 in the late group and 62 in the early group. There were 32 observed deaths, with 8 occurring within 30 d of the procedure. There was an increase in peri-procedural and post-procedural complications with delayed PEG placement which was not statistically significant. Hospital length of stay was significantly less in patients with early PEG tube placement (12.9 vs 22.34 d, P < 0.001). Protein calorie malnutrition, presence of SIRS criteria and/or documented infection prior to procedure or having a cardiovascular disease risk equivalent did not significantly predict mortality or complications.
CONCLUSION Early PEG tube placement following a stroke did not result in a higher rate of mortality or complications and significantly decreased hospital length of stay. Given similar safety outcomes in both groups, early PEG tube placement should be considered in the appropriate patient to potentially reduce length of hospital stay and incurred costs.
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Affiliation(s)
- Kavya M Reddy
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA 90095, United States
| | - Preston Lee
- Department of Internal Medicine, Santa Clara Valley Medical Center, San Jose, CA 95128, United States
| | - Parul J Gor
- Division of Gastroenterology and Hepatology, Mercy Hospital, Saint Louis, MO 63141, United States
| | - Antonio Cheesman
- Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, Saint Louis, MO 63104, United States
| | - Noor Al-Hammadi
- Saint Louis University Center for Health Outcomes Research, Saint Louis University, Saint Louis, MO 63104, United States
| | - David John Westrich
- Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, Saint Louis, MO 63104, United States
| | - Jason Taylor
- Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, Saint Louis, MO 63104, United States
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Portegijs S, Ong AY, Halbesma N, Hutchison A, Sudlow CLM, Jackson CA. Long-term mortality and recurrent vascular events in lacunar versus non-lacunar ischaemic stroke: A cohort study. Eur Stroke J 2021; 7:57-65. [PMID: 35287300 PMCID: PMC8915237 DOI: 10.1177/23969873211062019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 11/04/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Studies of differences in very long-term outcomes between people with lacunar/small vessel disease (SVD) versus other types of ischaemic stroke report mixed findings, with limited data on myocardial infarction (MI). We investigated whether long-term mortality, recurrent stroke and MI risks differ in people with versus without lacunar/SVD ischaemic stroke. Patients and methods We included first-ever strokes from a hospital-based stroke cohort study recruited in 2002–2005. We compared risks of death, recurrent stroke and MI during follow-up among lacunar/SVD versus other ischaemic stroke subtypes using Cox regression, adjusting for confounding factors. Results We included 812 participants, 283 with lacunar/SVD ischaemic stroke and 529 with other stroke. During a median of 9.2 years (interquartile range 3.1–11.8), there were 519 deaths, 181 recurrent strokes and 79 MIs. Lacunar/SVD stroke was associated with lower mortality (adjusted HR 0.79, 95% CI 0.65 to 0.95), largely due to markedly lower all-cause mortality in the first year. From one year onwards this difference attenuated, with all-cause mortality only slightly and not statistically significantly lower in the lacunar/SVD group (0.86, 95% CI 0.70 to 1.05). There was no clear difference in risk of recurrent stroke (HR 0.84, 95% CI 0.61–1.15) or MI (HR 0.83, 95% CI 0.52–1.34). Conclusion Long-term risks of all-cause mortality, recurrent stroke and MI are similar, or only slightly lower, in patients with lacunar/SVD as compared to other ischaemic stroke. Patients and physicians should be as vigilant in optimising short- and long-term secondary prevention of vascular events in lacunar/SVD as for other stroke types.
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Affiliation(s)
- Suzanne Portegijs
- Usher Institute, University of Edinburgh, Edinburgh, Scotland
- Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | | - Nynke Halbesma
- Usher Institute, University of Edinburgh, Edinburgh, Scotland
| | - Aidan Hutchison
- Usher Institute, University of Edinburgh, Edinburgh, Scotland
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, Scotland
| | - Cathie LM Sudlow
- Usher Institute, University of Edinburgh, Edinburgh, Scotland
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, Scotland
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Shah AS, Lee KK, Pérez JAR, Campbell D, Astengo F, Logue J, Gallacher PJ, Katikireddi SV, Bing R, Alam SR, Anand A, Sudlow C, Fischbacher CM, Lewsey J, Perel P, Newby DE, Mills NL, McAllister DA. Clinical burden, risk factor impact and outcomes following myocardial infarction and stroke: A 25-year individual patient level linkage study. THE LANCET REGIONAL HEALTH. EUROPE 2021; 7:100141. [PMID: 34405203 PMCID: PMC8351196 DOI: 10.1016/j.lanepe.2021.100141] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Understanding trends in the incidence and outcomes of myocardial infarction and stroke, and how these are influenced by changes in cardiovascular risk factors can inform health policy and healthcare provision. METHODS We identified all patients 30 years or older with myocardial infarction or stroke in Scotland. Risk factor levels were determined from national health surveys. Incidence, potential impact fractions and burden attributable to risk factor changes were calculated. Risk of subsequent fatal and non-fatal events (myocardial infarction, stroke, bleeding and heart failure hospitalization) were calculated with multi-state models. FINDINGS From 1990 to 2014, there were 372,873 (71±13 years) myocardial infarctions and 290,927 (74±13 years) ischemic or hemorrhagic strokes. Age-standardized incidence per 100,000 fell from 1,069 (95% confidence interval, 1,024-1,116) to 276 (263-290) for myocardial infarction and from 608 (581-636) to 188 (178-197) for ischemic stroke. Systolic blood pressure, smoking and cholesterol decreased, but body-mass index increased, and diabetes prevalence doubled. Changes in risk factors accounted for a 74% (57-91%) reduction in myocardial infarction and 68% (55-83%) reduction in ischemic stroke. Following myocardial infarction, the risk of death decreased (30% to 20%), but non-fatal events increased (20% to 24%) whereas the risk of both death (47% to 34%) and non-fatal events (22% to 17%) decreased following stroke. INTERPRETATION Over the last 25 years, substantial reductions in myocardial infarction and ischemic stroke incidence are attributable to major shifts in risk factor levels. Deaths following the index event decreased for both myocardial infarction and stroke, but rates remained substantially higher for stroke. FUNDING British heart foundation.
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Affiliation(s)
- Anoop S.V. Shah
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine,London, United Kingdom
- Department of Cardiology, Imperial College NHS Trust, London, United Kingdom
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Desmond Campbell
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Federica Astengo
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Peter James Gallacher
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Rong Bing
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Shirjel R. Alam
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine,London, United Kingdom
| | - Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Catherine Sudlow
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Jim Lewsey
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Pablo Perel
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine,London, United Kingdom
| | - David E. Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Nicholas L. Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - David A. McAllister
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
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Hughes-McCormack LA, McGowan R, Pell JP, Mackay D, Henderson A, O'Leary L, Cooper SA. Birth incidence, deaths and hospitalisations of children and young people with Down syndrome, 1990-2015: birth cohort study. BMJ Open 2020; 10:e033770. [PMID: 32241786 PMCID: PMC7170621 DOI: 10.1136/bmjopen-2019-033770] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 03/03/2020] [Accepted: 03/10/2020] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To investigate current Down syndrome live birth and death rates, and childhood hospitalisations, compared with peers. SETTING General community. PARTICIPANTS All live births with Down syndrome, 1990-2015, identified via Scottish regional cytogenetic laboratories, each age-sex-neighbourhood deprivation matched with five non-Down syndrome controls. Record linkage to Scotland's hospital admissions and death data. PRIMARY OUTCOME HRs comparing risk of first hospitalisation (any and emergency), readmission for children with Down syndrome and matched controls were calculated using stratified Cox proportional hazards (PH) model, and length of hospital stay was calculated using a conditional log-linear regression model. RESULTS 689/1479 (46.6%) female and 769/1479 (51.9%) male children/young people with Down syndrome were identified (1.0/1000 births, with no reduction over time); 1235 were matched. 92/1235 (7.4%) died during the period, 18.5 times more than controls. More of the Down syndrome group had at least one admission (incidence rate ratio(IRR) 72.89 (68.72-77.32) vs 40.51 (39.15-41.92); adjusted HR=1.84 (1.68, 2.01)) and readmissions (IRR 54.85 (51.46-58.46) vs 15.06 (14.36-15.80); adjusted HR=2.56 (2.08, 3.14)). More of their admissions were emergencies (IRR 56.78 (53.13-60.72) vs 28.88 (27.73-30.07); first emergency admission adjusted HR=2.87 (2.61, 3.15)). Children with Down syndrome had 28% longer first admission after birth. Admission rate increased from 1990-2003 to 2004-2014 for the Down syndrome group (from 90.7% to 92.2%) and decreased for controls (from 63.3% to 44.8%). CONCLUSIONS We provide contemporaneous statistics on the live birth rate of babies with Down syndrome, and their childhood death rate. They require more hospital admissions, readmissions emergency admissions and longer lengths of stays than their peers, which has received scant research attention in the past. This demonstrates the importance of statutory planning as well as informal support to families to avoid added problems in child development and family bonding over and above that brought by the intellectual disabilities associated with Down syndrome.
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Affiliation(s)
- Laura Anne Hughes-McCormack
- Mental Health and Wellbeing research group, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Ruth McGowan
- West of Scotland Regional Genetics Service, Queen Elizabeth University Hospital, Glasgow, UK
| | - J P Pell
- Public Health, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Daniel Mackay
- Public Health, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Angela Henderson
- Mental Health and Wellbeing research group, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Lisa O'Leary
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, Edinburgh, UK
| | - Sally-Ann Cooper
- Mental Health and Wellbeing research group, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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Long-term survival and five year hospital resource usage following traumatic brain injury in Scotland from 1997 to 2015: A population-based retrospective cohort study. Injury 2019; 50:82-89. [PMID: 30266290 DOI: 10.1016/j.injury.2018.09.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 08/27/2018] [Accepted: 09/13/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND It is unclear if traumatic brain injury (TBI) results in excess mortality compared with head injury without injury to neural structures (HI). Because TBI populations exhibit significant demographic differences from uninjured populations, to determine the effect of TBI on survival, it is essential that a similarly injured control population be used. We aimed to determine if survival and hospital resource usage differ following TBI compared with HI. METHODS This retrospective population-based cohort study included all 25 319 patients admitted to a Scottish NHS hospital from 1997 to 2015 with TBI. Participants were identified using previously validated ICD-10 based definitions. For comparison, a control group of all 194 049 HI cases was also identified. Our main outcome measures were hazards of all-cause mortality for patients with TBI, compared with those with HI, over the 18-year follow-up period; and odds of mortality at one month post-injury. Number of days spent as inpatients and number of outpatient attendances per surviving month post-injury were used as measures of resource utilisation. RESULTS The adjusted odds ratio for mortality in the first month post-injury for TBI, compared with HI, was 7.12 (95% confidence interval [CI] 6.73-7.52; p < 0.001). For the remaining 18-year study period, the hazards of morality after TBI were 0.93 (CI 0.90-0.96; p < 0.001). During the five-year post-injury period, brain injury was associated with 2.15 (CI 2.10-2.20; p < 0.001) more days spent as inpatient and 1.09 times more outpatient attendances (CI 1.07-1.11; p < 0.001) compared with HI. CONCLUSIONS Although initial mortality following TBI is high, survivors of the first month post-injury can achieve comparable long-term survival to HI. However, this is associated with, and may require, increased utilisation of hospital services in the TBI group.
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Dave A, Cagniart K, Holtkamp MD. A Case for Telestroke in Military Medicine: A Retrospective Analysis of Stroke Cost and Outcomes in U.S. Military Health-Care System. J Stroke Cerebrovasc Dis 2018; 27:2277-2284. [PMID: 29887364 DOI: 10.1016/j.jstrokecerebrovasdis.2018.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 02/11/2018] [Accepted: 04/12/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The development of primary stroke centers has improved outcomes for stroke patients. Telestroke networks have expanded the reach of stroke experts to underserved, geographically remote areas. This study illustrates the outcome and cost differences between neurology and primary care ischemic stroke admissions to demonstrate a need for telestroke networks within the Military Health System (MHS). MATERIALS AND METHODS All adult admissions with a primary diagnosis of ischemic stroke in the MHS Military Mart database from calendar years 2010 to 2015 were reviewed. Neurology, primary care, and intensive care unit (ICU) admissions were compared across primary outcomes of (1) disposition status and (2) intravenous tissue plasminogen activator administration and for secondary outcomes of (1) total cost of hospitalization and (2) length of stay (LOS). RESULTS A total of 3623 admissions met the study's parameters. The composition was neurology 462 (12.8%), primary care 2324 (64.1%), ICU 677 (18.7%), and other/unknown 160 (4.4%). Almost all neurology admissions (97%) were at the 3 neurology training programs, whereas a strong majority of primary care admissions (80%) were at hospitals without a neurology admitting service. Hospitals without a neurology admitting service had more discharges to rehabilitation facilities and higher rates of in-hospital mortality. LOS was also longer in primary care admissions. CONCLUSIONS Ischemic stroke admissions to neurology had better outcomes and decreased LOS when compared to primary care within the MHS. This demonstrates a possible gap in care. Implementation of a hub and spoke telestroke model is a potential solution.
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Affiliation(s)
- Ajal Dave
- Department of Neurology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Kendra Cagniart
- Department of Neurology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Matthew D Holtkamp
- Department of Medicine, Carl R. Darnall Army Medical Center, Fort Hood, Texas.
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Findlay MD, Dawson J, MacIsaac R, Jardine AG, MacLeod MJ, Metcalfe W, Traynor JP, Mark PB. Inequality in Care and Differences in Outcome Following Stroke in People With ESRD. Kidney Int Rep 2018; 3:1064-1076. [PMID: 30197973 PMCID: PMC6127409 DOI: 10.1016/j.ekir.2018.04.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 04/18/2018] [Accepted: 04/23/2018] [Indexed: 11/27/2022] Open
Abstract
Introduction Stroke rate and mortality are greater in individuals with end-stage renal disease (ESRD) than in those without ESRD. We examined discrepancies in stroke care in ESRD patients and their influence on mortality. Methods This is a national record linkage cohort study of hospitalized stroke individuals from 2005 to 2013. Presentation, measures of care quality (admission to stroke unit, swallow assessment, antithrombotics, or thrombolysis use), and outcomes were compared in those with and without ESRD after propensity score matching (PSM). We examined the effect of being admitted to a stroke unit on survival using Kaplan-Meier and Cox survival analyses. Results A total of 8757 individuals with ESRD and 61,367 individuals with stroke were identified. ESRD patients (n =486) experienced stroke over 34,551.9 patient-years of follow-up; incidence rates were 25.3 (dialysis) and 4.5 (kidney transplant)/1000 patient-years. After PSM, dialysis patients were less likely to be functionally independent (61.4% vs. 77.7%; P < 0.0001) before stroke, less frequently admitted to stroke units (64.6% vs. 79.6%; P < 0.001), or to receive aspirin (75.3% vs. 83.2%; P = 0.01) than non-ESRD stroke patients. There were no significant differences in management of kidney transplantation patients. Stroke with ESRD was associated with a higher death rate during admission (dialysis 22.9% vs.14.4%, P = 0.002; transplantation: 19.6% vs. 9.3%; P = 0.034). Managing ESRD patients in a stroke unit was associated with a lower risk of death at follow-up (hazard ratio: 0.68; 95% confidence interval: 0.55-0.84). Conclusion Stroke incidence is high in ESRD. Individuals on dialysis are functionally more dependent before stroke and less frequently receive optimal stroke care. After a stroke, death is more likely in ESRD patients. Acute stroke unit care may be associated with lower mortality.
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Affiliation(s)
- Mark D Findlay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Rachael MacIsaac
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Alan G Jardine
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Mary Joan MacLeod
- Institute of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Wendy Metcalfe
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jamie P Traynor
- The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
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Altman MR, Colorafi K, Daratha KB. The Reliability of Electronic Health Record Data Used for Obstetrical Research. Appl Clin Inform 2018. [PMID: 29514352 DOI: 10.1055/s-0038-1627475] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Hospital electronic health record (EHR) data are increasingly being called upon for research purposes, yet only recently has it been tested to examine its reliability. Studies that have examined reliability of EHR data for research purposes have varied widely in methods used and field of inquiry, with little reporting of the reliability of perinatal and obstetric variables in the current literature. OBJECTIVE To assess the reliability of data extracted from a commercially available inpatient EHR as compared with manually abstracted data for common attributes used in obstetrical research. METHODS Data extracted through automated EHR reports for 3,250 women who delivered a live infant at a large hospital in the Pacific Northwest were compared with manual chart abstraction for the following perinatal measures: delivery method, labor induction, labor augmentation, cervical ripening, vertex presentation, and postpartum hemorrhage. RESULTS Almost perfect agreement was observed for all four modes of delivery (vacuum assisted: kappa = 0.92; 95% confidence interval [CI] = 0.88-0.95, forceps assisted: kappa = 0.90; 95%CI = 0.76-1.00, cesarean delivery: kappa = 0.91; 95%CI = 0.90-0.93, and spontaneous vaginal delivery: kappa = 0.91; 95%CI = 0.90-0.93). Cervical ripening demonstrated substantial agreement (kappa = 0.77; 95%CI = 0.73-0.80); labor induction (kappa = 0.65; 95%CI = 0.62-0.68) and augmentation (kappa = 0.54; 95%CI = 0.49-0.58) demonstrated moderate agreement between the two data sources. Vertex presentation (kappa = 0.35; 95%CI = 0.31-0.40) and post-partum hemorrhage (kappa = 0.21; 95%CI = 0.13-0.28) demonstrated fair agreement. CONCLUSION Our study demonstrates variability in the reliability of obstetrical data collected and reported through the EHR. While delivery method was satisfactorily reliable in our sample, other examined perinatal measures were less so when compared with manual chart abstraction. The use of multiple modalities for assessing reliability presents a more consistent and rigorous approach for assessing reliability of data from EHR systems and underscores the importance of requiring validation of automated EHR data for research purposes.
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Read SH, McAllister DA, Colhoun HM, Farran B, Fischbacher C, Kerssens JJ, Leese GP, Lindsay RS, McCrimmon RJ, McGurnaghan S, Philip S, Sattar N, Wild SH. Incident ischaemic stroke and Type 2 diabetes: trends in incidence and case fatality in Scotland 2004-2013. Diabet Med 2018; 35:99-106. [PMID: 29044687 DOI: 10.1111/dme.13528] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2017] [Indexed: 11/27/2022]
Abstract
AIM To describe trends in first ischaemic stroke incidence and case fatality in adults with and without a diagnosis of Type 2 diabetes prior to their ischaemic stroke event in Scotland between 2004 and 2013. METHODS Using population-wide hospital admission, death and diabetes datasets, we conducted a retrospective cohort study. Negative binomial and logistic regression models were used to calculate year-specific incidence and case-fatality rates for people with Type 2 diabetes and for people without diabetes. RESULTS During 41.0 million person-years of follow-up there were 69 757 ischaemic stroke events. Type 2 diabetes prevalence among patients who experienced ischaemic stroke increased from 13.5% to 20.3% between 2004 and 2013. Stroke incidence rates declined by 2.7% (95% CI 2.4, 3.0) annually for people with and without diabetes [diabetes/year interaction: rate ratio 0.99 (95% CI 0.98, 1.01)]. Type 2 diabetes was associated with an increased risk of ischaemic stroke in men [rate ratio 1.23 (95% CI 1.17, 1.30)] and women [rate ratio 1.41 (95% CI 1.35, 1.48)]. Case-fatality rates were 14.2% and 12.7% in people with Type 2 diabetes and without diabetes, respectively. Case fatality declined by 3.5% (95% CI 2.7, 4.5) annually [diabetes/year interaction: odds ratio 1.01 (95% CI 0.98, 1.02)]. CONCLUSIONS Ischaemic stroke incidence declined no faster in people with a diagnosis of Type 2 diabetes than in people without diabetes. Increasing prevalence of Type 2 diabetes among stroke patients may mean that declines in case fatality over time will be less marked in the future.
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Affiliation(s)
- S H Read
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - D A McAllister
- Institutes of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - H M Colhoun
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - B Farran
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - C Fischbacher
- Information Services Division, NHS National Services, Edinburgh, UK
| | - J J Kerssens
- Information Services Division, NHS National Services, Edinburgh, UK
| | - G P Leese
- Department of Diabetes and Endocrinology, University of Dundee, Dundee, UK
| | - R S Lindsay
- Institutes of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - R J McCrimmon
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - S McGurnaghan
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - S Philip
- Department of Diabetes and Endocrinology, NHS Grampian, Aberdeen, UK
| | - N Sattar
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - S H Wild
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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Attenello FJ, Mack WJ. Pitfalls of administrative database analysis are evident when assessing the 'weekend effect' in stroke. ACTA ACUST UNITED AC 2016; 22:35. [PMID: 27815303 DOI: 10.1136/ebmed-2016-110557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Frank J Attenello
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - William J Mack
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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12
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Li L, Rothwell PM. Biases in detection of apparent "weekend effect" on outcome with administrative coding data: population based study of stroke. BMJ 2016; 353:i2648. [PMID: 27185754 PMCID: PMC4868367 DOI: 10.1136/bmj.i2648] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To determine the accuracy of coding of admissions for stroke on weekdays versus weekends and any impact on apparent outcome. DESIGN Prospective population based stroke incidence study and a scoping review of previous studies of weekend effects in stroke. SETTING Primary and secondary care of all individuals registered with nine general practices in Oxfordshire, United Kingdom (OXVASC, the Oxford Vascular Study). PARTICIPANTS All patients with clinically confirmed acute stroke in OXVASC identified with multiple overlapping methods of ascertainment in 2002-14 versus all acute stroke admissions identified by hospital diagnostic and mortality coding alone during the same period. MAIN OUTCOMES MEASURES Accuracy of administrative coding data for all patients with confirmed stroke admitted to hospital in OXVASC. Difference between rates of "false positive" or "false negative" coding for weekday and weekend admissions. Impact of inaccurate coding on apparent case fatality at 30 days in weekday versus weekend admissions. Weekend effects on outcomes in patients with confirmed stroke admitted to hospital in OXVASC and impacts of other potential biases compared with those in the scoping review. RESULTS Among 92 728 study population, 2373 episodes of acute stroke were ascertained in OXVASC, of which 826 (34.8%) mainly minor events were managed without hospital admission, 60 (2.5%) occurred out of the area or abroad, and 195 (8.2%) occurred in hospital during an admission for a different reason. Of 1292 local hospital admissions for acute stroke, 973 (75.3%) were correctly identified by administrative coding. There was no bias in distribution of weekend versus weekday admission of the 319 strokes missed by coding. Of 1693 admissions for stroke identified by coding, 1055 (62.3%) were confirmed to be acute strokes after case adjudication. Among the 638 false positive coded cases, patients were more likely to be admitted on weekdays than at weekends (536 (41.0%) v 102 (26.5%); P<0.001), partly because of weekday elective admissions after previous stroke being miscoded as new stroke episodes (267 (49.8%) v 26 (25.5%); P<0.001). The 30 day case fatality after these elective admissions was lower than after confirmed acute stroke admissions (11 (3.8%) v 233 (22.1%); P<0.001). Consequently, relative 30 day case fatality for weekend versus weekday admissions differed (P<0.001) between correctly coded acute stroke admissions and false positive coding cases. Results were consistent when only the 1327 emergency cases identified by "admission method" from coding were included, with more false positive cases with low case fatality (35 (14.7%)) being included for weekday versus weekend admissions (190 (19.5%) v 48 (13.7%), P<0.02). Among all acute stroke admissions in OXVASC, there was no imbalance in baseline stroke severity for weekends versus weekdays and no difference in case fatality at 30 days (adjusted odds ratio 0.85, 95% confidence interval 0.63 to 1.15; P=0.30) or any adverse "weekend effect" on modified Rankin score at 30 days (0.78, 0.61 to 0.99; P=0.04) or one year (0.76, 0.59 to 0.98; P=0.03) among incident strokes. CONCLUSION Retrospective studies of UK administrative hospital coding data to determine "weekend effects" on outcome in acute medical conditions, such as stroke, can be undermined by inaccurate coding, which can introduce biases that cannot be reliably dealt with by adjustment for case mix.
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Affiliation(s)
- Linxin Li
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, OX3 9DU, UK
| | - Peter M Rothwell
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, OX3 9DU, UK
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