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Richardson DR, Zhou X, Reeder-Hayes K, Jensen CE, Islam J, Loh KP, Gupta A, Basch E, Bennett AV, Bridges JFP, Wheeler SB, Wood WA, Baggett CD, Lund JL. Home Time Among Older Adults With Acute Myeloid Leukemia Following Chemotherapy. JAMA Oncol 2024; 10:1038-1046. [PMID: 38869885 PMCID: PMC11177219 DOI: 10.1001/jamaoncol.2024.1823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 02/16/2024] [Indexed: 06/14/2024]
Abstract
Importance Patients with acute myeloid leukemia (AML) recognize days spent at home (home time) vs in a hospital or nursing facility as an important factor in treatment decision making. No study has adequately described home time among older adults with AML. Objective To describe home time among older adults with AML (aged ≥66 years) and compare home time between 2 common treatments: anthracycline-based chemotherapy and hypomethylating agents (HMAs). Design, Setting, and Participants A cohort of adults aged 66 years or older with a new diagnosis of AML from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database in 2004 to 2016 was identified. Individuals were stratified into anthracycline-based therapy, HMAs, or chemotherapy, not otherwise specified (NOS) using claims. Main Outcomes and Measures The primary outcome was home time, quantified by subtracting the total number of person-days spent in hospitals and nursing facilities from the number of person-days survived and dividing by total person-days. A weighted multinomial regression model with stabilized inverse probability of treatment weighting to estimate adjusted home time was used. Results The cohort included 7946 patients with AML: 2824 (35.5%) received anthracyclines, 2542 (32.0%) HMAs, and 2580 (32.5%) were classified as chemotherapy, NOS. Median (IQR) survival was 11.0 (5.0-27.0) months for those receiving anthracyclines and 8.0 (3.0-17.0) months for those receiving HMAs. Adjusted home time for all patients in the first year was 52.4%. Home time was highest among patients receiving HMAs (60.8%) followed by those receiving anthracyclines (51.9%). Despite having a shorter median survival, patients receiving HMAs had more total days at home and 33 more days at home in the first year on average than patients receiving anthracyclines (222 vs 189). Conclusions and Relevance This retrospective study of older adults with AML using SEER-Medicare data and propensity score weighting suggests that the additional survival afforded by receiving anthracycline-based therapy was entirely offset by admission to the hospital or to nursing facilities.
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Affiliation(s)
- Daniel R. Richardson
- University of North Carolina School of Medicine, Chapel Hill
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Xi Zhou
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Katherine Reeder-Hayes
- University of North Carolina School of Medicine, Chapel Hill
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Christopher E. Jensen
- University of North Carolina School of Medicine, Chapel Hill
- Cecil B. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill
| | | | - Kah Poh Loh
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Arjun Gupta
- University of Minnesota Masonic Cancer Center, Minneapolis
| | - Ethan Basch
- University of North Carolina School of Medicine, Chapel Hill
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Antonia V. Bennett
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
- University of North Carolina Department of Health Policy and Management, Gillings School of Global Public Health, Chapel Hill
| | | | - Stephanie B. Wheeler
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
- University of North Carolina Department of Health Policy and Management, Gillings School of Global Public Health, Chapel Hill
| | - William A. Wood
- University of North Carolina School of Medicine, Chapel Hill
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Christopher D. Baggett
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
- University of North Carolina Department of Epidemiology, Gillings School of Global Public Health, Chapel Hill
| | - Jennifer L. Lund
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
- University of North Carolina Department of Epidemiology, Gillings School of Global Public Health, Chapel Hill
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Donnelly J, Hong JB, Boyle L, Yong VTY, Diprose WK, Meyer J, Campbell D, Barber PA. Days Alive and Out of Hospital as an Outcome Measure in Patients Receiving Hyperacute Stroke Intervention. J Am Heart Assoc 2024; 13:e032321. [PMID: 38958146 PMCID: PMC11292750 DOI: 10.1161/jaha.123.032321] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 03/18/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Patient outcome after stroke is frequently assessed with clinical scales such as the modified Rankin Scale score (mRS). Days alive and out of hospital at 90 days (DAOH-90), which measures survival, time spent in hospital or rehabilitation settings, readmission and institutionalization, is an objective outcome measure that can be obtained from large administrative data sets without the need for patient contact. We aimed to assess the comparability of DAOH with mRS and its relationship with other prognostic variables after acute stroke reperfusion therapy. METHODS AND RESULTS Consecutive patients with ischemic stroke treated with intravenous thrombolysis or endovascular thrombectomy were analyzed. DAOH-90 was calculated from a national minimum data set, a mandatory nationwide administrative database. mRS score at day 90 (mRS-90) was assessed with in-person or telephone interviews. The study included 1278 patients with ischemic stroke (714 male, median age 70 [59-79], median National Institutes of Health Stroke Scale score 14 [9-20]). Median DAOH-90 was 71 [29-84] and median mRS-90 score was 3 [2-5]. DAOH-90 was correlated with admission National Institutes of Health Stroke Scale score (Spearman rho -0.44, P<0.001) and Alberta Stroke Program Early CT [Computed Tomography] Score (Spearman rho 0.24, P<0.001). There was a strong association between mRS-90 and DAOH-90 (Spearman rho correlation -0.79, P<0.001). Area under receiver operating curve for predicting mRS score >0 was 0.86 (95% CI, 0.84-0.88), mRS score >1 was 0.88 (95% CI, 0.86-0.90) and mRS score >2 was 0.90 (95% CI, 0.89-0.92). CONCLUSIONS In patients with stroke treated with reperfusion therapies, DAOH-90 shows reasonable comparability to the more established outcome measure of mRS-90. DAOH-90 can be readily obtained from administrative databases and therefore has the potential to be used in large-scale clinical trials and comparative effectiveness studies.
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Affiliation(s)
- Joseph Donnelly
- Department of MedicineUniversity of AucklandAucklandNew Zealand
- Department of NeurologyAuckland City HospitalAucklandNew Zealand
| | - Jae Beom Hong
- Department of NeurologyAuckland City HospitalAucklandNew Zealand
| | - Luke Boyle
- Department of StatisticsUniversity of AucklandAucklandNew Zealand
| | - Vivien TY Yong
- Department of MedicineUniversity of AucklandAucklandNew Zealand
- Department of NeurologyAuckland City HospitalAucklandNew Zealand
| | | | - Juliette Meyer
- Department of MedicineUniversity of AucklandAucklandNew Zealand
| | - Douglas Campbell
- Department of AnaesthesiologyUniversity of AucklandAucklandNew Zealand
| | - P. Alan Barber
- Department of MedicineUniversity of AucklandAucklandNew Zealand
- Department of NeurologyAuckland City HospitalAucklandNew Zealand
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Joundi RA, Hill MD, Stang J, Nicol D, Yu AYX, Kapral MK, King JA, Halabi ML, Smith EE. Association Between Time to Treatment With Endovascular Thrombectomy and Home-Time After Acute Ischemic Stroke. Neurology 2024; 102:e209454. [PMID: 38848515 DOI: 10.1212/wnl.0000000000209454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Home-time is a patient-prioritized stroke outcome that can be derived from administrative data linkages. The effect of faster time-to-treatment with endovascular thrombectomy (EVT) on home-time after acute stroke is unknown. METHODS We used the Quality Improvement and Clinical Research registry to identify a cohort of patients who received EVT for acute ischemic stroke between 2015 and 2022 in Alberta, Canada. We calculated days at home in the first 90 days after stroke. We used ordinal regression across 6 ordered categories of home-time to evaluate the association between onset-to-arterial puncture and higher home-time, adjusting for age, sex, rural residence, NIH Stroke Scale, comorbidities, intravenous thrombolysis, and year of treatment. We used restricted cubic splines to assess the nonlinear relationship between continuous variation in time metrics and higher home-time, and also reported the adjusted odds ratios within time categories. We additionally evaluated door-to-puncture and reperfusion times. Finally, we analyzed home-time with zero-inflated models to determine the minutes of earlier treatment required to gain 1 day of home-time. RESULTS We had 1,885 individuals in our final analytic sample. There was a nonlinear increase in home-time with faster treatment when EVT was within 4 hours of stroke onset or 2 hours of hospital arrival. There was a higher odds of achieving more days at home when onset-to-puncture time was <2 hours (adjusted odds ratio 2.36, 95% CI 1.77-3.16) and 2 to <4 hours (1.37, 95% CI 1.11-1.71) compared with ≥6 hours, and when door-to-puncture time was <1 hour (aOR 2.25, 95% CI 1.74-2.90), 1 to <1.5 hours (aOR 1.89, 95% CI 1.47-2.41), and 1.5 to <2 hours (1.35, 95% CI 1.04-1.76) compared with ≥2 hours. Results were consistent for reperfusion times. For every hour of faster treatment within 6 hours of stroke onset, there was an estimated increase in home-time of 4.7 days, meaning that approximately 1 day of home-time was gained for each 12.8 minutes of faster treatment. DISCUSSION Faster time-to-treatment with EVT for acute stroke was associated with greater home-time, particularly within 4 hours of onset-to-puncture and 2 hours of door-to-puncture time. Within 6 hours of stroke onset, each 13 minutes of faster treatment is associated with a gain of 1 day of home-time.
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Affiliation(s)
- Raed A Joundi
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Ontario; Departments of Clinical Neurosciences (M.D.H., E.E.S.) and Community Health Sciences (E.E.S.), Cumming School of Medicine, University of Calgary; Data and Analytics (DnA) (J.S., D.N.) and Cardiovascular Health and Stroke Strategic Clinical Network (M.-L.H.), Alberta Health Services; ICES (A.Y.X.Y., M.K.K.), Toronto; Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto; Sunnybrook Health Sciences Centre (A.Y.X.Y.), Ontario; Department of Medicine (A.Y.X.Y.), Division of Neurology, University of Toronto; Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario; Alberta Strategy for Patient Oriented Research Support Unit Data Platform (J.A.K.); and Provincial Research Data Services (J.A.K.), Alberta Health Services, Canada
| | - Michael D Hill
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Ontario; Departments of Clinical Neurosciences (M.D.H., E.E.S.) and Community Health Sciences (E.E.S.), Cumming School of Medicine, University of Calgary; Data and Analytics (DnA) (J.S., D.N.) and Cardiovascular Health and Stroke Strategic Clinical Network (M.-L.H.), Alberta Health Services; ICES (A.Y.X.Y., M.K.K.), Toronto; Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto; Sunnybrook Health Sciences Centre (A.Y.X.Y.), Ontario; Department of Medicine (A.Y.X.Y.), Division of Neurology, University of Toronto; Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario; Alberta Strategy for Patient Oriented Research Support Unit Data Platform (J.A.K.); and Provincial Research Data Services (J.A.K.), Alberta Health Services, Canada
| | - Jillian Stang
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Ontario; Departments of Clinical Neurosciences (M.D.H., E.E.S.) and Community Health Sciences (E.E.S.), Cumming School of Medicine, University of Calgary; Data and Analytics (DnA) (J.S., D.N.) and Cardiovascular Health and Stroke Strategic Clinical Network (M.-L.H.), Alberta Health Services; ICES (A.Y.X.Y., M.K.K.), Toronto; Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto; Sunnybrook Health Sciences Centre (A.Y.X.Y.), Ontario; Department of Medicine (A.Y.X.Y.), Division of Neurology, University of Toronto; Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario; Alberta Strategy for Patient Oriented Research Support Unit Data Platform (J.A.K.); and Provincial Research Data Services (J.A.K.), Alberta Health Services, Canada
| | - Dana Nicol
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Ontario; Departments of Clinical Neurosciences (M.D.H., E.E.S.) and Community Health Sciences (E.E.S.), Cumming School of Medicine, University of Calgary; Data and Analytics (DnA) (J.S., D.N.) and Cardiovascular Health and Stroke Strategic Clinical Network (M.-L.H.), Alberta Health Services; ICES (A.Y.X.Y., M.K.K.), Toronto; Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto; Sunnybrook Health Sciences Centre (A.Y.X.Y.), Ontario; Department of Medicine (A.Y.X.Y.), Division of Neurology, University of Toronto; Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario; Alberta Strategy for Patient Oriented Research Support Unit Data Platform (J.A.K.); and Provincial Research Data Services (J.A.K.), Alberta Health Services, Canada
| | - Amy Ying Xin Yu
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Ontario; Departments of Clinical Neurosciences (M.D.H., E.E.S.) and Community Health Sciences (E.E.S.), Cumming School of Medicine, University of Calgary; Data and Analytics (DnA) (J.S., D.N.) and Cardiovascular Health and Stroke Strategic Clinical Network (M.-L.H.), Alberta Health Services; ICES (A.Y.X.Y., M.K.K.), Toronto; Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto; Sunnybrook Health Sciences Centre (A.Y.X.Y.), Ontario; Department of Medicine (A.Y.X.Y.), Division of Neurology, University of Toronto; Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario; Alberta Strategy for Patient Oriented Research Support Unit Data Platform (J.A.K.); and Provincial Research Data Services (J.A.K.), Alberta Health Services, Canada
| | - Moira K Kapral
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Ontario; Departments of Clinical Neurosciences (M.D.H., E.E.S.) and Community Health Sciences (E.E.S.), Cumming School of Medicine, University of Calgary; Data and Analytics (DnA) (J.S., D.N.) and Cardiovascular Health and Stroke Strategic Clinical Network (M.-L.H.), Alberta Health Services; ICES (A.Y.X.Y., M.K.K.), Toronto; Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto; Sunnybrook Health Sciences Centre (A.Y.X.Y.), Ontario; Department of Medicine (A.Y.X.Y.), Division of Neurology, University of Toronto; Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario; Alberta Strategy for Patient Oriented Research Support Unit Data Platform (J.A.K.); and Provincial Research Data Services (J.A.K.), Alberta Health Services, Canada
| | - James A King
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Ontario; Departments of Clinical Neurosciences (M.D.H., E.E.S.) and Community Health Sciences (E.E.S.), Cumming School of Medicine, University of Calgary; Data and Analytics (DnA) (J.S., D.N.) and Cardiovascular Health and Stroke Strategic Clinical Network (M.-L.H.), Alberta Health Services; ICES (A.Y.X.Y., M.K.K.), Toronto; Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto; Sunnybrook Health Sciences Centre (A.Y.X.Y.), Ontario; Department of Medicine (A.Y.X.Y.), Division of Neurology, University of Toronto; Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario; Alberta Strategy for Patient Oriented Research Support Unit Data Platform (J.A.K.); and Provincial Research Data Services (J.A.K.), Alberta Health Services, Canada
| | - Mary-Lou Halabi
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Ontario; Departments of Clinical Neurosciences (M.D.H., E.E.S.) and Community Health Sciences (E.E.S.), Cumming School of Medicine, University of Calgary; Data and Analytics (DnA) (J.S., D.N.) and Cardiovascular Health and Stroke Strategic Clinical Network (M.-L.H.), Alberta Health Services; ICES (A.Y.X.Y., M.K.K.), Toronto; Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto; Sunnybrook Health Sciences Centre (A.Y.X.Y.), Ontario; Department of Medicine (A.Y.X.Y.), Division of Neurology, University of Toronto; Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario; Alberta Strategy for Patient Oriented Research Support Unit Data Platform (J.A.K.); and Provincial Research Data Services (J.A.K.), Alberta Health Services, Canada
| | - Eric E Smith
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Ontario; Departments of Clinical Neurosciences (M.D.H., E.E.S.) and Community Health Sciences (E.E.S.), Cumming School of Medicine, University of Calgary; Data and Analytics (DnA) (J.S., D.N.) and Cardiovascular Health and Stroke Strategic Clinical Network (M.-L.H.), Alberta Health Services; ICES (A.Y.X.Y., M.K.K.), Toronto; Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto; Sunnybrook Health Sciences Centre (A.Y.X.Y.), Ontario; Department of Medicine (A.Y.X.Y.), Division of Neurology, University of Toronto; Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario; Alberta Strategy for Patient Oriented Research Support Unit Data Platform (J.A.K.); and Provincial Research Data Services (J.A.K.), Alberta Health Services, Canada
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Kumar RG, Evans E, Albrecht JS, Gardner RC, Dams-O'Connor K, Thomas KS. Healthy Days at Home Among Older Medicare Beneficiaries With Traumatic Brain Injury Requiring Inpatient Rehabilitation. J Head Trauma Rehabil 2024:00001199-990000000-00141. [PMID: 38598697 DOI: 10.1097/htr.0000000000000954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
OBJECTIVE The objectives of this study were to characterize and identify correlates of healthy days at home (HDaH) before and after TBI requiring inpatient rehabilitation. Setting: Inpatient hospital, nursing home, and home health services. PARTICIPANTS Average of n= 631 community-dwelling fee-for-service age 66+ Medicare beneficiaries across 30 replicate samples who were hospitalized for traumatic brain injury (TBI) between 2012 and 2014 and admitted to an inpatient rehabilitation facility (IRF) within 72 hours of hospital discharge. DESIGN Retrospective study using data from Medicare claims supplemented with data from the National Trauma Databank. MAIN MEASURES The primary outcome, HDaH, was calculated as time alive not using inpatient hospital, nursing home, and home health services in the year before TBI hospitalization and after IRF discharge. RESULTS We found HDaH declined from 93.2% in the year before TBI hospitalization to 65.3% in the year after IRF discharge (73.6% among survivors only). Most variability in HDaH was: (1) in the first 3 months after discharge and (2) by discharge disposition, with persons discharged from IRF to another acute hospital having the worst prognosis for utilization and death. In negative binomial regression models, the strongest predictors of HDaH in the year after discharge were rehabilitation Functional Independence Measure mobility score (β = 0.03; 95% CI, 0.002-0.06) and inpatient Charlson Comorbidity Index score (β = - 0.06; 95% CI, -0.13 to 0.001). Dual Medicaid eligible was associated with less HDaH among survivors (β = - 0.37; 95% CI, -0.66 to -0.07). CONCLUSION In this study, among community-dwelling older adults with TBI, we found a notable decrease in the proportion of time spent alive at home without higher-level care after IRF discharge compared to before TBI. The finding that physical disability and comorbidities were the biggest drivers of healthy days alive in this population suggests that a chronic disease management model is required for older adults with TBI to manage their complex health care needs.
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Affiliation(s)
- Raj G Kumar
- Author Affiliations: Department of Rehabilitation and Human Performance (Drs Kumar and Dams-O'Connor), Department of Neurology (Dr Dams-O'Connor), Icahn School of Medicine at Mount Sinai, New York, New York; Department of Physical Therapy (Dr Evans), College of Health and Rehabilitation Sciences: Sargent College, Boston University, Boston, Massachusetts; Department of Epidemiology and Public Health (Dr Albrecht), University of Maryland School of Medicine, Baltimore, Maryland; Joseph Sagol Neuroscience Center (Dr Gardner), Sheba Medical Center, Ramat Gan, Israel; and Department of Health Services, Policy, and Practice (Dr Thomas), Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
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Joundi RA, King JA, Stang J, Nicol D, Hill MD, Yu AYX, Kapral MK, Smith EE. Age-Specific Association of Co-Morbidity With Home-Time After Acute Stroke. Can J Neurol Sci 2024:1-9. [PMID: 38532570 DOI: 10.1017/cjn.2024.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
OBJECTIVE To examine the association of co-morbidity with home-time after acute stroke and whether the association is influenced by age. METHODS We conducted a province-wide study using linked administrative databases to identify all admissions for first acute ischemic stroke or intracerebral hemorrhage between 2007 and 2018 in Alberta, Canada. We used ischemic stroke-weighted Charlson Co-morbidity Index of 3 or more to identify those with severe co-morbidity. We used zero-inflated negative binomial models to determine the association of severe co-morbidity with 90-day and 1-year home-time, and logistic models for achieving ≥ 80 out of 90 days of home-time, assessing for effect modification by age and adjusting for sex, stroke type, comprehensive stroke center care, hypertension, atrial fibrillation, year of study, and separately adjusting for estimated stroke severity. We also evaluated individual co-morbidities. RESULTS Among 28,672 patients in our final cohort, severe co-morbidity was present in 27.7% and was associated with lower home-time, with a greater number of days lost at younger age (-13 days at age < 60 compared to -7 days at age 80+ years for 90-day home-time; -69 days at age < 60 compared to -51 days at age 80+ years for 1-year home-time). The reduction in probability of achieving ≥ 80 days of home-time was also greater at younger age (-22.7% at age < 60 years compared to -9.0% at age 80+ years). Results were attenuated but remained significant after adjusting for estimated stroke severity and excluding those who died. Myocardial infarction, diabetes, and cancer/metastases had a greater association with lower home-time at younger age, and those with dementia had the greatest reduction in home time. CONCLUSION Severe co-morbidity in acute stroke is associated with lower home-time, more strongly at younger age.
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Affiliation(s)
- Raed A Joundi
- Division of Neurology, Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, ON, Canada
| | - James A King
- Provincial Research Data Services, Alberta Health Services, Alberta Strategy for Patient Oriented Research Support Unit Data Platform, Calgary, AB, Canada
| | - Jillian Stang
- Data and Analytics (DnA), Alberta Health Services, Edmonton, AB, Canada
| | - Dana Nicol
- Data and Analytics (DnA), Alberta Health Services, Edmonton, AB, Canada
| | - Michael D Hill
- Department of Clinical Neuroscience and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Amy Y X Yu
- ICES, Toronto, ON, Canada
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Moira K Kapral
- ICES, Toronto, ON, Canada
- Department of Medicine, Division of General Internal Medicine, University of Toronto, Toronto, ON, Canada
| | - Eric E Smith
- Department of Clinical Neuroscience and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Nair R, Khan K, Stang JM, Halabi ML, Youngson E, Alrohimi A, Shuaib A. Thrombolysis in Stroke Mimics: Comprehensive Stroke Centers vs Telestroke Sites. Can J Neurol Sci 2023; 50:838-844. [PMID: 36453234 DOI: 10.1017/cjn.2022.325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND Hyperacute treatment of acute stroke may lead to thrombolysis in stroke mimics (SM). Our aim was to determine the frequency of thrombolysis in SM in primary stroke centers (PSC) dependent on telestroke versus comprehensive stroke centers (CSC). METHOD Retrospective review of prospectively collected data from the Quality improvement and Clinical Research (QuICR) registry, the Discharge Abstract Database (DAD), and The National Ambulatory Care Reporting System (NACRS) of consecutive patients treated with intravenous thrombolysis for acute ischemic stroke in Alberta (Canada) from April 2016 to March 2021. RESULT A total of 2471 patients who received thrombolysis were included. Linking the QuICR registry to DAD 169 (6.83%) patients were identified as SM; however, on our review of the records, only 112 (4.53%) were actual SM. SMs were younger with a mean age of 61.66 (±16.15) vs 71.08 (±14.55) in stroke. National Institute of Health Stroke Scale was higher in stroke with a median (IQR) of 10 (5-17) vs 7 (5-10) in SM. Only one patient (0.89 %) in SM groups had a small parenchymal hemorrhage versus 155 (6.57%) stroke patients had a parenchymal hemorrhage. There was no death among patients of thrombolysed SM during hospitalization versus 276 (11.69%) in stroke. There was no significant difference in the rate of SM among thrombolysed patients between PSC 27 (5.36%) versus CSC 85 (4.3%) (P = 0.312). The most responsible diagnosis of SM was migraine/migraine equivalent, functional disorder, seizure, and delirium. CONCLUSION The diagnosis of SM may not always be correct when the information is extracted from databases. The rate of thrombolysis in SM via telestroke is similar to treatment in person at CSC.
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Affiliation(s)
- Radhika Nair
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Khurshid Khan
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | | | | | | | - Anas Alrohimi
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
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Boyle L, Lumley T, Cumin D, Campbell D, Merry AF. Using days alive and out of hospital to measure surgical outcomes in New Zealand: a cross-sectional study. BMJ Open 2023; 13:e063787. [PMID: 37491100 PMCID: PMC10373692 DOI: 10.1136/bmjopen-2022-063787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Abstract
OBJECTIVES To measure differences at various deciles in days alive and out of hospital to 90 days (DAOH90) and explore its utility for identifying outliers of performance among district health boards (DHBs). METHODS Days in hospital and mortality within 90 days of surgery were extracted by linking data from the New Zealand National Minimum Data Set and the births and deaths registry between 1 January 2011 and 31 December 2021 for all adults in New Zealand undergoing acute laparotomy (AL-a relatively high-risk group), elective total hip replacement (THR-a medium risk group) or lower segment caesarean section (LSCS-a low-risk group). DAOH90 was calculated without censoring to zero in cases of mortality. For each DHB, direct risk standardisation was used to adjust for potential confounders and presented in deciles according to baseline patient risk. The Mann-Whitney U test assessed overall DAOH90 differences between DHBs, and comparisons are presented between selected deciles of DAOH90 for each operation. RESULTS We obtained national data for 35 175, 52 032 and 117 695 patients undergoing AL, THR and LSCS procedures, respectively. We have demonstrated that calculating DAOH without censoring zero allows for differences between procedures and DHBs to be identified. Risk-adjusted national mean DAOH90 Scores were 64.0 days, 79.0 days and 82.0 days at the 0.1 decile and 75.0 days, 82.0 days and 84.0 days at the 0.2 decile for AL, THR and LSCS, respectively, matching to their expected risk profiles. Differences between procedures and DHBs were most marked at lower deciles of the DAOH90 distribution, and outlier DHBs were detectable. Corresponding 90-day mortality rates were 5.45%, 0.78% and 0.01%. CONCLUSION In New Zealand after direct risk adjustment, differences in DAOH90 between three types of surgical procedure reflected their respective risk levels and associated mortality rates. Outlier DHBs were identified for each procedure. Thus, our approach to analysing DAOH90 appears to have considerable face validity and potential utility for contributing to the measurement of perioperative outcomes in an audit or quality improvement setting.
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Affiliation(s)
- Luke Boyle
- Department of Statistics, The University of Auckland, Auckland, New Zealand
| | - Thomas Lumley
- Department of Statistics, The University of Auckland, Auckland, New Zealand
| | - David Cumin
- Department of Anaesthesiology, The University of Auckland, Auckland, New Zealand
| | - Doug Campbell
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - Alan Forbes Merry
- Department of Anaesthesiology, The University of Auckland, Auckland, New Zealand
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
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8
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Marella P, Laupland KB, Shekar K, Tabah A, Edwards F, Ramanan M. Institution-free days after critical illness: A multicenter retrospective study. J Crit Care 2023; 74:154253. [PMID: 36640478 DOI: 10.1016/j.jcrc.2023.154253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 12/31/2022] [Accepted: 01/03/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Patient-centered outcomes beyond mortality such as institution-free days (IFD) are becoming increasingly relevant in critical care trials. METHODS We calculated IFD using three definitions which differed in the way death and censoring of after-hospital deaths were handled analysing data from adult patient databases admitted to four ICUs of North Brisbane, Australia. Differences in distribution of IFD using different definitions were explored with descriptive statistics and histograms. Six pre-specified variables (age, illness severity, comorbidities index, elective status, surgical/medical admission and treatment limitations) were assessed and reported as determinants of IFDs for the proposed definitions. RESULTS Data from 25,371 ICU admissions was analysed. The density distribution of IFD was bimodal with a peak at 0 days and a variable right-sided peak depending on the definition used. The mean IFD varied from 253 (standard deviation(SD) 151.3) to 295 (SD 116.2) depending on definition used. Multivariable zero-inflated negative binomial regression modelling showed that the six pre-specified variables had significant associations with IFD and their magnitude of effect varied with the definition used. CONCLUSIONS IFD is a simple, easily measurable patient-centered outcome that varies depending on the definition used. Patient input should be sought to define the optimum definition and clinical use of IFD.
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Affiliation(s)
- Prashanti Marella
- Intensive Care Unit, Caboolture Hospital, Metro North Hospital and Health Services, Queensland, Australia; Mater Clinical Unit, University of Queensland, Brisbane, Australia
| | - Kevin B Laupland
- Queensland University of Technology (QUT), Brisbane, Queensland, Australia; Department of Intensive Care Services, Royal Brisbane and Womens hospital, Brisbane, Queensland, Australia
| | - Kiran Shekar
- The Prince Charles Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Alexis Tabah
- Queensland University of Technology (QUT), Brisbane, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Intensive Care Unit, Redcliffe Hospital, Metro North Hospital and Health Services, Queensland, Australia
| | - Felicity Edwards
- Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Metro North Hospital and Health Services, Queensland, Australia; The Prince Charles Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia.
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9
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Taran S, Coiffard B, Huszti E, Li Q, Chu L, Thomas C, Burns S, Robles P, Herridge MS, Goligher EC. Association of Days Alive and at Home at Day 90 After Intensive Care Unit Admission With Long-term Survival and Functional Status Among Mechanically Ventilated Patients. JAMA Netw Open 2023; 6:e233265. [PMID: 36929399 PMCID: PMC10020882 DOI: 10.1001/jamanetworkopen.2023.3265] [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: 03/18/2023] Open
Abstract
IMPORTANCE Many conventional end points in randomized clinical trials of interventions for critically ill patients do not account for patient-centered concerns such as time at home, physical function, and quality of life after critical illness. OBJECTIVE To establish whether days alive and at home at day 90 (DAAH90) is associated with long-term survival and functional outcomes in mechanically ventilated patients. DESIGN, SETTING, AND PARTICIPANTS The RECOVER prospective cohort study was conducted from February 2007 to March 2014, using data from 10 intensive care units (ICUs) in Canada. Patients were included in the baseline cohort if they were aged 16 years or older and underwent invasive mechanical ventilation for 7 or more days. The follow-up cohort analyzed here comprised RECOVER patients who were alive and had functional outcomes ascertained at 3, 6, and 12 months. Secondary data analysis occurred from July 2021 to August 2022. EXPOSURES Composite of survival and days alive and at home at day 90 after ICU admission (DAAH90). MAIN OUTCOMES AND MEASURES Functional outcomes at 3, 6, and 12 months were evaluated with the Functional Independence Measure (FIM), the 6-Minute Walk Test (6MWT), the Medical Research Council (MRC) Scale for Muscle Strength, and the 36-Item Short Form Health Survey physical component summary (SF-36 PCS). Mortality was evaluated at 1 year from ICU admission. Ordinal logistic regression was used to describe the association between DAAH90 tertiles and outcomes. Cox proportional hazards regression models were used to examine the independent association of DAAH90 tertiles with mortality. RESULTS The baseline cohort comprised 463 patients. Their median age was 58 years (IQR, 47-68 years), and 278 patients (60.0%) were men. In these patients, Charlson Comorbidity Index score, Acute Physiology and Chronic Health Evaluation II score, ICU intervention (eg, kidney replacement therapy or tracheostomy), and ICU length of stay were independently associated with lower DAAH90. The follow-up cohort comprised 292 patients. Their median age was 57 years (IQR, 46-65 years), and 169 patients (57.9%) were men. Among patients who survived to day 90, lower DAAH90 was associated with higher mortality at 1 year after ICU admission (tertile 1 vs tertile 3: adjusted hazard ratio [HR], 0.18 [95% CI, 0.07-0.43]; P < .001). At 3 months of follow-up, lower DAAH90 was independently associated with lower median scores on the FIM (tertile 1 vs tertile 3, 76 [IQR, 46.2-101] vs 121 [IQR, 112-124.2]; P = .04), 6MWT (tertile 1 vs tertile 3, 98 [IQR, 0-239] vs 402 [IQR, 300-494]; P < .001), MRC (tertile 1 vs tertile 3, 48 [IQR, 32-54] vs 58 [IQR, 51-60]; P < .001), and SF-36 PCS (tertile 1 vs tertile 3, 30 [IQR, 22-38] vs 37 [IQR, 31-47]; P = .001) measures. Among patients who survived to 12 months, being in tertile 3 vs tertile 1 for DAAH90 was associated with higher FIM score at 12 months (estimate, 22.4 [95% CI, 14.8-30.0]; P < .001), but this association was not present for ventilator-free days (estimate, 6.0 [95% CI, -2.2 to 14.1]; P = .15) or ICU-free days (estimate, 5.9 [95% CI, -2.1 to 13.8]; P = .15) at day 28. CONCLUSIONS AND RELEVANCE In this study, lower DAAH90 was associated with greater long-term mortality risk and worse functional outcomes among patients who survived to day 90. These findings suggest that the DAAH90 end point reflects long-term functional status better than standard clinical end points in ICU studies and may serve as a patient-centered end point in future clinical trials.
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Affiliation(s)
- Shaurya Taran
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Benjamin Coiffard
- Department of Respiratory Medicine, Assistance Publique-Hopitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Ella Huszti
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Qixuan Li
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Leslie Chu
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Claire Thomas
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Stacey Burns
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Priscila Robles
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Margaret S. Herridge
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
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Kamal H, Assaf S, Kabalan M, El Maissi R, Salhab D, Rahme D, Lahoud N. Evaluation of stroke pre-hospital management in Lebanon from symptoms onset to hospital arrival and impact on patients' status at discharge: a pilot study. BMC Neurol 2022; 22:494. [PMID: 36539720 PMCID: PMC9764570 DOI: 10.1186/s12883-022-03018-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Hospital arrival time after acute ischemic stroke onset is the major factor limiting the eligibility of patients to receive intravenous thrombolysis. Shortening the prehospital delay is crucial to reducing morbidity and mortality for stroke patients. The study was conducted to investigate the factors that influence hospital arrival time after acute stroke onset in the Lebanese population and to assess the effect of the prehospital phase on patients' prognosis at discharge. METHOD A prospective cross-sectional study was performed in eleven hospitals from April to July 2021 including 100 patients having stroke symptoms or transient ischemic attack (TIA). Two questionnaires were used to collect data addressing patient management in the pre-hospital phase and the in-hospital phase. Descriptive and bivariate analyses were done to evaluate the potential associations between prognosis, pre-hospital characteristics, and other factors. RESULTS The patients' mean age was 70.36 ± 12.25 years, 43 (53.8%) of them were females, and 79 (85%) arrived within 3 hours after symptoms onset. Diabetic patients had a significant delay in hospital arrival compared with non-diabetics (27.0%vs.7.1%, p-value = 0.009). Moreover, 37 (75.5%) of school-level education patients arrived early at the hospital compared to 7 (100%) of university-level education (p-value = 0.009). The modified Rankin Scale (mRS) at discharge in patients with hemorrhagic stroke (10 (90%)) was worse than that in patients with ischemic stroke (38 (80%)) or TIA (3 (15%)) (p-value< 0.001). CONCLUSION The study findings make it imperative to raise awareness about stroke symptoms among the Lebanese population. Emergency Medical Services should be utilized appropriately in the transportation of stroke patients to achieve optimal patient outcomes.
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Affiliation(s)
- Hiba Kamal
- grid.411324.10000 0001 2324 3572Faculty of Public Health, Lebanese University, Fanar, Lebanon
| | - Sara Assaf
- grid.411324.10000 0001 2324 3572Faculty of Pharmacy, Lebanese University, Hadath, Lebanon
| | - Mayssan Kabalan
- grid.411324.10000 0001 2324 3572Faculty of Pharmacy, Lebanese University, Hadath, Lebanon
| | - Raneem El Maissi
- grid.411324.10000 0001 2324 3572Faculty of Pharmacy, Lebanese University, Hadath, Lebanon
| | - Dima Salhab
- grid.411324.10000 0001 2324 3572Faculty of Public Health, Lebanese University, Fanar, Lebanon
| | - Deema Rahme
- grid.18112.3b0000 0000 9884 2169Pharmacy Practice Department, Faculty of Pharmacy, Beirut Arab University, Beirut, Lebanon
| | - Nathalie Lahoud
- grid.411324.10000 0001 2324 3572Faculty of Pharmacy, Lebanese University, Hadath, Lebanon
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Awada HN, Larsen MH, Kjær EKR, Jensen JS, Jakobsen KK, Scott S, Wessel I, Kehlet H, Grønhøj C, von Buchwald C. Days alive and out of hospital following primary surgery for oral cavity squamous cell carcinoma. Acta Oncol 2022; 61:1463-1472. [PMID: 36527436 DOI: 10.1080/0284186x.2022.2156810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Days Alive and Out of Hospital (DAOH) is a recently introduced, readily obtainable postoperative outcome measure method that expresses procedure and disease-associated morbidity and mortality. In this study, we evaluated DAOH with 30- and 365-days follow-up periods after primary surgery (DAOH30 and DAOH365, respectively) for patients with oral cavity squamous cell carcinoma (OSCC). The aim of this study is to identify patient-, procedure- and disease-associated risk factors for patients treated with primary surgery for primary OSCC. MATERIAL AND METHODS This retrospective cohort study from a prospective collected database represents patients from Eastern Denmark surgically treated for primary OSCC in the period 2000-2014. DAOH30 and DAOH365 were calculated and associations with patient characteristics including comorbidity, tumor characteristics, clinical outcomes such as length of stay, readmission, and mortality were evaluated. Tests for difference and significance between groups were assessed with Mann-Whitney U test and quantile linear regression. RESULTS We included 867 patients (63% males, median age: 63 years (IQR 56-70 years)). Median DAOH30 and DAOH365 after OSCC surgery were 25 days (IQR 21-27 days) and 356 days (IQR 336-360 days), respectively. Alcohol consumption had a significant association with a lower DAOH365, p < 0.01, but not with DAOH30. Advanced T-stage, adjuvant radiotherapy (RT) and increased Charlson Comorbidity Index (CCI) score was significantly associated with a lower DAOH30 and DAOH365. CONCLUSION In this population-based study in OSCC patients treated with primary surgery, we found that DAOH after 30 days was 25 days (83%), while DAOH after 365 days was 356 days (98%). Advanced T-stage acts as a predictor for significant DAOH30 and DAOH365 reduction while excessive alcohol consumption predicts a significant DAOH365 reduction. Readmission within 30 days following surgery was associated with further readmission within one year.
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Affiliation(s)
- Hussein Nasser Awada
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark.,Surgical Pathophysiology Unit, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Mikkel Holm Larsen
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Eva Kristine Ruud Kjær
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Jakob Schmidt Jensen
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Kathrine Kronberg Jakobsen
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Susanne Scott
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Irene Wessel
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Kehlet
- Surgical Pathophysiology Unit, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Grønhøj
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian von Buchwald
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
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12
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Singh N, Holodinsky JK, Kashani N, McDonough RV, Bala F, Horn M, Stang J, Demchuk AM, Hill MD, Almekhlafi MA. Prediction of 90 day home time among patients with low baseline ASPECTS undergoing endovascular thrombectomy: results from Alberta's Provincial Stroke Registry (QuICR). J Neurointerv Surg 2022:jnis-2022-019064. [PMID: 35858778 DOI: 10.1136/jnis-2022-019064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/02/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND The benefit of endovascular thrombectomy (EVT) in stroke patients with a low baseline Alberta Stroke Program Early CT Score (ASPECTS, ≤5) is uncertain. We aim to use random forest regression modeling to predict 90 day home time in patients with low ASPECTS. METHODS We used the Quality Improvement and Clinical Research (QuICR) provincial stroke registry and administrative data from southern Alberta to identify patients who underwent EVT in our center from July 2015 to November 2020. Baseline ASPECTS on non-contrast CT and CT angiography data were scored by a two physician consensus. The primary outcome was the predicted 90 day home time (the number of nights a patient is back at their premorbid living situation without an increase in level of care within 90 days of the stroke) using random forests regression. Estimates were generated using 200 bootstrapped datasets. Covariate contribution to home time was determined using partial dependence plots. RESULTS Of 657 EVT patients, 85 (12.9%) had baseline ASPECTS ≤5 (mean age 70.9 years, 44.7% women, 93.9% good-moderate collaterals, 60% M1-middle cerebral artery occlusion). Using partial dependence estimates, mean predicted home times were similar in the low ASPECTS (44.3 days) versus higher ASPECTS (43.1) groups. Factors predicting lower 90 day home time in this population were diabetes mellitus (-8.8 days), hypertension (-5.7 days), and atrial fibrillation (-3.6 days). There was no meaningful difference in predicted 90 day home time by sex, baseline National Institutes of Health Stroke Severity Scale score, occlusion site, tandem lesion, collateral grade or thrombolysis. CONCLUSIONS Patients with low ASPECTS who are selected for EVT using demographic and clinical profiles similar to higher ASPECTS patients achieved comparable outcomes.
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Affiliation(s)
- Nishita Singh
- Department of Clinical Neurosciences, Calgary Stroke Program, Calgary, Alberta, Canada
| | - Jessalyn K Holodinsky
- Department of Clinical Neurosciences, Calgary Stroke Program, Calgary, Alberta, Canada
| | - Nima Kashani
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada.,Department of Neurosurgery, Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | | | - Fouzi Bala
- Department of Clinical Neurosciences, Calgary Stroke Program, Calgary, Alberta, Canada
| | - MacKenzie Horn
- Department of Clinical Neurosciences, Calgary Stroke Program, Calgary, Alberta, Canada
| | - Jillian Stang
- Department of Clinical Neurosciences, Calgary Stroke Program, Calgary, Alberta, Canada.,Alberta Health Services, Foothills Medical CEnter, Calgary, Alberta, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Calgary Stroke Program, Calgary, Alberta, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, Calgary Stroke Program, Calgary, Alberta, Canada
| | - Mohammed A Almekhlafi
- Department of Clinical Neurosciences, Calgary Stroke Program, Calgary, Alberta, Canada.,Department of Radiology, University of Calgary, Calgary, Alberta, Canada
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13
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External validation of the Passive Surveillance Stroke Severity Indicator. Neurol Sci 2022; 50:399-404. [PMID: 35478064 DOI: 10.1017/cjn.2022.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The Passive Surveillance Stroke Severity (PaSSV) Indicator was derived to estimate stroke severity from variables in administrative datasets but has not been externally validated. METHODS We used linked administrative datasets to identify patients with first hospitalization for acute stroke between 2007-2018 in Alberta, Canada. We used the PaSSV indicator to estimate stroke severity. We used Cox proportional hazard models and evaluated the change in hazard ratios and model discrimination for 30-day and 1-year case fatality with and without PaSSV. Similar comparisons were made for 90-day home time thresholds using logistic regression. We also linked with a clinical registry to obtain National Institutes of Health Stroke Scale (NIHSS) and compared estimates from models without stroke severity, with PaSSV, and with NIHSS. RESULTS There were 28,672 patients with acute stroke in the full sample. In comparison to no stroke severity, addition of PaSSV to the 30-day case fatality models resulted in improvement in model discrimination (C-statistic 0.72 [95%CI 0.71-0.73] to 0.80 [0.79-0.80]). After adjustment for PaSSV, admission to a comprehensive stroke center was associated with lower 30-day case fatality (adjusted hazard ratio changed from 1.03 [0.96-1.10] to 0.72 [0.67-0.77]). In the registry sample (N = 1328), model discrimination for 30-day case fatality improved with the inclusion of stroke severity. Results were similar for 1-year case fatality and home time outcomes. CONCLUSION Addition of PaSSV improved model discrimination for case fatality and home time outcomes. The validity of PASSV in two Canadian provinces suggests that it is a useful tool for baseline risk adjustment in acute stroke.
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Ekestubbe S, Fu M, Giang KW, Lindgren M, Rosengren A, Schioler L, Schaufelberger M. Increasing home-time after a first diagnosis of heart failure in Sweden, 20 years trends. ESC Heart Fail 2022; 9:555-563. [PMID: 34837891 PMCID: PMC8788024 DOI: 10.1002/ehf2.13714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 10/22/2021] [Accepted: 10/31/2021] [Indexed: 11/11/2022] Open
Abstract
AIMS This study was performed to compare trends in home-time for patients with heart failure (HF) between those of working age and those of retirement age in Sweden from 1992 to 2012. METHODS AND RESULTS The National Inpatient Register (IPR) was used to identify all patients aged 18 to 84 years with a first hospitalization for HF in Sweden from 1992 to 2012. Information on date of death, comorbidities, and sociodemographic factors were collected from the Swedish National Register on Cause of Death, the IPR, and the longitudinal integration database for health insurance and labour market studies, respectively. The patients were divided into two groups according to their age: working age (<65 years) and retirement age (≥65 years). Follow-up was 4 years. In total, following exclusions, 388 775 patients aged 18 to 84 years who were alive 1 day after discharge from a first hospitalization for HF were included in the study. The working age group comprised 62 428 (16%) patients with a median age of 58 (interquartile range, 53-62) years and 31.2% women, and the retirement age group comprised 326 347 (84%) patients with a median age of 77 (interquartile range, 73-81) years and 47.4% women. Patients of working age had more home-time than patients of retirement age (83.8% vs. 68.2%, respectively), mainly because of their lower 4 year mortality rate (14.2% vs. 29.7%, respectively). Home-time increased over the study period for both age groups, but the increase levelled off for older women after 2007, most likely because of less reduction in mortality in older women than in the other groups. CONCLUSIONS This nationwide study showed increasing home-time over the study period except for women of retirement age and older for whom the increase stalled after 2007, mainly because of a lower mortality reduction in this group. Efforts to improve patient-related outcome measures specifically targeted to this group may be warranted.
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Affiliation(s)
- Sofia Ekestubbe
- Region Västra GötalandSahlgrenska University Hospital/ÖstraGothenburgSweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Michael Fu
- Region Västra GötalandSahlgrenska University Hospital/ÖstraGothenburgSweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Kok Wai Giang
- Region Västra GötalandSahlgrenska University Hospital/ÖstraGothenburgSweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Martin Lindgren
- Region Västra GötalandSahlgrenska University Hospital/ÖstraGothenburgSweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Annika Rosengren
- Region Västra GötalandSahlgrenska University Hospital/ÖstraGothenburgSweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Linus Schioler
- Section of Occupational and Environmental Medicine, Department of Public Health and Community Medicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Maria Schaufelberger
- Region Västra GötalandSahlgrenska University Hospital/ÖstraGothenburgSweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
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Mujanovic A, Smajlovic D. Major epidemiological features of first-ever ischemic stroke in Tuzla Canton, Bosnia and Herzegovina. Health Sci Rep 2021; 4:e445. [PMID: 34877411 PMCID: PMC8628780 DOI: 10.1002/hsr2.445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND AIMS Opacity of data on stroke for Bosnia and Herzegovina (B&H) is mainly due to the lack of a unified national stroke registry. This article aims to present updated epidemiological data on the etiology and risk factors for first-ever ischemic stroke in Tuzla Canton, B&H. METHODS This retrospective hospital-based study included all first-ever ischemic stroke patients admitted between January 1, 2018 and December 31, 2018 at the Neurology Department, University Clinical Center Tuzla. RESULTS First-ever ischemic stroke was diagnosed in 739 patients. Leading risk factors were hypertension (94%), diabetes mellitus (40.7%), and dyslipidemia (38.8%). The most common stroke subtypes were atherothrombotic (36.8%), cardioembolic (21.9%), and stroke of undetermined etiologies (19.2%). Mean NIHSS score at discharge was 13 (IQR 2-16), and favorable patient outcome (mRs ≤2) was recorded in 26.4% patients. Men (aOR 0.39; 95% CI 0.24-0.64) and younger patients (aOR 0.96; 95% CI 0.93-0.98) had significantly higher probability of having a favorable outcome at discharge. Dyslipidemia could be considered as a predictive factor for patient outcome (aOR 0.66; 95% CI 0.43-1.00). CONCLUSIONS More than 92% of our patients had at least one modifiable risk factor, with hypertension and diabetes being at the forefront. One out of four patients had become functionally independent at discharge, while hospital mortality was lower than in other Eastern European countries. The overarching goal should be steered toward the development of a national stroke registry, which should be used as a reference for all further stroke management activities.
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Affiliation(s)
- Adnan Mujanovic
- Medical FacultyUniversity of TuzlaTuzlaBosnia and Herzegovina
| | - Dzevdet Smajlovic
- Medical FacultyUniversity of TuzlaTuzlaBosnia and Herzegovina
- Department of NeurologyUniversity Clinical Center TuzlaTuzlaBosnia and Herzegovina
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16
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Nair R, Gao Y, Vaughan-Sarrazin MS, Perencevich E, Girotra S, Pandey A. Risk-Standardized Home Time as a Novel Hospital Performance Metric for Pneumonia Hospitalization Among Medicare Beneficiaries: a Retrospective Cohort Study. J Gen Intern Med 2021; 36:3031-3039. [PMID: 33904043 PMCID: PMC8481448 DOI: 10.1007/s11606-021-06712-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services (CMS) use hospital readmissions as a performance metric to incentivize hospital care for acute conditions including pneumonia. However, there are limitations to using readmission alone as a hospital performance metric. OBJECTIVE To characterize 30-day risk-standardized home time (RSHT), a novel patient-centered post-discharge performance metric for acute pneumonia hospitalizations in Medicare patients, and compare hospital rankings based on this metric with mortality and readmissions. STUDY DESIGN Retrospective, cohort study. PARTICIPANTS A cohort of Medicare fee-for-service beneficiaries admitted between January 01, 2015 and November 30, 2017. INTERVENTIONS None. MAIN MEASURES Risk-standardized hospital-level home time within 30 days of discharge was evaluated as a novel performance metric. Multilevel regression models were used to calculate hospital-level estimates and rank hospitals based on RSHT, readmission rate (RSRR), and mortality rate (RSMR). KEY RESULTS A total of 1.7 million pneumonia admissions admitted to one of the 3116 hospitals were eligible for inclusion. The median 30-day RSHT was 20.5 days (interquartile range: 18.9-21.9 days; range: 5-29 days). Hospital-level characteristics such as case volume, bed size, for-profit ownership, rural location of the hospital, teaching status, and participation in the bundled payment program were significantly associated with home time. We found a modest, inverse correlation of RSHT with RSRR (rho: -0.233, p< 0.0001) and RSMR (rho: -0.223, p< 0.0001) for pneumonia. About 1/3rd of hospitals were reclassified as high performers based on their RSHT metric compared with the rank on their RSRR and RSMR metrics. CONCLUSION Home time is a novel, patient-centered, hospital-level metric that can be easily calculated using claims data and accounts for mortality, readmission to an acute care facility, and admission to a skilled nursing facility or long-term care facility after discharge. Utilization of this patient-centered metric could have policy implications in assessing hospital performance on delivery of healthcare to pneumonia patients.
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Affiliation(s)
- Rajeshwari Nair
- Division of General Internal Medicine, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.,Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, IA, USA
| | - Yubo Gao
- Division of General Internal Medicine, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.,Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, IA, USA
| | - Mary S Vaughan-Sarrazin
- Division of General Internal Medicine, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.,Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, IA, USA
| | - Eli Perencevich
- Division of General Internal Medicine, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.,Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, IA, USA
| | - Saket Girotra
- Division of General Internal Medicine, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.,Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, IA, USA.,Division of Cardiovascular Diseases, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Fernando SM, Qureshi D, Talarico R, Dowlatshahi D, Sood MM, Smith EE, Hill MD, McCredie VA, Scales DC, English SW, Rochwerg B, Tanuseputro P, Kyeremanteng K. Short- and Long-term Health Care Resource Utilization and Costs Following Intracerebral Hemorrhage. Neurology 2021; 97:e608-e618. [PMID: 34108269 DOI: 10.1212/wnl.0000000000012355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/03/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We sought to evaluate the short- and long-term resource use and costs associated with intracerebral hemorrhage (ICH) taken from an entire population. We in addition sought to evaluate the association of oral anticoagulation (OAC) and health care costs. METHODS This was a retrospective cohort study of adult patients (≥18 years) with ICH in the entire population of Ontario, Canada (2009-2017). We captured outcomes through linkage to health administrative databases. We used generalized linear models to identify factors associated with total cost. Analysis of OAC use was limited to patients ≥66 years of age. The primary outcome was total 1-year direct health care costs in 2020 US dollars. RESULTS Among 16,248 individuals with ICH (mean age 71.2 years, male 52.3%), 1-year mortality was 46.0%, and 24.2% required mechanical ventilation. The median total 1-year cost was $26,886 (interquartile range [IQR] $9,641-$62,907) with costs for those who died in hospital of $7,268 (IQR $4,031-$14,966) vs $44,969 (IQR $20,264-$82,414, p < 0.001) for survivors to discharge. OAC use (analysis limited to individuals ≥66 years old) was associated with higher total 1-year costs (cost ratio 1.06 [95% confidence interval 1.01-1.11]). Total 1-year costs for the entire cohort exceeded $120 million per year over the study period. CONCLUSIONS ICH is associated with significant health care costs, and the median cost of a patient with ICH is roughly 10 times the median inpatient cost in Ontario. Costs were higher among survivors than deceased patients. OAC use is independently associated with increased costs. To maximize cost-effectiveness, future therapies for ICH must aim to reduce disability, not only improve mortality.
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Affiliation(s)
- Shannon M Fernando
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada.
| | - Danial Qureshi
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Robert Talarico
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Manish M Sood
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Eric E Smith
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Michael D Hill
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Victoria A McCredie
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Damon C Scales
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Shane W English
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Bram Rochwerg
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Kwadwo Kyeremanteng
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
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Holodinsky JK, Yu AYX, Kapral MK, Austin PC. Using random forests to model 90-day hometime in people with stroke. BMC Med Res Methodol 2021; 21:102. [PMID: 33971827 PMCID: PMC8112132 DOI: 10.1186/s12874-021-01289-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 04/21/2021] [Indexed: 02/05/2023] Open
Abstract
Background Ninety-day hometime, the number of days a patient is living in the community in the first 90 after stroke, exhibits a non-normal bucket-shaped distribution, with lower and upper constraints making its analysis difficult. In this proof-of-concept study we evaluated the performance of random forests regression in the analysis of hometime. Methods Using administrative data we identified stroke hospitalizations between 2010 and 2017 in Ontario, Canada. We used random forests regression to predict 90-day hometime using 15 covariates. Model accuracy was determined using the r-squared statistic. Variable importance in prediction and the marginal effects of each covariate were explored. Results We identified 75,745 eligible patients. Median 90-day hometime was 59 days (Q1: 2, Q3: 83). Random forests predicted hometime with reasonable accuracy (adjusted r-squared 0.3462); no implausible values were predicted but extreme values were predicted with low accuracy. Frailty, stroke severity, and age exhibited inverse non-linear relationships with hometime and patients arriving by ambulance had less hometime than those who did not. Conclusions Random forests may be a useful method for analyzing 90-day hometime and capturing the complex non-linear relationships which exist between predictors and hometime. Future work should compare random forests to other models and focus on improving the accuracy of predictions of extreme values of hometime. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01289-8.
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Affiliation(s)
- Jessalyn K Holodinsky
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N4N1, Canada.
| | - Amy Y X Yu
- ICES, Toronto, ON, Canada.,Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Moira K Kapral
- ICES, Toronto, ON, Canada.,Department of Medicine (General Internal Medicine), University of Toronto and University Health Network, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Peter C Austin
- ICES, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,Schulich Heart Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
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19
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Fernando SM, Qureshi D, Talarico R, Tanuseputro P, Dowlatshahi D, Sood MM, Smith EE, Hill MD, McCredie VA, Scales DC, English SW, Rochwerg B, Kyeremanteng K. Intracerebral Hemorrhage Incidence, Mortality, and Association With Oral Anticoagulation Use: A Population Study. Stroke 2021; 52:1673-1681. [PMID: 33685222 DOI: 10.1161/strokeaha.120.032550] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Spontaneous intracerebral hemorrhage (ICH) is a devastating form of stroke associated with significant morbidity and mortality. Recent epidemiological data on incidence, mortality, and association with oral anticoagulation are needed. METHODS Retrospective cohort study of adult patients (≥18 years) with ICH in the entire population of Ontario, Canada (April 1, 2009-March 30, 2019). We captured outcome data using linked health administrative databases. The primary outcome was mortality during hospitalization, as well as at 1 year following ICH. RESULTS We included 20 738 patients with ICH. Mean (SD) age was 71.3 (15.1) years, and 52.6% of patients were male. Overall incidence of ICH throughout the study period was 19.1/100 000 person-years and did not markedly change over the study period. In-hospital and 1-year mortality were high (32.4% and 45.4%, respectively). Mortality at 2 years was 49.5%. Only 14.5% of patients were discharged home independently. Over the study period, both in-hospital and 1-year mortality reduced by 10.4% (37.5% to 27.1%, P<0.001) and 7.6% (50.0% to 42.4%, P<0.001), respectively. Use of oral anticoagulation was associated with both in-hospital mortality (adjusted odds ratio 1.37 [95% CI, 1.26-1.49]) and 1-year mortality (hazard ratio, 1.18 [95% CI, 1.12-1.25]) following ICH. CONCLUSIONS Both short- and long-term mortality have decreased in the past decade. Most survivors from ICH are likely to be discharged to long-term care. Oral anticoagulation is associated with both short- and long-term mortality following ICH. These findings highlight the devastating nature of ICH, but also identify significant improvement in outcomes over time.
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Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine (S.M.F., S.W.E., K.K.), University of Ottawa, ON, Canada.,Department of Emergency Medicine (S.M.F.), University of Ottawa, ON, Canada
| | - Danial Qureshi
- School of Epidemiology and Public Health (D.Q., P.T., D.D., M.M.S., S.W.E.), University of Ottawa, ON, Canada.,ICES, Toronto, ON, Canada (D.Q., R.T., P.T., M.M.S., P.T.).,Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (D.Q., R.T., P.T., D.D., M.M.S., S.W.E., K.K.).,Bruyère Research Institute, Ottawa, ON, Canada (D.Q., P.T.)
| | - Robert Talarico
- ICES, Toronto, ON, Canada (D.Q., R.T., P.T., M.M.S., P.T.).,Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (D.Q., R.T., P.T., D.D., M.M.S., S.W.E., K.K.)
| | - Peter Tanuseputro
- School of Epidemiology and Public Health (D.Q., P.T., D.D., M.M.S., S.W.E.), University of Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine (P.T., K.K.), University of Ottawa, ON, Canada.,ICES, Toronto, ON, Canada (D.Q., R.T., P.T., M.M.S., P.T.).,Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (D.Q., R.T., P.T., D.D., M.M.S., S.W.E., K.K.).,Bruyère Research Institute, Ottawa, ON, Canada (D.Q., P.T.)
| | - Dar Dowlatshahi
- School of Epidemiology and Public Health (D.Q., P.T., D.D., M.M.S., S.W.E.), University of Ottawa, ON, Canada.,Division of Neurology, Department of Medicine (D.D.), University of Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (D.Q., R.T., P.T., D.D., M.M.S., S.W.E., K.K.)
| | - Manish M Sood
- School of Epidemiology and Public Health (D.Q., P.T., D.D., M.M.S., S.W.E.), University of Ottawa, ON, Canada.,Division of Nephrology, Department of Medicine (M.M.S.), University of Ottawa, ON, Canada.,ICES, Toronto, ON, Canada (D.Q., R.T., P.T., M.M.S., P.T.).,Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (D.Q., R.T., P.T., D.D., M.M.S., S.W.E., K.K.)
| | - Eric E Smith
- Calgary Stroke Program, Hotchkiss Brain Institute (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, AB, Canada.,Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Michael D Hill
- Calgary Stroke Program, Hotchkiss Brain Institute (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, AB, Canada.,Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, ON, Canada (V.A.M., D.C.S.).,Krembil Research Institute, Toronto Western Hospital, University Health Network, ON, Canada (V.A.M.).,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (V.A.M., D.C.S.)
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, ON, Canada (V.A.M., D.C.S.).,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (V.A.M., D.C.S.).,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada (D.C.S.)
| | - Shane W English
- Division of Critical Care, Department of Medicine (S.M.F., S.W.E., K.K.), University of Ottawa, ON, Canada.,School of Epidemiology and Public Health (D.Q., P.T., D.D., M.M.S., S.W.E.), University of Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (D.Q., R.T., P.T., D.D., M.M.S., S.W.E., K.K.)
| | - Bram Rochwerg
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (V.A.M., D.C.S.).,Department of Medicine, Division of Critical Care (B.R.), McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton, ON, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine (S.M.F., S.W.E., K.K.), University of Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine (P.T., K.K.), University of Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (D.Q., R.T., P.T., D.D., M.M.S., S.W.E., K.K.).,Institut du Savoir Montfort, Ottawa, ON, Canada (K.K.)
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20
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Guttman MP, Tillmann BW, Nathens AB, Saskin R, Bronskill SE, Huang A, Haas B. Alive and at home: Five-year outcomes in older adults following emergency general surgery. J Trauma Acute Care Surg 2021; 90:287-295. [PMID: 33502146 DOI: 10.1097/ta.0000000000003018] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND While the short-term risks of emergency general surgery (EGS) admission among older adults have been studied, little is known about long-term functional outcomes in this population. Our objective was to evaluate the relationship between EGS admission and the probability of an older adult being alive and residing in their own home 5 years later. We also examined the extent to which specific EGS diagnoses, need for surgery, and frailty modified this relationship. METHODS We performed a population-based, retrospective cohort study of community-dwelling older adults (age, ≥65 years) admitted to hospital for one of eight EGS diagnoses (appendicitis, cholecystitis, diverticulitis, strangulated hernia, bowel obstruction, peptic ulcer disease, intestinal ischemia, or perforated viscus) between 2006 and 2018 in Ontario, Canada. Cases were matched to controls from the general population. Time spent alive and at home (measured as time to nursing home admission or death) was compared between cases and controls using Kaplan-Meier analysis and Cox models. RESULTS A total of 90,245 older adults admitted with an EGS diagnosis were matched with controls. In the 5 years following an EGS admission, cases experienced significantly fewer months alive and at home compared with controls (mean time, 43 vs. 50 months; p < 0.001). Except for patients operated on for appendicitis and cholecystitis, all remaining patient subgroups experienced reduced time alive and at home compared with controls (p < 0.001). Cases remained at elevated risk of nursing home admission or death compared with controls for the entirety of the 5-year follow-up (hazard ratio, 1.17-5.11). CONCLUSION Older adults who required hospitalization for an EGS diagnosis were at higher risk for death or admission to a nursing home for at least 5 years following admission compared with controls. However, most patients (57%) remained alive and living in their own home at the end of this 5-year period. LEVEL OF EVIDENCE Epidemiological, level III.
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Affiliation(s)
- Matthew P Guttman
- From the Institute of Health Policy, Management, and Evaluation (M.P.G., B.W.T., A.B.N., S.E.B., B.H.), Department of Surgery (M.P.G., A.B.N., B.H.), and Interdepartmental Division of Critical Care Medicine, Department of Medicine (B.W.T., B.H.), University of Toronto; Evaluative Clinical Sciences, Sunnybrook Research Institute (A.B.N., S.E.B., B.H.), Toronto, Ontario, Canada; American College of Surgeons, Trauma Quality Improvement Program (A.B.N.), Chicago, Illinois; and ICES Central, ICES (R.S., S.E.B., A.H.), Toronto, Ontario, Canada
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21
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Zhang L, Wu HL, Yu HF, Zhou JL. Time spent outside of the hospital, CKD progression, and mortality: a prospective cohort study. Int Urol Nephrol 2021; 53:1659-1663. [PMID: 33386581 DOI: 10.1007/s11255-020-02749-8] [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: 09/13/2020] [Accepted: 12/07/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Home time-being out of any healthcare facility-has been proposed as a patient-centered outcome. This novel measure has not been investigated in patients with chronic kidney disease (CKD). The aim of this study is to determine whether there was an association between home time and occurrence of end-stage renal disease (ESRD) or all-cause mortality during 1 year of follow-up. METHODS We assembled a prospective cohort of patients with CKD not requiring dialysis at the Nephrology Center of First Affiliated Hospital of Jiaxing University between May 2014 and April 2017 and followed up for 1 year. Home time was calculated as the number of days spent out of a hospital, rehabilitation facility, or skilled nursing facility. Outcomes included progression to ESRD and all-cause mortality. RESULTS Among 943 patients, 882 (93.5%) had complete follow-up through 1 year. Mean home time was 246.9 ± 126.7 days. In regression analysis, several patient characteristics were associated with significantly reduced home time, including diabetes mellitus, cardiovascular disease, and albuminuria. Home time was strongly correlated with time-to-event endpoints of ESRD (τ=0.324) and all-cause mortality (τ=0.785). CONCLUSIONS Home time is significantly reduced for patients with CKD not requiring dialysis and is highly correlated with traditional time-to-event endpoints. Home time serves as a novel, easily calculated, patient-centered outcome that may reflect effect of interventions on future CKD research.
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Affiliation(s)
- Lin Zhang
- Department of Nephrology, Affiliated Hospital of Jiaxing University, 1882 Zhonghuan South Road, Jiaxing, 314000, China
| | - Heng-Lan Wu
- Department of Nephrology, Affiliated Hospital of Jiaxing University, 1882 Zhonghuan South Road, Jiaxing, 314000, China
| | - Hai-Feng Yu
- Department of Nephrology, Affiliated Hospital of Jiaxing University, 1882 Zhonghuan South Road, Jiaxing, 314000, China
| | - Jun-Liang Zhou
- Department of Nephrology, Affiliated Hospital of Jiaxing University, 1882 Zhonghuan South Road, Jiaxing, 314000, China.
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22
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Ortiz JF, Ruxmohan S, Saxena A, Morillo Cox Á, Bashir F, Tambo W, Ghani MR, Moya G, Córdova I. Minocycline and Magnesium As Neuroprotective Agents for Ischemic Stroke: A Systematic Review. Cureus 2020; 12:e12339. [PMID: 33520535 PMCID: PMC7837630 DOI: 10.7759/cureus.12339] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 12/28/2020] [Indexed: 02/07/2023] Open
Abstract
Stroke is a leading cause of death, disability, and dementia worldwide. Strokes can be divided into ischemic strokes and hemorrhagic strokes. At the moment, tissue plasminogen activator (tPA) is the only FDA-approved drug for ischemic stroke. Minocycline (MC) and Magnesium (Mg) are promising therapies for ischemic stroke, especially in the pre-hospital setting. These drugs are readily available, inexpensive, and generally safe. We decided to investigate these drugs' neuroprotective effects in treating ischemic stroke in the acute and chronic setting. We conducted a systematic review of the published literature on MC and Mg's functional outcome in ischemic stroke. This paper's methodology included only clinical trials published in the last 15 years, using PubMed as a database. The systematic review demonstrated that MC infusion in the pre-hospital and hospital setting improved functional outcomes and disability scores. Furthermore, MC also decreased matrix metalloproteinase 9 (MMP-9) levels. MC might have a more significant effect on men than women because different molecular pathways of cerebral ischemia seem to be involved between both genders. The systematic review showed that patients with ischemic stroke did not benefit from magnesium sulfate infusion in the pre-hospital and hospital setting. Nevertheless, patients with lacunar strokes and patients who supplemented their meals with potassium-magnesium salt in the diet had better functional outcomes. Future studies would need a more significant sample of participants and a better selection to increase the study's power and avoid selection bias, respectively. Further publications could benefit from subcategorizing strokes and investigating the gender role in stroke treatment. These directives could give a more robust conclusion regarding the neuroprotective effects of these drugs.
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Affiliation(s)
- Juan Fernando Ortiz
- Neurology, Universidad San Francisco de Quito, Quito, ECU
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | | | - Alisha Saxena
- Neurology, Dayanand Medical College and Hospital, Ludhiana, IND
| | | | - Farah Bashir
- Internal Medicine, Liaquat University of Medical & Health Sciences, Hyderabad, PAK
| | - Willians Tambo
- Neurology, Universidad San Francisco de Quito, Quito, ECU
| | - Mohammad R Ghani
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Gustavo Moya
- Emergency Medicine, Carlos Andrade Marín Hospital, Quito, ECU
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23
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Fernando SM, Qureshi D, Tanuseputro P, Talarico R, Hibbert B, Mathew R, Rochwerg B, Belley-Côté EP, Fan E, Combes A, Brodie D, Schmidt M, Simard T, Di Santo P, Kyeremanteng K. Long-term mortality and costs following use of Impella® for mechanical circulatory support: a population-based cohort study. Can J Anaesth 2020; 67:1728-1737. [PMID: 32671805 DOI: 10.1007/s12630-020-01755-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/22/2020] [Accepted: 04/27/2020] [Indexed: 12/11/2022] Open
Abstract
PURPOSE The Impella® device is a form of mechanical circulatory support (MCS) used in critically ill adults with cardiogenic shock. We sought to evaluate short- and long-term outcomes following the use of Impella, including mortality, healthcare utilization, and costs. METHODS Population-based, retrospective cohort study of adult patients (≥ 16 yr) receiving Impella in Ontario, Canada (1 April 2012-31March 2019). We captured outcomes through linkage to health administrative databases. The primary outcome was mortality during hospitalization. Secondary outcomes included mortality at 30 days, 90 days, and one year following Impella insertion. We analyzed health system costs in Canadian dollars in the year following the date of the index admission, including the costs of inpatient admission. RESULTS We included 162 patients. Mean (standard deviation) age was 59.2 (14.5) yr, and 73.5% of patients were male. Median [interquartile range (IQR)] time to Impella insertion from date of hospital admission was 2 [1-9] days. In-hospital mortality was 56.8%, and a significant proportion of patients were bridged to a ventricular assist device (67.9%). Mortality at one year was 61.7%. Among hospital survivors, only 38.6% were discharged home independently. Median [IQR] total cost in the year following admission among all patients was $88,397 [32,718-225,628], of which $66,529 [22,789-183,165] was attributed to inpatient care. CONCLUSIONS In-hospital mortality among patients with cardiogenic shock receiving Impella is high, but with minimal increase at one year. While Impella patients accrued substantial costs, these largely reflected inpatient costs, and not costs incurred following hospital discharge.
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Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Danial Qureshi
- ICES, Toronto, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
| | - Peter Tanuseputro
- ICES, Toronto, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Robert Talarico
- ICES, Toronto, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Benjamin Hibbert
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Rebecca Mathew
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Côté
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Alain Combes
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Pitié Salpêtrière, Paris, France
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Matthieu Schmidt
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Pitié Salpêtrière, Paris, France
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Trevor Simard
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Pietro Di Santo
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Institut du Savoir Montfort, Ottawa, ON, Canada
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24
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Yu AYX, Hill MD. In-Hospital Acute Strokes—Opportunities to Optimize Care and Improve Outcomes. JAMA Neurol 2020; 77:1482-1483. [DOI: 10.1001/jamaneurol.2020.3368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Amy Y. X. Yu
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michael D. Hill
- Department of Clinical Neurosciences, Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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25
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Sex Differences in Endovascular Treatment for Stroke: A Population-based Analysis. Can J Neurol Sci 2020; 48:479-486. [PMID: 33081850 DOI: 10.1017/cjn.2020.237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Acute ischemic stroke may affect women and men differently. We aimed to evaluate sex differences in outcomes of endovascular treatment (EVT) for ischemic stroke due to large vessel occlusion in a population-based study in Alberta, Canada. METHODS AND RESULTS Over a 3-year period (April 2015-March 2018), 576 patients fit the inclusion criteria of our study and constituted the EVT group of our analysis. The medical treatment group of the ESCAPE trial had 150 patients. Thus, our total sample size was 726. We captured outcomes in clinical routine using administrative data and a linked database methodology. The primary outcome of our study was home-time. Home-time refers to the number of days that the patient was back at their premorbid living situation without an increase in the level of care within 90 days of the index stroke event. In adjusted analysis, EVT was associated with an increase of 90-day home-time by an average of 6.08 (95% CI -2.74-14.89, p-value 0.177) days in women compared to an average of 11.20 (95% CI 1.94-20.46, p-value 0.018) days in men. Further analysis revealed that the association between EVT and 90-day home-time in women was confounded by age and onset-to-treatment time. CONCLUSIONS We found a nonsignificant nominal reduction of 90-day home-time gain for women compared to men in this province-wide population-based study of EVT for large vessel occlusion, which was only partially explained by confounding.
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26
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Kamal N, Jeerakathil T, Stang J, Liu M, Rogers E, Smith EE, Demchuk AM, Siddiqui M, Mann B, Bestard J, Lang E, Shand E, Benard M, Collins L, Martin K, Hartley C, Reiber M, Valaire S, Mrklas KJ, Hill MD, Allen D, Anderson B, Angelstand J, Anokye E, Antymniuk C, Arsenault N, Ashman B, Baker K, Bakker J, Balenga D, Berg M, Berry LA, Betzner M, Black L, Blain D, Boutilier T, Brady J, Lynn Brewster S, Brown P, Buchynski K, Bugbee E, Bullard M, Burke D, Burnett C, Butcher K, Cackett P, Canham H, Chiovetti A, Chivers L, Cobb C, Cote M, Coutts S, Currie D, Eric Daniels J, Desouza N, Diebert M, Dixon T, Dotchin J, Duckett S, Dustow V, Dwyer R, Dymond M, Edmond C, Eesa M, Elias N, Elliott T, Empson S, Falls L, Forder M, Foreman R, Forsythe D, Fortier T, Fowler L, Franklin S, Garland J, Garon C, Gerl D, Ghauri I, Gough S, Mark KG, Mary-Lou Halabi G, Halldorson S, Harsch J, Hatcher C, Hebner K, Hemsley R, Holloway D, Holman D, Holsworth S, Holton S, Hull G, Hyciek B, Ibach R, Imoukhuede O, Jeal B, Jill D, Johnson M, Jones O, Kabaroff A, Kalashyan H, Kay F, Kaytor P, Keppy T, King P, Kiszszak S, Klick R, Koshurba E, Kruhlak R, Lacasse J, Lane M, Laughs T, Laut-Barss L, Lavalee P, Leclair T, Linden P, Linderman T, Livingstone J, Lodder M, Lundgard K, Lyle E, Mackenzie K, Malarczuk A, Malfair D, Malone J, Manosalva Alzate H, McCann K, McCarthy S, McKenzie M, McRobert L, Meroniuk D, Millar R, Miller R, Mir B, Montpetit J, Morissette J, Morrison L, Murray-Galbraith F, Mydeen F, Namagiri L, Neidig N, Neil G, Newcommon N, Newell C, Nichol C, Norris C, Norton D, Noseworthy S, O’Hara L, O’Neail S, Orr W, Panes E, Panes T, Paradis J, Parry T, Peacock D, Peebles T, Petersen S, Phelps I, Pooley R, Potvin N, Pryor R, Ramsahoye M, Rashead M, Reedyk K, Reynolds D, Rideout S, Rimmer K, Salih E, San Agustin P, Sandbeck D, Sattar S, Sauter N, Schmidt K, Seib E, Selzler J, Sevcik B, Sharman D, Shuaib A, Smith D, Snider B, Snider J, Stander J, Stephenson C, Stewart C, Stoyberg C, Suranyi Y, Tablin M, Taralson C, Throndson J, Traverse K, van der Nest D, Van Mulligan T, Van Vuuren C, Vanderlinde E, Vilneff R, Volk G, Wall K, Wang DJ(T, Warharft D, Watson J, Weir L, Weiss D, Welch D, Winder T, Winsor W, Woudstra D, Youn D, Young L, Zerna C. Provincial Door-to-Needle Improvement Initiative Results in Improved Patient Outcomes Across an Entire Population. Stroke 2020; 51:2339-2346. [DOI: 10.1161/strokeaha.120.029734] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
Improving door-to-needle times (DNTs) for thrombolysis of acute ischemic stroke patients improves outcomes, but participation in DNT improvement initiatives has been mostly limited to larger, academic medical centers with an existing interest in stroke quality improvement. It is not known whether quality improvement initiatives can improve DNT at a population level, including smaller community hospitals. This study aims to determine the effect of a provincial improvement collaborative intervention on improvement of DNT and patient outcomes.
Methods:
A pre post cohort study was conducted over 10 years in the Canadian province of Alberta with 17 designated stroke centers. All ischemic stroke patients who received thrombolysis in the Canadian province of Alberta were included in the study. The quality improvement intervention was an improvement collaborative that involved creation of interdisciplinary teams from each stroke center, participation in 3 workshops and closing celebration, site visits, webinars, and data audit and feedback.
Results:
Two thousand four hundred eighty-eight ischemic stroke patients received thrombolysis in the pre- and postintervention periods (630 in the post period). The mean age was 71 years (SD, 14.6 years), and 46% were women. DNTs were reduced from a median of 70.0 minutes (interquartile range, 51–93) to 39.0 minutes (interquartile range, 27–58) for patients treated per guideline (
P
<0.0001). The percentage of patients discharged home from acute care increased from 45.6% to 59.5% (
P
<0.0001); the median 90-day home time increased from 43.3 days (interquartile range, 27.3–55.8) to 53.6 days (interquartile range, 36.8–64.6) (
P
=0.0015); and the in-hospital mortality decreased from 14.5% to 10.5% (
P
=0.0990).
Conclusions:
The improvement collaborative was likely the key contributing factor in reducing DNTs and improving outcomes for ischemic stroke patients across Alberta.
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Affiliation(s)
- Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, Nova Scotia, Canada (N.K.)
- Department of Clinical Neurosciences (N.K., E.E.S., A.M.D., M.D.H.), University of Calgary, Alberta, Canada
| | - Thomas Jeerakathil
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (T.J., M.S.)
| | - Jillian Stang
- Data Analytics, Alberta Health Services, Canada (J.S., M.L.)
| | - Mingfu Liu
- Data Analytics, Alberta Health Services, Canada (J.S., M.L.)
| | - Edwin Rogers
- Strategic Management Branch, Government of Saskatchewan, Regina, Canada (E.R.)
| | - Eric E. Smith
- Department of Clinical Neurosciences (N.K., E.E.S., A.M.D., M.D.H.), University of Calgary, Alberta, Canada
- Department of Community Health Sciences (E.E.S., K.J.M., M.D.H.), University of Calgary, Alberta, Canada
| | - Andrew M. Demchuk
- Department of Clinical Neurosciences (N.K., E.E.S., A.M.D., M.D.H.), University of Calgary, Alberta, Canada
- Department of Radiology (A.M.D., M.D.H.), University of Calgary, Alberta, Canada
| | - Muzaffar Siddiqui
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (T.J., M.S.)
- Grey Nuns Community Hospital, Edmonton, Alberta, Canada (M.S.)
| | - Balraj Mann
- Cardiovascular Health and Stroke, Strategic Clinical Network, Alberta Health Services, Edmonton, Canada (B.M., S.V.)
| | | | - Eddy Lang
- Department of Emergency Medicine (E.L.), University of Calgary, Alberta, Canada
| | - Elaine Shand
- Red Deer Regional Hospital Centre, Alberta, Canada (J.B., E.S.)
| | | | - Lisa Collins
- North Zone, Alberta Health Services, Cold Lake, Canada (L.C.)
| | - Kevin Martin
- Chinook Regional Hospital, Lethbridge, Alberta, Canada (K.M., C.H.)
| | - Corinna Hartley
- Chinook Regional Hospital, Lethbridge, Alberta, Canada (K.M., C.H.)
| | - Marnie Reiber
- Lloydminster Hospital, Lloydminster, Alberta/Saskatchewan, Canada (M.R.)
| | - Shelley Valaire
- Cardiovascular Health and Stroke, Strategic Clinical Network, Alberta Health Services, Edmonton, Canada (B.M., S.V.)
| | - Kelly J. Mrklas
- Department of Community Health Sciences (E.E.S., K.J.M., M.D.H.), University of Calgary, Alberta, Canada
- System Innovation and Programs, Strategic Clinical Networks, Alberta Health Services, Calgary, Canada (K.J.M.)
| | - Michael D. Hill
- Department of Clinical Neurosciences (N.K., E.E.S., A.M.D., M.D.H.), University of Calgary, Alberta, Canada
- Department of Community Health Sciences (E.E.S., K.J.M., M.D.H.), University of Calgary, Alberta, Canada
- Department of Radiology (A.M.D., M.D.H.), University of Calgary, Alberta, Canada
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Sung SF, Su CC, Hsieh CY, Cheng CL, Chen CH, Lin HJ, Chen YW, Kao Yang YH. Home-Time as a Surrogate Measure for Functional Outcome After Stroke: A Validation Study. Clin Epidemiol 2020; 12:617-624. [PMID: 32606987 PMCID: PMC7305833 DOI: 10.2147/clep.s245817] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 05/05/2020] [Indexed: 01/05/2023] Open
Abstract
Purpose Home-time has been found to correlate well with modified Rankin Scale (mRS) scores in patients with stroke. This study aimed to determine its correlations in patients with different types of stroke at various time points after stroke in a non-Western population. Methods This study used linked data from multi-center stroke registry databases and a nationwide claims database of health insurance. Functional outcomes as measured with the modified Rankin Scale were obtained from the registry databases and home-time was derived from the claims database. Spearman correlation coefficients were used to assess the correlation between home-time and mRS scores. The area under the receiver operating characteristic curve (AUC) was used to evaluate the performance of home-time in predicting good functional outcome. Results This study included 7959 patients hospitalized for stroke or transient ischemic attack (TIA), for whom mRS scores were available in 6809, 6694, and 4330 patients at 90, 180, and 365 days, respectively. Home-time was highly correlated with mRS scores at the three time-points in patients with ischemic (Spearman's rho -0.69 to -0.83) or hemorrhagic (Spearman's rho -0.86 to -0.88) stroke, but the correlation was only weak to moderate in those with TIA (Spearman's rho -0.32 to -0.58). Home-time predicted good functional outcome with excellent discrimination in patients with ischemic (AUCs >0.8) or hemorrhagic (AUCs >0.9) stroke but less so in those with TIA (AUCs >0.7). Conclusion Home-time was highly correlated with mRS scores and showed excellent discrimination in predicting good functional outcome in patients with ischemic or hemorrhagic stroke. Home-time could serve as a valid surrogate measure for functional outcome after stroke.
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Affiliation(s)
- Sheng-Feng Sung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi, Taiwan
| | - Chien-Chou Su
- Department of Pharmacy, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Health Outcome Research Center, National Cheng Kung University, Tainan, Taiwan
| | - Cheng-Yang Hsieh
- Department of Pharmacy, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan
| | - Ching-Lan Cheng
- Department of Pharmacy, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Health Outcome Research Center, National Cheng Kung University, Tainan, Taiwan.,School of Pharmacy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Hung Chen
- Department of Neurology, National Cheng Kung University Hospital and College of Medicine, Tainan, Taiwan
| | - Huey-Juan Lin
- Department of Neurology, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Wei Chen
- Department of Neurology, Landseed International Hospital, Taoyuan, Taiwan.,Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yea-Huei Kao Yang
- Department of Pharmacy, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Health Outcome Research Center, National Cheng Kung University, Tainan, Taiwan.,School of Pharmacy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Ganesh A, Luengo-Fernandez R, Pendlebury ST, Rothwell PM. Weights for ordinal analyses of the modified Rankin Scale in stroke trials: A population-based cohort study. EClinicalMedicine 2020; 23:100415. [PMID: 32577611 PMCID: PMC7300241 DOI: 10.1016/j.eclinm.2020.100415] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/13/2020] [Accepted: 05/27/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Ordinal/shift analyses of ordered measures like the modified Rankin Scale(mRS) are underused as primary trial outcomes for neurological disorders - despite statistical advantages - potentially hindered by poor clinical interpretability versus dichotomies, and by valuing state-transitions equally (linear scale). Weighted ordinal analyses incorporating step-changes at key transitions might have greater statistical validity and clinical applicability. METHODS In a prospective population-based cohort of ischaemic stroke (Oxford Vascular Study, recruited 2002-2014), we stratified 5-year outcomes of death, dementia, and/or institutionalization, health/social-care costs, and EuroQol-derived quality-adjusted life-expectancy(QALE) by 3-month mRS. We compared root-mean-square errors(RMSEs) from linear regressions for these outcomes with the mRS coded as a linear scale versus incorporating a spline at transitions 1-2, 2-3, or 3-4. We derived 3-month mRS weights for probability of 5-year death/dementia/institutionalization using age/sex-adjusted logistic regressions, and cost and QALE weights from 1000-bootstraps. We applied these weights to analyse recent trials of thrombectomy for acute ischaemic stroke. FINDINGS Among 1,607 patients, a non-linear (S-shaped) relationship was observed between 3-month mRS and each 5-year outcome, with RMSEs 18-73% lower using a spline at mRS 2-3 versus a linear representation. Age/sex-adjusted probability weights for 5-year death/dementia/institutionalization were: mRS 0=0.19; 1=0.27; 2=0.41; 3=0.73; 4=0.77; 5=0.94 (mRS 6=1 by definition). Similar trends were seen with costs; estimated 5-year QALEs were: mRS 0=3.88; 1=3.49; 2=3.01; 3=1.87; 4=1.30; 5=0.06; 6=0. Results were similar stratifying by age/sex, and excluding pre-morbidly disabled patients. Using a weighted ordinal approach, estimates of thrombectomy impact were more favourable than estimates with dichotomous approaches, 5-year cost reductions being 29% higher than with 0-2/3-6, and over three-fold higher than with 0-1/2-6 dichotomy. INTERPRETATION Our findings favour weighting the mRS in ordinal analyses for stroke and other neurological disorders, as state-transitions differ in clinical prognosis, quality-of-life, and costs. These weights could also be used for prognostication and cost-effectiveness analyses. FUNDING Wellcome Trust, Wolfson Foundation, NIHR Oxford Biomedical Research Centre, Rhodes Trust.
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29
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Gattellari M, Goumas C, Jalaludin B, Worthington J. Measuring stroke outcomes for 74 501 patients using linked administrative data: System-wide estimates and validation of 'home-time' as a surrogate measure of functional status. Int J Clin Pract 2020; 74:e13484. [PMID: 32003055 DOI: 10.1111/ijcp.13484] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/20/2020] [Accepted: 01/27/2020] [Indexed: 01/06/2023] Open
Abstract
AIMS Administrative data offer cost-effective, whole-of-population stroke surveillance yet the lack of validated measures of functional status is a shortcoming. The number of days spent living at home after stroke ('home-time') is a patient-centred outcome that can be objectively ascertained from administrative data. Population-based validation against both severity and outcome measures and for all subtypes is lacking. We aimed to report representative 'home-time' estimates and validate 'home-time' as a surrogate measure of functional status after stroke. METHODS Stroke hospitalisations from a state-wide census in New South Wales, Australia, from January 1, 2005 to March 31, 2014 were linked to prehospital data, poststroke admissions and deaths. We correlated 90-day 'home-time' with Glasgow Coma Scale (GCS) scores, measured upon a patient's initial contact with paramedics and Functional Independence Measure (FIM) scores, measured upon entry to rehabilitation after the acute hospital stroke admission. Negative binomial regressions identified predictors of 'home-time'. RESULTS Patients with stroke (N = 74 501) spent a median of 53 days living at home 90 days after the event. Median 'home-time' was 60 days after ischaemic stroke, 49 days after subarachnoid haemorrhage and 0 days after intracerebral haemorrhage. GCS and FIM scores significantly correlated with 'home-time' (P < .001). Women spent significantly less time at home compared with men after stroke, although being married increased 'home-time' after ischaemic stroke and subarachnoid haemorrhage. CONCLUSIONS These findings underscore the immediate and adverse impact of stroke. 'Home-time' measured using administrative data is a robust, replicable and valid patient-centred outcome enabling inexpensive population-based surveillance and system-wide quality assessment.
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Affiliation(s)
- Melina Gattellari
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Chris Goumas
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
- School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Bin Jalaludin
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
- Population Health Intelligence, Healthy People and Places Unit, South Western Sydney Local Health District, Sydney, NSW, Australia
- School of Public Health, The University of New South Wales, Sydney, NSW, Australia
| | - John Worthington
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, NSW, Australia
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30
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Zerna C, Rogers E, Rabi DM, Demchuk AM, Kamal N, Mann B, Jeerakathil T, Buck B, Shuaib A, Rempel J, Menon BK, Goyal M, Hill MD. Comparative Effectiveness of Endovascular Treatment for Acute Ischemic Stroke: A Population-Based Analysis. J Am Heart Assoc 2020; 9:e014541. [PMID: 32208827 PMCID: PMC7428615 DOI: 10.1161/jaha.119.014541] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background A heterogeneous patient population receives endovascular treatment (EVT) for acute ischemic stroke caused by proximal large-vessel occlusion every day. We aimed to conduct a population-based study of EVT in the province of Alberta, Canada, to understand the effectiveness in a complete population and how the magnitude of effect differs from the artificial world of clinical trials. Methods and Results Within a 3-year period (April 2015 to March 2018), 576 patients fit the inclusion criteria of our study and constituted the EVT group of our analysis. The medical treatment group of the ESCAPE (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT [Computed Tomography] to Recanalization Times) trial had 150 patients. Thus, our total sample size was 726. We captured outcomes in clinical routine using administrative data and a linked database method. Primary outcome of our study was home-time. Home-time refers to the number of days that the patient was back at premorbid living situation without increase in level of care within 90 days of index stroke event. Median age of patients was 70 years (interquartile range, 59-81 years), and 47.8% were women. Median National Institutes of Health Stroke Scale score was 17 (interquartile range, 13-20). EVT was associated with an increased 90-day home-time by an average of 8.5 days compared with medical treatment alone using Cragg hurdle regression (P=0.009). Age and higher National Institutes of Health Stroke Scale score were associated with decreased 90-day home-time (both P<0.001). Multivariable logistic regression showed no association between EVT and mortality at 90 days (odds ratio, 0.76; 95% CI, 0.47-1.24). Conclusions EVT for acute ischemic stroke caused by proximal large-vessel occlusion was effective in our province-wide population-based study and results in an increase of 90-day home-time by ~8.5 days.
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Affiliation(s)
- Charlotte Zerna
- Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Alberta Canada.,Department of Community Health Sciences University of Calgary Alberta Canada
| | - Edwin Rogers
- Clinical Analytics Alberta Health Services Edmonton Alberta Canada
| | - Doreen M Rabi
- Department of Community Health Sciences University of Calgary Alberta Canada.,Department of Medicine Cumming School of Medicine University of Calgary Alberta Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Alberta Canada.,Hotchkiss Brain Institute University of Calgary Alberta Canada.,Department of Radiology Cumming School of Medicine University of Calgary Alberta Canada
| | - Noreen Kamal
- Department of Industrial Engineering Dalhousie University Halifax Nova Scotia Canada
| | - Balraj Mann
- Cardiovascular Health and Stroke Strategic Clinical Network Alberta Health Services Edmonton Alberta Canada
| | - Tom Jeerakathil
- Division of Neurology Department of Medicine University of Alberta Edmonton Alberta Canada
| | - Brian Buck
- Division of Neurology Department of Medicine University of Alberta Edmonton Alberta Canada
| | - Ashfaq Shuaib
- Division of Neurology Department of Medicine University of Alberta Edmonton Alberta Canada
| | - Jeremy Rempel
- Department of Radiology and Diagnostic Imaging University of Alberta Edmonton Alberta Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Alberta Canada.,Hotchkiss Brain Institute University of Calgary Alberta Canada
| | - Mayank Goyal
- Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Alberta Canada.,Department of Radiology Cumming School of Medicine University of Calgary Alberta Canada
| | - Michael D Hill
- Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Alberta Canada.,Hotchkiss Brain Institute University of Calgary Alberta Canada.,Department of Community Health Sciences University of Calgary Alberta Canada.,Department of Radiology Cumming School of Medicine University of Calgary Alberta Canada
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31
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Savsin M, Dubourg D, Coppieters Y, Collart P. [Analysis of comorbidities in hospitalized patients for ischemic stroke and their effects on lethality]. Ann Cardiol Angeiol (Paris) 2020; 69:31-36. [PMID: 31542203 DOI: 10.1016/j.ancard.2019.07.008] [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: 09/27/2018] [Revised: 03/07/2019] [Accepted: 07/22/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES The aim of the study consists of analyzing the comorbidities of acute ischemic stroke and those influencing its hospital lethality. METHODS We considered patients from Wallonia aged 25 years or more and admitted to a Belgian hospital for an acute ischemic stroke in 2013 and 2014. The analyzed medico-administrative data are taken from the Minimum Hospital Summary. A factorial correspondence analysis (FCA) was used to demonstrate the comorbidities profiles. A logistic regression was used to analyse the comorbidities influencing hospital lethality by ischemic stroke. RESULTS The stroke risk factors vary according to the age. Cardiac problems are more common in older people aged 85 years or more. High blood pressure, hypercholesterolemia and diabetes are more present between 65- and 84-year-olds. Overweight is more present between 55 and 74-year-olds. People who are addicted to alcohol or tobacco are often 65 years or younger. The logistic regression showed that age and heart problems are the risk factors that increase lethality. However there is a lethality diminution in the presence of high blood pressure, hypercholesterolemia, overweight and addiction to alcohol or tobacco. CONCLUSION This study demonstrates that medico-administrative databases and factorial statistical methods are perfectly adapted to confirm the ischemic stroke risk factors. This type of study will allow to target with more precision the secondary and tertiary prevention actions of stroke.
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Affiliation(s)
- M Savsin
- Centre de recherche épidémiologie, biostatistiques et recherche clinique, école de santé publique, université libre de Bruxelles (U.L.B.), Route de Lennik 808, CP 596, 1070 Brussels, Belgique.
| | - D Dubourg
- Agence pour une vie de qualité, rue de la Rivelaine 21, 6061 Charleroi, Belgique.
| | - Y Coppieters
- Centre de recherche épidémiologie, biostatistiques et recherche clinique, école de santé publique, université libre de Bruxelles (U.L.B.), Route de Lennik 808, CP 596, 1070 Brussels, Belgique.
| | - P Collart
- Centre de recherche épidémiologie, biostatistiques et recherche clinique, école de santé publique, université libre de Bruxelles (U.L.B.), Route de Lennik 808, CP 596, 1070 Brussels, Belgique; Agence pour une vie de qualité, rue de la Rivelaine 21, 6061 Charleroi, Belgique.
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Kim MS, Joo MC, Sohn MK, Lee J, Kim DY, Lee SG, Shin YI, Kim SY, Oh GJ, Lee YS, Han EY, Han J, Ahn J, Chang WH, Kim YH, Choi JY, Hyun Kang S, Kim YT. Development and validation of a prediction model for home discharge in patients with moderate stroke: The Korean stroke cohort for functioning and rehabilitation study. Top Stroke Rehabil 2020; 27:453-461. [PMID: 31941411 DOI: 10.1080/10749357.2019.1711338] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Previous studies have investigated the predictors for home discharge without considering stroke severity. OBJECTIVES To develop a practical assessment tool that predicts home discharge for moderate stroke patients after subacute rehabilitation therapy in the tertiary hospitals. METHODS Stroke patients with National Institutes of Health Stroke Scale scores of 6 to 13 were included in this prospective cohort study. Various demographic, clinical, and functional factors were analyzed as potential predictive factors. A weighted scoring model was developed through the following three-step process: 1) selection of the factors by logistic regression analyses, 2) development of a weighted scoring model, and 3) validation of the generalizability of the model. RESULTS The home discharge rate was 51% (n = 372), and the overall mean length of stay of hospitalization was 32.5 days. 1) The Cognitive Functional Independence Measure, 2) the Functional Ambulation Categories, 3) the modified Charlson Comorbidity Index, and 4) marital status were independent predictors of home discharge. The coefficient value for marital status was adjusted to 1 in the scoring system, and the values of the other parameters were proportionally converted to the nearest integer. Possible total scores ranged from 0 to 13 in the model, with a higher score indicating a higher probability of home discharge. With a cutoff point of 7, this model showed 87.0% sensitivity and 86.2% specificity (area under the curve = 0.90). CONCLUSIONS This novel assessment tool can be useful in predicting home discharge after subacute rehabilitation of moderate stroke patients.
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Affiliation(s)
- Min-Su Kim
- Department of Rehabilitation Medicine, Wonkwang University School of Medicine , Iksan, Republic of Korea
| | - Min Cheol Joo
- Department of Rehabilitation Medicine, Wonkwang University School of Medicine , Iksan, Republic of Korea
| | - Min Kyun Sohn
- Department of Rehabilitation Medicine, School of Medicine, Chungnam National University , Daejeon, Republic of Korea
| | - Jongmin Lee
- Department of Rehabilitation Medicine, Konkuk University School of Medicine , Seoul, Republic of Korea
| | - Deog Young Kim
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine , Seoul, Republic of Korea
| | - Sam-Gyu Lee
- Department of Physical and Rehabilitation Medicine, Chonnam National University Medical School , Gwangju, Republic of Korea
| | - Yong-Il Shin
- Department of Rehabilitation Medicine, Pusan National University School of Medicine, Pusan National University Yangsan Hospital , Busan, Republic of Korea
| | - Soo-Yeon Kim
- Department of Rehabilitation Medicine, Pusan National University School of Medicine, Pusan National University Yangsan Hospital , Busan, Republic of Korea
| | - Gyung-Jae Oh
- Department of Preventive Medicine, Wonkwang University, School of Medicine , Iksan, Republic of Korea
| | - Yang-Soo Lee
- Department of Rehabilitation Medicine, Kyungpook National University School of Medicine, Kyungpook National University Hospital , Daegu, Republic of Korea
| | - Eun Young Han
- Department of Rehabilitation Medicine, Jeju National University Hospital, Jeju National University School of Medicine , Jeju, Republic of Korea
| | - Junhee Han
- Department of Statistics, Hallym University , Chuncheon, Republic of Korea
| | - Jeonghoon Ahn
- Department of Health Convergence, Ewha Womans University , Seoul, Republic of Korea
| | - Won Hyuk Chang
- Department of Physical and Rehabilitation Medicine, Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine , Seoul, Republic of Korea
| | - Yun-Hee Kim
- Department of Physical and Rehabilitation Medicine, Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine , Seoul, Republic of Korea
| | - Ji Yoo Choi
- Korea Centers for Disease Control and Prevention, Division of Chronic Disease Prevention,Center for Disease
| | - Sung Hyun Kang
- Korea Centers for Disease Control and Prevention, Division of Chronic Disease Prevention,Center for Disease
| | - Young Taek Kim
- Korea Centers for Disease Control and Prevention, Division of Chronic Disease Prevention,Center for Disease
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Jerath A, Austin PC, McCormack D, Wijeysundera DN. Impact of postoperative intensive care unit utilization on postoperative outcomes in adults undergoing major elective noncardiac surgery. J Clin Anesth 2020; 62:109707. [PMID: 31951918 DOI: 10.1016/j.jclinane.2020.109707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/02/2019] [Accepted: 01/04/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE There is a wide variation between hospitals with respect to rates of use of postoperative intensive care unit (ICU) after major noncardiac surgery. Whether ICU care improves patient-centered outcomes remains unknown. Days alive and out of hospital (DAH) is a novel patient-centered outcome that has been validated for surgical patients. We conducted a population-based cohort study to evaluate the association of hospital-level postoperative ICU use with DAH after select major elective noncardiac surgery. DESIGN Historical cohort study. SETTING Acute hospitals in Ontario, Canada. PATIENTS Adults aged ≥40 years who underwent lower gastrointestinal, peripheral arterial disease and nephrectomy surgery between 2006 and 2016. INTERVENTION The main exposure was admission to ICU within 24 h after surgery. MEASUREMENT The primary outcome was DAH at 30 days (DAH30) and secondary outcomes were DAH at 90 and 180 days (DAH90 and DAH180). Hospitals were ranked into quartiles based on the hospital-specific proportion of patients admitted to ICU within 24 h post-surgery. Descriptive statistics and hierarchical multivariable quantile regression modeling were used to assess the unadjusted and adjusted association of hospital-level ICU use with the primary and secondary outcomes for each surgical procedure. MAIN RESULTS The cohort included 91,950 patients. Median DAH30 was 23 days for lower gastrointestinal resection, 24 days for peripheral arterial disease and 26 days for nephrectomy. Higher hospital-specific use of ICU use after surgery was not associated with improved DAH30, DAH90 or DAH180 for any surgical group. CONCLUSIONS Hospital-specific ICU admission practice showed no association with the patient-centered outcome of DAH in select elective major noncardiac surgical procedures.
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Affiliation(s)
- Angela Jerath
- Department of Anesthesia, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, M3200, Toronto, ON M4N 3M5, Canada; Department of Anesthesiology and pain management, University of Toronto, Room 1201, 123 Edward St, Toronto, Ontario M5G 1E2, Canada; ICES, 2075 Bayview Avenue, G-Wing, Toronto, Ontario M4N 3M5, Canada; Toronto General Hospital Research Institute, 200 Elizabeth St, Toronto, Ontario M5G 2C4, Canada; Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, Canada.
| | - Peter C Austin
- ICES, 2075 Bayview Avenue, G-Wing, Toronto, Ontario M4N 3M5, Canada
| | - Daniel McCormack
- ICES, 2075 Bayview Avenue, G-Wing, Toronto, Ontario M4N 3M5, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesiology and pain management, University of Toronto, Room 1201, 123 Edward St, Toronto, Ontario M5G 1E2, Canada; ICES, 2075 Bayview Avenue, G-Wing, Toronto, Ontario M4N 3M5, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond St, Toronto, Ontario M5B 1W8, Canada; Department of Anesthesia, St. Michael's Hospital, 30 Bond St, Toronto, Ontario M5B 1W8, Canada
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34
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Ung D, Kim J, Thrift AG, Cadilhac DA, Andrew NE, Sundararajan V, Kapral MK, Reeves M, Kilkenny MF. Promising Use of Big Data to Increase the Efficiency and Comprehensiveness of Stroke Outcomes Research. Stroke 2020; 50:1302-1309. [PMID: 31009352 DOI: 10.1161/strokeaha.118.020372] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- David Ung
- From the Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (D.U., J.K., A.G.T., D.A.C., N.E.A., M.F.K.)
| | - Joosup Kim
- From the Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (D.U., J.K., A.G.T., D.A.C., N.E.A., M.F.K.).,Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (J.K., D.A.C., M.F.K.)
| | - Amanda G Thrift
- From the Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (D.U., J.K., A.G.T., D.A.C., N.E.A., M.F.K.)
| | - Dominique A Cadilhac
- From the Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (D.U., J.K., A.G.T., D.A.C., N.E.A., M.F.K.).,Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (J.K., D.A.C., M.F.K.)
| | - Nadine E Andrew
- From the Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (D.U., J.K., A.G.T., D.A.C., N.E.A., M.F.K.).,Peninsula Clinical School, Central Clinical School, Monash University, Frankston, VIC, Australia (N.E.A.)
| | - Vijaya Sundararajan
- La Trobe University, Melbourne, VIC, Australia (V.S.).,Department of Public Health, School of Psychology and Public Health, College of Science Health and Engineering, La Trobe University, Bundoora, VIC, Australia (V.S.)
| | - Moira K Kapral
- Division of General Internal Medicine, Department of Medicine, University of Toronto, ON, Canada (M.K.K.)
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI (M.R.)
| | - Monique F Kilkenny
- From the Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (D.U., J.K., A.G.T., D.A.C., N.E.A., M.F.K.).,Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (J.K., D.A.C., M.F.K.)
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Yu AYX, Fang J, Porter J, Austin PC, Smith EE, Kapral MK. Hospital-based cohort study to determine the association between home-time and disability after stroke by age, sex, stroke type and study year in Canada. BMJ Open 2019; 9:e031379. [PMID: 31719083 PMCID: PMC6858198 DOI: 10.1136/bmjopen-2019-031379] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Home-time is an emerging patient-centred stroke outcome metric, but it is not well described in the population. We aimed to determine the association between 90-day home-time and global disability after stroke. We hypothesised that longer home-time would be associated with less disability. DESIGN Hospital-based cohort study of patients with ischaemic stroke or intracerebral haemorrhage admitted to an acute care hospital between 1 April 2002 and 31 March 2013. SETTING All regional stroke centres and a simple random sample of patients from all other hospitals across the province of Ontario, Canada. PARTICIPANTS We included 39 417 adult patients (84% ischaemic, 16% haemorrhage), 53% male, with a median age of 74 years. We excluded non-residents of Ontario, patients without a valid health insurance number, patients discharged against medical advice or those who failed to return from a pass, patients living in a long-term care centre at baseline and stroke events occurring in-hospital. PRIMARY OUTCOME MEASURE Association between 90-day home-time, defined as the number of days spent at home in the first 90 days after stroke, obtained using linked administrative data and modified Rankin Scale score at discharge. RESULTS Compared with people with no disability, those with minimal disability had less home-time (adjusted rate ratio (aRR) 0.96, 95% CI 0.93 to 0.98) and those with the most severe disability had the least home-time (aRR 0.05, 95% CI 0.04 to 0.05). We found no clinically relevant modification by stroke type, sex or study year. However, for a given level of disability, older patients experienced less home-time compared with younger patients. CONCLUSIONS Our results provide content validity for home-time to be used to monitor stroke outcomes in large populations or to study temporal trends. Older patients experience less home-time for a given level of disability, suggesting the need for stratification by age.
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Affiliation(s)
- Amy Ying Xin Yu
- Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Jiming Fang
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Joan Porter
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Eric E Smith
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Moira K Kapral
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Medicine (General Internal Medicine), University of Toronto, Toronto, Ontario, Canada
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Jørgensen CC, Petersen PB, Kehlet H, Madsen F, Hansen TB, Husted H, Laursen M, Hansen LT, Kjærsgaard-Andersen P, Solgaard S, Jorn LP. Days alive and out of hospital after fast-track total hip and knee arthroplasty: an observational cohort study in 16 137 patients. Br J Anaesth 2019; 123:671-678. [DOI: 10.1016/j.bja.2019.07.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 07/10/2019] [Accepted: 07/29/2019] [Indexed: 01/01/2023] Open
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Yu AYX, Fang J, Kapral MK. One-Year Home-Time and Mortality After Thrombolysis Compared With Nontreated Patients in a Propensity-Matched Analysis. Stroke 2019; 50:3488-3493. [PMID: 31570086 DOI: 10.1161/strokeaha.119.026922] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Intravenous thrombolysis with r-tPA (recombinant tissue-type plasminogen activator) is associated with improved early functional outcome after stroke, but its long-term effects are less understood. We aimed to determine the association between r-tPA and 1-year outcomes after stroke. Methods- We used the Ontario Stroke Registry to identify patients diagnosed with ischemic stroke between 2002 and 2013 in Ontario, Canada, their baseline characteristics, and whether they received r-tPA. We used propensity score methods to match patients treated with r-tPA to nontreated patients. The primary outcome was 1-year home-time, defined as the number of days spent outside of any healthcare institutions in the first 365 days after the index date of admission. Secondary outcomes were admission to a nursing home and all-cause mortality in the first year. Outcomes were determined using linked administrative data. We used paired t tests to compare mean home-time days and Cox proportional hazards models for mortality and nursing home admission to estimate hazard ratios and 95% CI. Results- All 4449 patients treated with r-tPA in the registry were matched to nontreated patients. Compared with nontreated patients, those treated with r-tPA experienced more time at home in the first year (mean±SD was 248.9 days±137.2 treated versus 239.4 days±139.0 nontreated, P=0.005) and were less likely to be admitted to nursing homes (9.4% treated versus 12.2% nontreated; hazard ratio, 0.84; 95% CI, 0.78-0.91). One-year all-cause mortality was similar between the 2 groups (13.2% treated versus 12.4% nontreated; hazard ratio, 1.07; 95% CI, 0.96-1.20). Conclusions- Despite similar mortality, patients who received r-tPA spent more time at home and were less likely to require nursing home admission in the first year after stroke compared with nontreated patients, suggesting long-term benefits and safety of this treatment.
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Affiliation(s)
- Amy Y X Yu
- From the Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, ON, Canada (A.Y.X.Y.).,ICES, Toronto, ON, Canada (A.Y.X.Y., J.F., M.K.K.)
| | - Jiming Fang
- ICES, Toronto, ON, Canada (A.Y.X.Y., J.F., M.K.K.)
| | - Moira K Kapral
- ICES, Toronto, ON, Canada (A.Y.X.Y., J.F., M.K.K.).,Department of Medicine (General Internal Medicine), University of Toronto-University Health Network, ON, Canada (M.K.K.)
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Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Days alive and out of hospital is a potentially useful patient-centered quality measure for perioperative care in adult surgical patients. However, there has been very limited prior validation of this endpoint with respect to its ability to capture differences in patient-level risk factor profiles and longer-term postoperative outcomes. The main objective of this study was assessment of the feasibility and validity of days alive and out of hospital as a patient-centered outcome for perioperative medicine.
Methods
The authors evaluated 540,072 adults undergoing 1 of 12 major elective noncardiac surgical procedures between 2006 to 2014. Primary outcome was days alive and out of hospital at 30 days, secondary outcomes were days alive and out of hospital at 90 days and 180 days. Unadjusted and risk-adjusted adjusted analyses were used to determine the association of days alive and out of hospital with patient-, surgery-, and hospital-level characteristics. Patients with days alive and out of hospital at 30 days values less than the tenth percentile were also classified as having poor days alive and out of hospital at 30 days. The authors then determined the association of poor days alive and out of hospital at 30 days with in-hospital complications, poor days alive and out of hospital at 90 days (less than the tenth percentile), and poor days alive and out of hospital at 180 days (less than the tenth percentile).
Results
Overall median (interquartile range) days alive and out of hospital at 30, 90, and 180 days were 26 (24 to 27), 86 (84 to 87), and 176 (173 to 177) days, respectively. Median days alive and out of hospital at 30 days was highest for hysterectomy and endovascular aortic aneurysm repair (27 days) and lowest for upper gastrointestinal surgery (22 days). Days alive and out of hospital at 30 days was associated with clinically sensible patient-level factors (comorbidities, advanced age, postoperative complications), but not measured hospital-level factors (academic status, bed size). Of patients with good days alive and out of hospital at 30 days, 477,163 of 486,087 (98%) and 470,093 of 486,087 (97%) remained within this group (greater than the tenth percentile) at days alive and out of hospital at 90 and 180 days.
Conclusions
Days alive and out of hospital is a feasibly measured patient-centered outcome that is associated with clinically sensible patient characteristics, surgical complexity, in-hospital complications, and longer-term outcomes. Days alive and out of hospital forms a novel patient-centered outcome for future clinical trials and observational studies for adult surgical patients.
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Home-time Is a Patient-Centered Outcome Variable for Stroke: An Executive Summary. J Neurosci Nurs 2019; 51:110-112. [DOI: 10.1097/jnn.0000000000000437] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kasner SE, Siegler JE, Zamzam A, Kleindorfer D. Expanding Eligibility in Stroke Prevention Trials to Patients with Early Disability. J Stroke Cerebrovasc Dis 2019; 28:2268-2272. [PMID: 31160220 DOI: 10.1016/j.jstrokecerebrovasdis.2019.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/06/2019] [Accepted: 05/14/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND PURPOSE Early disability after stroke is common, though many patients improve. Stroke secondary prevention trials often prohibit the recruitment of nonambulatory patients, limiting their access to potential treatment options and impeding trial enrollment. We aimed to determine outcomes after early dependence around the time of transition from acute care to recovery. METHODS Data were obtained from a composite of patients enrolled in acute stroke clinical trials within the Virtual International Stroke Trials Archive (VISTA-Acute). Early disability was defined by the modified Rankin Scale (mRS) of 4 or 5 between days 3-10 after onset, representing the time of discharge or transition to a rehabilitation-focused care setting. We developed multivariable models to identify factors associated with recovery to independent ambulatory function and recurrent stroke during the 90 days after stroke. RESULTS 4965 patients were included, with 2905 (59%) having early disability. Patients with early dependence were older, more likely to be women, had higher baseline NIHSS scores, and had more atrial fibrillation and diabetes mellitus, compared with those who were initially ambulatory. Recovery to ambulatory function occurred in 58% with early mRS = 4, compared to only 16% with early mRS = 5. Of those with early mRS = 4, return to independent ambulatory status by 90 days was associated in multivariable analysis with age, diabetes, prior stroke, NIH motor and gaze subscores, and thrombolysis. Recurrent ischemic stroke through day 90 was reported in 126 of 2905 (4.3%) subjects with early dependence compared to 63 of 2060 (3.1%), which was not different after adjustment for age, sex, and risk factors (odds ratio 1.27; 95% confidence interval 0.92-1.73). CONCLUSIONS Favorable outcomes are common among ischemic stroke patients previously enrolled in acute clinical trials despite early dependence (mRS = 4) after initial acute hospital care. Further, their risk of recurrent stroke is high in the short term. These patients likely benefit from aggressive poststroke care and should be actively recruited into secondary prevention trials.
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Affiliation(s)
- Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - James E Siegler
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ahmad Zamzam
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dawn Kleindorfer
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio
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Gattellari M, Goumas C, Jalaludin B, Worthington J. The impact of disease severity adjustment on hospital standardised mortality ratios: Results from a service-wide analysis of ischaemic stroke admissions using linked pre-hospital, admissions and mortality data. PLoS One 2019; 14:e0216325. [PMID: 31112556 PMCID: PMC6528964 DOI: 10.1371/journal.pone.0216325] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 04/18/2019] [Indexed: 11/19/2022] Open
Abstract
Background Administrative data are used to examine variation in thirty-day mortality across health services in several jurisdictions. Hospital performance measurement may be error-prone as information about disease severity is not typically available in routinely collected data to incorporate into case-mix adjusted analyses. Using ischaemic stroke as a case study, we tested the extent to which accounting for disease severity impacts on hospital performance assessment. Methods We linked all recorded ischaemic stroke admissions between July, 2011 and June, 2014 to death registrations and a measure of stroke severity obtained at first point of patient contact with health services, across New South Wales, Australia’s largest health service jurisdiction. Thirty-day hospital standardised mortality ratios were adjusted for either comorbidities, as is typically done, or for both comorbidities and stroke severity. The impact of stroke severity adjustment on mortality ratios was determined using 95% and 99% control limits applied to funnel plots and by calculating the change in rank order of hospital risk adjusted mortality rates. Results The performance of the stroke severity adjusted model was superior to incorporating comorbidity burden alone (c-statistic = 0.82 versus 0.75; N = 17,700 patients, 176 hospitals). Concordance in outlier classification was 89% and 97% when applying 95% or 99% control limits to funnel plots, respectively. The sensitivity rates of outlier detection using comorbidity adjustment compared with gold-standard severity and comorbidity adjustment was 74% and 83% with 95% and 99% control limits, respectively. Corresponding positive predictive values were 74% and 91%. Hospital rank order of risk adjusted mortality rates shifted between 0 to 22 places with severity adjustment (Median = 4.0, Inter-quartile Range = 2–7). Conclusions Rankings of mortality rates varied widely depending on whether stroke severity was taken into account. Funnel plots yielded largely concordant results irrespective of severity adjustment and may be sufficiently accurate as a screening tool for assessing hospital performance.
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Affiliation(s)
- Melina Gattellari
- Heart and Brain Collaboration, Ingham Institute for Applied Medical Research, Liverpool, Sydney, New South Wales, Australia
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Camperdown, Sydney, New South Wales, Australia
| | - Chris Goumas
- Heart and Brain Collaboration, Ingham Institute for Applied Medical Research, Liverpool, Sydney, New South Wales, Australia
| | - Bin Jalaludin
- Population Health Intelligence, Healthy People and Places Unit; South Western Sydney Local Health District, Liverpool, Sydney, New South Wales, Australia
- School of Public Health, The University of New South Wales, Kensington, Sydney, New South Wales, Australia
| | - John Worthington
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Camperdown, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Liverpool, Sydney, New South Wales, Australia
- * E-mail:
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Lee H, Shi SM, Kim DH. Home Time as a Patient-Centered Outcome in Administrative Claims Data. J Am Geriatr Soc 2018; 67:347-351. [PMID: 30578532 DOI: 10.1111/jgs.15705] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 10/15/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Home time, the number of days alive and spent out of hospital and skilled nursing facility, has been proposed as a patient-centered outcome that can be readily calculated in administrative claims data. OBJECTIVES To compare home time against existing patient-centered outcome measures. DESIGN Retrospective cohort study. SETTING Community. PARTICIPANTS A total of 4594 Medicare beneficiaries 65 years or older with complete survey and claims data in the Medicare Current Beneficiary Survey 2010 to 2011. MEASUREMENTS Home time was calculated from the 2011 claims data (range, 0-365 days). The 1-year incidence of patient-centered outcomes (poor self-rated health, mobility impairment, depression, limited social activity, and difficulty in self-care) was measured. The minimum clinically important difference (MCID) was derived by contrasting the mean home time between those who experienced functional decline or death and those who did not. RESULTS The mean home time was 355.8 days (SD, 42.1 days); 84.1% had a home time of 365 days, and 5.7% had a home time of 336 days or fewer. The incidence of poor self-rated health ranged from 2% (home time, 365 days) to 21% (home time, less than 337 days). Similarly, the corresponding incidence risks were 11% to 59% for mobility impairment, 5% to 19% for depression, 17% to 67% for limited social activity, and 13% to 68% for difficulty in self-care. The risk of mobility impairment, depression, and difficulty in self-care increased steeply after home time loss of 15 days or greater. The MCID of home time was 18.6 days. CONCLUSION A loss in home time is associated with decline in several patient-centered outcome measures in community-dwelling Medicare beneficiaries. These results provide empirical evidence to promote adoption of home time and its clinical interpretation for database studies of medical interventions. J Am Geriatr Soc 67:347-351, 2019.
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Affiliation(s)
- Hemin Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sandra M Shi
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
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Ganesh A, Luengo-Fernandez R, Wharton RM, Rothwell PM. Ordinal vs dichotomous analyses of modified Rankin Scale, 5-year outcome, and cost of stroke. Neurology 2018; 91:e1951-e1960. [PMID: 30341155 PMCID: PMC6260198 DOI: 10.1212/wnl.0000000000006554] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 08/08/2018] [Indexed: 11/17/2022] Open
Abstract
Objective To compare how 3 common representations (ordinal vs dichotomized as 0–1/2–6 or 0–2/3–6) of the modified Rankin Scale (mRS)—a commonly used trial outcome measure—relate to long-term outcomes, and quantify trial ineligibility rates based on premorbid mRS. Methods In consecutive patients with ischemic stroke in a population-based, prospective, cohort study (Oxford Vascular Study; 2002–2014), we related 3-month mRS to 1-year and 5-year disability and death (logistic regressions), and health/social care costs (generalized linear model), adjusted for age/sex, and compared goodness-of-fit values (C statistic, mean absolute error). We also calculated the proportion of patients in whom premorbid mRS score >1 or >2 would result in exclusion from trials using dichotomous analysis. Results Among 1,607 patients, the ordinal mRS was more strongly related to 5-year mortality than both the 0–1/2–6 and 0–2/3–6 dichotomies (all p < 0.0001). Results were similar for 5-year disability, and 5-year care costs were also best captured by the ordinal model (change in mean absolute error vs age/sex: −$3,059 for ordinal, −$2,805 for 0–2/3–6, −$1,647 for 0–1/2–6). Two hundred forty-four (17.1%) 3-month survivors had premorbid mRS score >2 and 434 (30.5%) had mRS score >1; both proportions increased with female sex, socioeconomic deprivation, and age (all p < 0.0001). Conclusion The ordinal form of the 3-month mRS relates better to long-term outcomes and costs in survivors of ischemic stroke than either dichotomy. This finding favors using ordinal approaches in trials analyzing the mRS. Exclusion of patients with higher premorbid disability by use of dichotomous primary outcomes will also result in unrepresentative samples.
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Affiliation(s)
- Aravind Ganesh
- From the Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Ramon Luengo-Fernandez
- From the Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Rose M Wharton
- From the Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Peter M Rothwell
- From the Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK.
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Boulanger JM, Lindsay MP, Gubitz G, Smith EE, Stotts G, Foley N, Bhogal S, Boyle K, Braun L, Goddard T, Heran MKS, Kanya-Forster N, Lang E, Lavoie P, McClelland M, O’Kelly C, Pageau P, Pettersen J, Purvis H, Shamy M, Tampieri D, vanAdel B, Verbeek R, Blacquiere D, Casaubon L, Ferguson D, Hegedus Y, Jacquin GJ, Kelly M, Kamal N, Linkewich B, Lum C, Mann B, Milot G, Newcommon N, Poirier P, Simpkin W, Snieder E, Trivedi A, Whelan R, Eustace M, Smitko E, Butcher K. Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018. Int J Stroke 2018; 13:949-984. [DOI: 10.1177/1747493018786616] [Citation(s) in RCA: 191] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider’s recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.
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Affiliation(s)
- JM Boulanger
- Charles-LeMoyne Hospital, Neurology, Longueuil, Quebec, Canada
- Université de Sherbrooke, Faculty of Medicine, Sherbrooke, Quebec, Canada
| | - MP Lindsay
- Heart and Stroke Foundation of Canada, Toronto, Ontario, Canada
| | - G Gubitz
- Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada
- Department of Medicine (Neurology), Dalhousie University, Halifax, Nova Scotia, Canada
- Canadian Stroke Consortium, Oakville, Ontario, Canada
| | - EE Smith
- Calgary Stroke Program, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - G Stotts
- Canadian Stroke Consortium, Oakville, Ontario, Canada
- Ottawa Stroke Program, Ottawa Hospital, Ottawa, Ontario, Canada
| | - N Foley
- workHORSE Consulting Services, London, Ontario, Canada
| | - S Bhogal
- workHORSE Consulting Services, London, Ontario, Canada
| | - K Boyle
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - L Braun
- Emergency Medical Services, Winnipeg, Manitoba, Canada
| | - T Goddard
- Department of Medicine (Neurology), Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Emergency Medicine, Valley Regional Hospital, Kentville, Nova Scotia, Canada
| | - MKS Heran
- Vancouver General Hospital, Vancouver, British Columbia, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - N Kanya-Forster
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada
- Timmins & District Hospital, Timmins, Ontario, Canada
| | - E Lang
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
- Canadian Association of Emergency Physicians, Ottawa, Ontario, Canada
| | - P Lavoie
- Department of Surgery, Laval University, Quebec, Canada
| | - M McClelland
- Interior Health Research Department, Kelowna General Hospital, Kelowna, British Columbia, Canada
| | - C O’Kelly
- Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - P Pageau
- Canadian Association of Emergency Physicians, Ottawa, Ontario, Canada
- Department of Emergency Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - J Pettersen
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - H Purvis
- Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | - M Shamy
- Ottawa Stroke Program, Ottawa Hospital, Ottawa, Ontario, Canada
| | - D Tampieri
- Montreal Neurological Hospital and Institute, Montreal, Quebec, Canada
| | - B vanAdel
- Division of Neurology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - R Verbeek
- Canadian Association of Emergency Physicians, Ottawa, Ontario, Canada
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - D Blacquiere
- Canadian Stroke Consortium, Oakville, Ontario, Canada
- Saint John Regional Health Centre, Saint John, New Brunswick, Canada
| | - L Casaubon
- Canadian Stroke Consortium, Oakville, Ontario, Canada
- University Health Network (Toronto Western Hospital) Stroke Program, Toronto, Ontario, Canada
| | - D Ferguson
- Saint John Regional Health Centre, Saint John, New Brunswick, Canada
| | - Y Hegedus
- Vancouver Island Health Authority, Vancouver, British Columbia, Canada
| | - GJ Jacquin
- Centre hospitalier de l’université de Montréal, Montreal, Quebec, Canada
| | - M Kelly
- Division of Neurosurgery, Department of Surgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - N Kamal
- Calgary Stroke Program, Calgary, Alberta, Canada
| | - B Linkewich
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - C Lum
- Ottawa Stroke Program, Ottawa Hospital, Ottawa, Ontario, Canada
| | - B Mann
- Alberta Health Services, Edmonton, Alberta, Canada
| | - G Milot
- CHU de Québec, Laval University, Laval, Quebec, Canada
| | - N Newcommon
- Calgary Stroke Program, Calgary, Alberta, Canada
| | - P Poirier
- Paramedic Association of Canada, Ottawa, Ontario, Canada
| | - W Simpkin
- Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada
| | - E Snieder
- Ottawa Stroke Program, Ottawa Hospital, Ottawa, Ontario, Canada
| | - A Trivedi
- Section of Neurology, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - R Whelan
- University Hospital, Saskatoon, Saskatchewan, Canada
| | - M Eustace
- Health Sciences Centre, St. Johns, Newfoundland, Canada
| | - E Smitko
- Heart and Stroke Foundation of Canada, Toronto, Ontario, Canada
| | - K Butcher
- Division of Neurology, University of Alberta, Edmonton, Alberta, Canada
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Mingina T, Zhao M. Role of PARK7 and NDKA in stroke management: a review of PARK7 and NDKA as stroke biomarkers. Biomark Med 2018; 12:419-425. [PMID: 29697269 DOI: 10.2217/bmm-2018-0013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
AIM Biomarkers are molecules measured in plasma, serum or other body fluids to characterize a disease. PARK7 and NDKA roles in the management of stroke are still on study. Therefore, their potentials need to be developed in totality. The aim of this review is to demonstrate that PARK7 and NDKA could present more clinical important information as biomarkers for management of stroke disease. Main contents: Four main aspects of PARK7 and NDKA are exploited in this review. First, their diagnostic value is discussed in order to demonstrate their possible role as stroke diagnosis markers. Second, this article will exploit the correlation of both markers with time, by showing their dynamic changes in serum and plasma. Third, it describes the observed relationship of their levels with NIH Stroke Scale. The last aspect visits the possibility of their implementation in stroke therapy. CONCLUSION This article explores recent findings and proposes the potential roles that PARK7 and NDKA play in the management of acute stroke disease.
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Affiliation(s)
- Tulantched Mingina
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, Shenyang 11004, PR China
| | - Min Zhao
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, Shenyang 11004, PR China
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