Moderate sensitivity and high specificity of emergency department administrative data for transient ischemic attacks

Admission prioritization of heart failure patients with multiple comorbidities

The primary objective of this study was to enhance the operational efficiency of the current healthcare system by proposing a quicker and more effective approach for healthcare providers to deliver services to individuals facing acute heart failure (HF) and concurrent medical conditions. The aim was to support healthcare staff in providing urgent services more efficiently by developing an automated decision-support Patient Prioritization (PP) Tool that utilizes a tailored machine learning (ML) model to prioritize HF patients with chronic heart conditions and concurrent comorbidities during Urgent Care Unit admission. The study applies key ML models to the PhysioNet dataset, encompassing hospital admissions and mortality records of heart failure patients at Zigong Fourth People's Hospital in Sichuan, China, between 2016 and 2019. In addition, the model outcomes for the PhysioNet dataset are compared with the Healthcare Cost and Utilization Project (HCUP) Maryland (MD) State Inpatient Data (SID) for 2014, a secondary dataset containing heart failure patients, to assess the generalizability of results across diverse healthcare settings and patient demographics. The ML models in this project demonstrate efficiencies surpassing 97.8% and specificities exceeding 95% in identifying HF patients at a higher risk and ranking them based on their mortality risk level. Utilizing this machine learning for the PP approach underscores risk assessment, supporting healthcare professionals in managing HF patients more effectively and allocating resources to those in immediate need, whether in hospital or telehealth settings.

Performance of International Classification of Disease-10 codes in detecting emergency department patients with opioid misuse

BACKGROUND AND AIMS

Accurate case discovery is critical for disease surveillance, resource allocation and research. International Classification of Disease (ICD) diagnosis codes are commonly used for this purpose. We aimed to determine the sensitivity, specificity and positive predictive value (PPV) of ICD-10 codes for opioid misuse case discovery in the emergency department (ED) setting.

DESIGN AND SETTING

Retrospective cohort study of ED encounters from January 2018 to December 2020 at an urban academic hospital in the United States. A sample of ED encounters enriched for opioid misuse was developed by oversampling ED encounters with positive urine opiate screens or pre-existing opioid-related diagnosis codes in addition to other opioid misuse risk factors.

CASES

A total of 1200 randomly selected encounters were annotated by research staff for the presence of opioid misuse within health record documentation using a 5-point scale for likelihood of opioid misuse and dichotomized into cohorts of opioid misuse and no opioid misuse.

MEASUREMENTS

Using manual annotation as ground truth, the sensitivity and specificity of ICD-10 codes entered during the encounter were determined with PPV adjusted for oversampled data. Metrics were also determined by disposition subgroup: discharged home or admitted.

FINDINGS

There were 541 encounters annotated as opioid misuse and 617 with no opioid misuse. The majority were males (54.4%), average age was 47 years and 68.5% were discharged directly from the ED. The sensitivity of ICD-10 codes was 0.56 (95% confidence interval [CI], 0.51-0.60), specificity 0.99 (95% CI, 0.97-0.99) and adjusted PPV 0.78 (95% CI, 0.65-0.92). The sensitivity was higher for patients discharged from the ED (0.65; 95% CI, 0.60-0.69) than those admitted (0.31; 95% CI, 0.24-0.39).

CONCLUSIONS

International Classification of Disease-10 codes appear to have low sensitivity but high specificity and positive predictive value in detecting opioid misuse among emergency department patients in the United States.

Comorbidity patterns in cardiovascular diseases: the role of life-stage and socioeconomic status

Cardiovascular diseases stand as a prominent global cause of mortality, their intricate origins often entwined with comorbidities and multimorbid conditions. Acknowledging the pivotal roles of age, sex, and social determinants of health in shaping the onset and progression of these diseases, our study delves into the nuanced interplay between life-stage, socioeconomic status, and comorbidity patterns within cardiovascular diseases. Leveraging data from a cross-sectional survey encompassing Mexican adults, we unearth a robust association between these variables and the prevalence of comorbidities linked to cardiovascular conditions. To foster a comprehensive understanding of multimorbidity patterns across diverse life-stages, we scrutinize an extensive dataset comprising 47,377 cases diagnosed with cardiovascular ailments at Mexico's national reference hospital. Extracting sociodemographic details, primary diagnoses prompting hospitalization, and additional conditions identified through ICD-10 codes, we unveil subtle yet significant associations and discuss pertinent specific cases. Our results underscore a noteworthy trend: younger patients of lower socioeconomic status exhibit a heightened likelihood of cardiovascular comorbidities compared to their older counterparts with a higher socioeconomic status. By empowering clinicians to discern non-evident comorbidities, our study aims to refine therapeutic designs. These findings offer profound insights into the intricate interplay among life-stage, socioeconomic status, and comorbidity patterns within cardiovascular diseases. Armed with data-supported approaches that account for these factors, clinical practices stand to be enhanced, and public health policies informed, ultimately advancing the prevention and management of cardiovascular disease in Mexico.

Diagnostic accuracy of telestroke consultation: a Louisiana based tele-network experience

Background and purpose

Telestroke has grown significantly since its implementation. Despite growing utilization, there is a paucity of data regarding the diagnostic accuracy of telestroke to distinguish between stroke and its mimics. We aimed to evaluate diagnostic accuracy of telestroke consultations and explore the characteristics of misdiagnosed patients with a focus on stroke mimics.

Methods

We conducted a retrospective study of all the consultations in our Ochsner Health's TeleStroke program seen between April 2015 and April 2016. Consultations were classified into one of three diagnostic categories: stroke/transient ischemic attack, mimic, and uncertain. Initial telestroke diagnosis was compared with the final diagnosis post review of all emergency department and hospital data. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR-) for diagnosis of stroke/TIA versus mimic were calculated. Area under receiver-operating characteristic curve (AUC) analysis to predict true stroke was performed. Bivariate analysis based on the diagnostic categories examined association with sex, age, NIHSS, stroke risk factors, tPA given, bleeding after tPA, symptom onset to last known normal, symptom onset to consult, timing in the day, and consult duration. Logistic regression was performed as indicated by bivariate analysis.

Results

Eight hundred and seventy-four telestroke evaluations were included in our analysis. Accurate diagnosis through teleneurological consultation was seen in 85% of which 532 were strokes (true positives) and 170 were mimics (true negatives). Sensitivity, specificity, PPV, NPV were 97.8, 82.5, 93.7 and 93.4%, respectively. LR+ and LR- were 5.6 and 0.03. AUC (95% CI) was 0.9016 (0.8749-0.9283). Stroke mimics were more common with younger age and female gender and in those with less vascular risk factors. LR revealed OR (95% CI) of misdiagnosis for female gender of 1.9 (1.3-2.9). Lower age and lower NIHSS score were other predictors of misdiagnosis.

Conclusion

We report high diagnostic accuracy of the Ochsner Telestroke Program in discriminating stroke/TIA and stroke mimics, with slight tendency towards over diagnosis of stroke. Female gender, younger age and lower NIHSS score were associated with misdiagnosis.

Telemedicine use and outcomes after transient ischemic attack and minor stroke during the COVID-19 pandemic: a population-based cohort study

BACKGROUND

The COVID-19 pandemic has led to an increase in telemedicine use. We compared care and outcomes in patients with transient ischemic attack (TIA) or minor ischemic stroke before and after the widespread adoption of telemedicine in Ontario, Canada, in 2020.

METHODS

In a population-based cohort study using linked administrative data, we identified patients with TIA or ischemic stroke discharged from any emergency department in Ontario before the widespread use of telemedicine (Apr. 1, 2015, to Mar. 31, 2020) and after (Apr. 1, 2020, to Mar. 31, 2021). We measured care, including visits with a physician, investigations and medication renewal. We compared 90-day death before and after 2020 using Cox proportional hazards models, and we compared 90-day admission using cause-specific hazard models.

RESULTS

We identified 47 601 patients (49.3% female; median age 73, interquartile range 62-82, yr) with TIA (n = 35 695, 75.0%) or ischemic stroke (n = 11 906, 25.0%). After 2020, 83.1% of patients had 1 or more telemedicine visit within 90 days of emergency department discharge, compared with 3.8% before. The overall access to outpatient visits within 90 days remained unchanged (92.9% before v. 94.0% after; risk difference 1.1, 95% confidence interval [CI] -1.3 to 3.5). Investigations and medication renewals were unchanged. Clinical outcomes were also similar before and after 2020; the adjusted hazard ratio was 0.97 (95% CI 0.91 to 1.04) for 90-day all-cause admission, 1.06 (95% CI 0.94 to 1.20) for stroke admission and 1.07 (95% CI 0.93 to 1.24) for death.

INTERPRETATION

Care and short-term outcomes after TIA or minor stroke remained stable after the widespread implementation of telemedicine during the COVID-19 pandemic. Our findings suggest that telemedicine is an effective method of health care delivery that can be complementary to in-person care for minor ischemic cerebrovascular events.

Lost to Follow-Up: A Nationwide Analysis of Patients With Transient Ischemic Attack Discharged From Emergency Departments With Incomplete Imaging

PURPOSE

Imaging guidelines for transient ischemic attack (TIA) recommend that patients undergo urgent brain and neurovascular imaging within 48 hours of symptom onset. Prior research suggests that most patients with TIA discharged from the emergency department (ED) do not complete recommended TIA imaging workup during their ED encounters. The purpose of this study was to determine the nationwide percentage of patients with TIA discharged from EDs with incomplete imaging workup who complete recommended imaging after discharge.

METHODS

Patients discharged from EDs with the diagnosis of TIA were identified from the Medicare 5% sample for 2017 and 2018 using International Classification of Diseases, tenth rev, Clinical Modification codes. Imaging performed was identified using Current Procedural Terminology codes. Incomplete imaging workup was defined as a TIA encounter without cross-sectional brain, brain-vascular, and neck-vascular imaging performed within the subsequent 30 days of the initial ED encounter. Patient- and hospital-level factors associated with incomplete TIA imaging were analyzed in a multivariable logistic regression.

RESULTS

In total, 6,346 consecutive TIA encounters were analyzed; 3,804 patients (59.9%) had complete TIA imaging workup during their ED encounters. Of the 2,542 patients discharged from EDs with incomplete imaging, 761 (29.9%) completed imaging during the subsequent 30 days after ED discharge. Among patients with TIA imaging workup completed after ED discharge, the median time to completion was 5 days. For patients discharged from EDs with incomplete imaging, the odds of incomplete TIA imaging at 30 days after discharge were highest for black (odds ratio, 1.84; 95% confidence interval, 1.27-2.66) and older (≥85 years of age; odds ratio, 2.41; 95% confidence interval, 1.78-3.26) patients. Reference values were age cohort 65 to 69 years; male gender; white race; no co-occurring diagnoses of hypertension, hyperlipidemia, or diabetes mellitus; household income > $63,029; hospital in the Northeast region; urban hospital location; hospital size > 400 beds; academically affiliated hospital; and facility with access to MRI.

CONCLUSIONS

Most patients discharged from EDs with incomplete TIA imaging workup do not complete recommended imaging within 30 days after discharge.

Prescription smoking-cessation medication pharmacy claims after stroke and transient ischemic attack

Smoking cessation is critical in secondary prevention after stroke and transient ischemic attack. Data regarding use of smoking-cessation interventions after stroke and transient ischemic attack are sparse. We examined the use of prescription smoking-cessation medications in these patients. This is a retrospective cohort study using 2013-2016 data from the INSIGHT Clinical Research Network, comprised of Medicare prescription claims data merged with electronic health record data for patients receiving care across five New York City health care institutions. Active smoking was ascertained based on a validated ICD-9-CM diagnosis code or the presence of an electronic health record active smoking indicator, reflecting clinician-entered data in the health record. The primary outcome was a claim for any prescription smoking-cessation medication (varenicline or bupropion) within 12 months of hospital discharge. We evaluated claims for any statin medication as a comparator because statins are a standard component of stroke secondary prevention. We identified 3,153 patients with stroke or transient ischemic attack who were active smokers at the time of their event. Among these patients, 3.1% (95% CI, 2.5-3.9) had a pharmacy claim for a prescription smoking-cessation medication at 6 months, and 4.7% (95% CI, 3.9-5.6) did at 12 months hospital discharge. In contrast, cumulative statin medication claims rates were 67.5% (95% CI, 65.5-69.5%) at 6 months and 74.6% (95% CI, 72.7-76.6%) at 12 months. Prescription smoking-cessation medications were infrequently used after stroke and transient ischemic attack.

Ischemic stroke mimics: A comprehensive review

BACKGROUND

Ischemic stroke is the leading cause of disability and one of the leading causes of death. Ischemic stroke mimics (SMs) can account for a noteble number of diagnosed acute strokes and even can be thrombolyzed.

METHODS

The aim of our comprehensive review was to summarize the findings of different studies focusing on the prevalence, type, risk factors, presenting symptoms, and outcome of SMs in stroke/thrombolysis situations.

RESULTS

Overall, 61 studies were selected with 62.664 participants. Ischemic stroke mimic rate was 24.8% (15044/60703). Most common types included peripheral vestibular dysfunction in 23.2%, toxic/metabolic in 13.2%, seizure in 13%, functional disorder in 9.7% and migraine in 7.76%. Ischemic stroke mimic have less vascular risk factors, younger age, female predominance, lower (nearly normal) blood pressure, no or less severe symptoms compared to ischemic stroke patients (p < 0.05 in all cases). 61.7% of ischemic stroke patients were thrombolysed vs. 26.3% among SMs (p < 0.001). (p < 0.001). Overall intracranial hemorrhage was reported in 9.4% of stroke vs. 0.7% in SM patients (p < 0.001). Death occurred in 11.3% of stroke vs 1.9% of SM patients (p < 0.001). Excellent outcome was (mRS 0-1) was reported in 41.8% ischemic stroke patients vs. 68.9% SMs (p < 0.001). Apart from HINTS manouvre or Hoover sign there is no specific method in the identification of mimics. MRI DWI or perfusion imaging have a role in the setup of differential diagnosis, but merit further investigation.

CONCLUSION

Our article is among the first complex reviews focusing on ischemic stroke mimics. Although it underscores the safety of thrombolysis in this situation, but also draws attention to the need of patient evaluation by physicians experienced in the diagnosis of both ischemic stroke and SMs, especially in vertigo, headache, seizure and conversional disorders.

Redundant Imaging in Transient Ischemic Attack: Evidence From the Nationwide Emergency Department Sample

PURPOSE

Increasing emergency department (ED) compliance with transient ischemic attack (TIA) imaging guidelines has previously been demonstrated, along with a substantial rise in imaging utilization over the past decade. The purpose of this study was to characterize the most commonly used combinations of imaging studies during ED workup of TIA and to quantify prevalence of redundant imaging (RI).

METHODS

TIA discharges from EDs in the United States from 2006 to 2017 were identified in the Nationwide Emergency Department Sample. Brain and neurovascular imaging obtained during the encounter was identified using Current Procedural Terminology codes. RI was defined as an ED encounter with any duplicate cross-sectional brain, brain-vascular, or neck-vascular imaging. Patient demographics and hospital characteristics were incorporated into a multivariable logistic regression analysis to identify significant associations with RI.

RESULTS

There were 184,870 discharges with TIA from EDs in 2017. RI (brain) was observed in 55,513 (30%) of encounters. RI (brain-vascular) and RI (neck-vascular) imaging was identified in 5,149 (2.8%) and 1,325 (0.7%) of encounters, respectively. Decreased odds of obtaining RI was observed in Medicaid patients(odds ratio [OR: 0.72, 95% confidence interval [CI]: 0.64-0.81), non-trauma centers(OR: 0.49, 95% CI: 0.26-0.93), rural hospital locations(OR: 0.18, 95% CI: 0.11-0.29), and weekend encounters(OR: 0.9, 95% CI: 0.85-0.96). Trend analysis from 2006 to 2017 demonstrated a rise in RI (brain) from 2.3% of encounters in 2006 to 30% of encounters in 2017. RI for patients discharged from EDs with TIA in 2017 resulted in additional charges of approximately US $8,670,832.

CONCLUSION

Increased imaging utilization for TIA workup across EDs in the United States is associated with rising use of redundant imaging. We identify imaging practices that could be targeted to mitigate health care expenditures, while adhering to TIA imaging guidelines.

Systematic Review and Meta-Analysis of Diagnostic Agreement in Suspected TIA

Objective

To determine the interrater variability for TIA diagnostic agreement among expert clinicians (neurologists/stroke physicians), administrative data, and nonspecialists.

Methods

We performed a meta-analysis of studies from January 1984 to January 2019 using MEDLINE, EMBASE, and PubMed. Two reviewers independently screened for eligible studies and extracted interrater variability measurements using Cohen's kappa scores to assess diagnostic agreement.

Results

Nineteen original studies consisting of 19,421 patients were included. Expert clinicians demonstrate good agreement for TIA diagnosis (κ = 0.71, 95% confidence interval [CI] = 0.62-0.81). Interrater variability between clinicians' TIA diagnosis and administrative data also demonstrated good agreement (κ = 0.68, 95% CI = 0.62-0.74). There was moderate agreement (κ = 0.41, 95% CI = 0.22-0.61) between referring clinicians and clinicians at TIA clinics receiving the referrals. Sixty percent of 748 patient referrals to TIA clinics were TIA mimics.

Conclusions

Overall agreement between expert clinicians was good for TIA diagnosis, although variation still existed for a sizeable proportion of cases. Diagnostic agreement for TIA decreased among nonspecialists. The substantial number of patients being referred to TIA clinics with other (often neurologic) diagnoses was large, suggesting that clinicians, who are proficient in managing TIAs and their mimics, should run TIA clinics.

Validation of Acute Myocardial Infarction and Heart Failure Diagnoses in Hospitalized Patients With the Nationwide Claim-Based JROAD-DPC Database

Background: Big data systems such as diagnosis procedure combination (DPC) datasets have recently been used for research purposes. However, there have been few validation studies to determine the accuracy of diagnoses. The aim of this study was to validate and evaluate 2 diagnoses, namely acute myocardial infarction (AMI) and heart failure (HF), using International Classification of Diseases, 10th revision (ICD-10) codes in the Japanese Registry Of All cardiac and vascular Disease (JROAD)-DPC database.

Methods and Results: ICD-10 codes I21.0–I21.9 and I50.0–I50.9 were used to identify AMI and HF, respectively, in the JROAD-DPC database. Diagnoses of AMI and HF were validated in clinical datasets assessing sensitivity and positive predictive value (PPV). Over 1–2 years, 742 patients hospitalized for AMI and 1,368 patients hospitalized for HF were identified in the DPC dataset. Sensitivity and PPV for AMI were 78.9% and 78.8%, respectively. When emergency hospitalization was included as a criterion, PPV increased to 84.9%. For HF, sensitivity and PPV were 84.7% and 57.0%, respectively. When emergency hospitalization and acute HF were included as criteria, PPV increased to 83.0%.

Conclusions: Using ICD-10 codes for AMI and HF diagnoses among hospitalized patients, the DPC dataset showed acceptable concordance with clinical datasets. PPV increased when any conditions of hospitalization were included, especially in HF.

Reduction in Stroke After Transient Ischemic Attack in a Province-Wide Cohort Between 2003 and 2015

BACKGROUND

Improvements in management of transient ischemic attack (TIA) have decreased stroke and mortality post-TIA. Studies examining trends over time on a provincial level are limited. We analyzed whether efforts to improve management have decreased the rate of stroke and mortality after TIA from 2003 to 2015 across an entire province.

METHODS

Using administrative data from the Canadian Institute for Health Information's (CIHI) databases from 2003 to 2015, we identified a cohort of patients with a diagnosis of TIA upon discharge from the emergency department (ED). We examined stroke rates at Day 1, 2, 7, 30, 90, 180, and 365 post-TIA and 1-year mortality rates and compared trends over time between 2003 and 2015.

RESULTS

From 2003 to 2015 in Ontario, there were 61,710 patients with an ED diagnosis of TIA. Linear regressions of stroke after the index TIA showed a significant decline between 2003 and 2015, decreasing by 25% at Day 180 and 32% at 1 year (p < 0.01). The 1-year stroke rate decreased from 6.0% in 2003 to 3.4% in 2015. Early (within 48 h) stroke after TIA continued to represent approximately half of the 1-year event rates. The 1-year mortality rate after ED discharge following a TIA decreased from 1.3% in 2003 to 0.3% in 2015 (p < 0.001).

INTERPRETATION

At a province-wide level, 1-year rates of stroke and mortality after TIA have declined significantly between 2003 and 2015, suggesting that efforts to improve management may have contributed toward the decline in long-term risk of stroke and mortality. Continued efforts are needed to further reduce the immediate risk of stroke following a TIA.

Compliance With Imaging Guidelines for Workup of Transient Ischemic Attack

Background and Purpose:

Multiple societal guidelines recommend urgent brain and neurovascular imaging in patients with transient ischemic attack (TIA) to identify and treat risk factors that may lead to future stroke. The purpose of this study was to evaluate whether national imaging utilization for workup of TIA complies with society guidelines.

Methods:

Analysis utilized the Nationwide Emergency Department Sample. Primary analysis was performed on a 2017 cohort, and secondary trend analysis was performed on cohorts from 2006 to2017. Patients diagnosed and discharged from emergency departments with TIA were identified using International Classification of Diseases, Ninth Revision and Tenth Revision codes. Brain and neurovascular imaging obtained during the encounter was identified using Current Procedural Terminology codes. Demographics, health insurance, patient income, and hospital-type covariates were analyzed using a hierarchical multivariable logistic regression analysis to identify predictors of obtaining neurovascular imaging during an emergency department encounter.

Results:

In 2017, there were 167 999 patients evaluated and discharged from emergency departments with TIA. The percentage of patients receiving brain and neurovascular imaging was 78.5% and 43.2%, respectively. The most common imaging workup utilized was a solitary computed tomography–brain without any neurovascular imaging (30.9% of encounters). Decreased odds of obtaining neurovascular imaging was observed in Medicaid patients (odds ratio, 0.65 [95% CI, 0.58–0.74]), rural hospitals (odds ratio, 0.26 [95% CI, 0.17–0.41]), nontrauma centers (odds ratio, 0.40 [95% CI, 0.21–0.74]), and weekend encounters (odds ratio, 0.91 [95% CI, 0.85–0.96]). Trend analysis demonstrated a steady rise in brain and neurovascular imaging in 2006 from 34.9% and 6.8% of encounters, respectively, to 78.5% and 43.2% of encounters in 2017.

Conclusions:

Compliance with imaging guidelines is improving; however, the majority of TIA patients discharged from the emergency department do not receive recommended neurovascular imaging during their encounter. Follow-up studies are needed to determine whether delayed or incomplete vascular screening increases the risk of future stroke.

Young Stroke Survivors With No Early Recurrence at High Long-Term Risk of Adverse Outcomes

Background

Approximately 8% to 21% of strokes affect adults aged <45 years. Although early stroke recurrence conveys the largest risk, long‐term risks for young survivors with no early complications are unclear.

Methods and Results

Longitudinal matched case‐control study (2003–2013). Consecutive patients with ischemic stroke or transient ischemic attack (young, ≤44 years) discharged from emergency or regional stroke centers in Ontario, Canada, with no death, recurrent stroke/transient ischemic attack, myocardial infarction, all‐cause hospitalization, or admission to a long‐term or continuing care facility (≤90 days) were matched 10:1 to general population controls on age (±1 year), sex, income, geography, and case date (±50 days). The primary outcome was a composite of death, stroke, myocardial infarction, and long‐term or continuing care facility admission at 1, 3, and 5 years. Absolute event rates for young stroke/transient ischemic attack patients were lower than for older patients at 1 (2.2% versus 9.9%), 3 (4.7% versus 24.6%), and 5 (7.1% versus 37.2%) years. However, piecewise constant hazard modeling revealed that, even after adjustment for vascular comorbidities, young patients showed a 7‐fold increased hazard of the composite outcome compared with young controls at 1 year (hazard ratio, 7.3; 95% CI, 4.0–13.6). Adjusted 5‐year piecewise hazard also remained >5× that of young controls (hazard ratio, 5.2; 95% CI, 2.8–9.4), compared with a 30% increase at 5 years for older patients (hazard ratio, 1.3; 95% CI, 1.3–1.4).

Conclusions

Young stable stroke/transient ischemic attack survivors show a higher long‐term hazard of adverse outcomes compared with matched controls than older patients. Findings support the need for long‐term follow‐up and aggressive risk reduction in young survivors and suggest secondary prevention guidelines for these patients are required.