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Naftali J, Tsur G, Auriel E, Raphaeli G, Findler M, Brauner R, Perlow A, Keret O, Barnea R. Impact of demographic and clinical factors on in-hospital delays in acute ischemic stroke treatment. Interv Neuroradiol 2024:15910199241264326. [PMID: 39053431 DOI: 10.1177/15910199241264326] [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: 07/27/2024] Open
Abstract
BACKGROUND Delays in reperfusion treatment, both intravenous thrombolysis (IVT) and endovascular treatment (EVT), adversely affect outcomes in patients with acute ischemic stroke (AIS). To alleviate these delays, it is essential to comprehend how patients' baseline and stroke characteristics impact in-hospital reperfusion delays. While demographic and socioeconomic factors affect stroke outcomes, their impact on in-hospital delays remains unclear. METHOD This is retrospective analysis at a tertiary stroke center, encompassing AIS patients receiving IVT and / or EVT between 2019 and 2022 (re-canalization cohort). Outcomes of interest were time intervals of admission to CT and admission to recanalization. Univariable analyses explored age, gender, baseline functional status, socioeconomic status (SES), ethnicity, vascular risk factors, and stroke characteristics. Subsequently, multivariable logistic regression analyses were performed. RESULTS Altogether, 313 patients treated with IVT and 293 with EVT were included in the re-canalization cohort. No demographic variables were found to be associated with stroke treatment time intervals. Following multivariable analysis, stroke severity (low NIHSS, p < 0.01), arrival to the hospital by other means than ambulance (p < 0.01), and atypical stroke symptoms (p < 0.01), were associated with in-hospital delays, both in the EVT and the IVT groups. CONCLUSION Our findings indicate that patients with a more severe ischemic stroke, typical stroke symptoms, and arrival by ambulance have shorter stroke treatment time intervals. These results emphasize that, in atypical cases, even a lower suspicion of stroke should promote urgent workup for stroke diagnosis. Our findings do not indicate any influence of demographic or SES on in-hospital reperfusion delays.
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Affiliation(s)
- Jonathan Naftali
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Gal Tsur
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
| | - Eitan Auriel
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Guy Raphaeli
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Interventional Neuroradiology unit, Rabin Medical Center, Petach Tikva, Israel
| | - Michael Findler
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Interventional Neuroradiology unit, Rabin Medical Center, Petach Tikva, Israel
| | - Ran Brauner
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Interventional Neuroradiology unit, Rabin Medical Center, Petach Tikva, Israel
| | - Alain Perlow
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Interventional Neuroradiology unit, Rabin Medical Center, Petach Tikva, Israel
| | - Ophir Keret
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Cognitive Neurology Clinic, Rabin Medical Center, Petach Tikva, Israel
| | - Rani Barnea
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
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Dhand A, Reeves MJ, Mu Y, Rosner BA, Rothfeld-Wehrwein ZR, Nieves A, Dhongade VA, Jarman M, Bergmark RW, Semco RS, Ader J, Marshall BDL, Goedel WC, Fonarow GC, Smith EE, Saver JL, Schwamm LH, Sheth KN. Mapping the Ecological Terrain of Stroke Prehospital Delay: A Nationwide Registry Study. Stroke 2024; 55:1507-1516. [PMID: 38787926 DOI: 10.1161/strokeaha.123.045521] [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: 10/12/2023] [Accepted: 04/12/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Delays in hospital presentation limit access to acute stroke treatments. While prior research has focused on patient-level factors, broader ecological and social determinants have not been well studied. We aimed to create a geospatial map of prehospital delay and examine the role of community-level social vulnerability. METHODS We studied patients with ischemic stroke who arrived by emergency medical services in 2015 to 2017 from the American Heart Association Get With The Guidelines-Stroke registry. The primary outcome was time to hospital arrival after stroke (in minutes), beginning at last known well in most cases. Using Geographic Information System mapping, we displayed the geography of delay. We then used Cox proportional hazard models to study the relationship between community-level factors and arrival time (adjusted hazard ratios [aHR] <1.0 indicate delay). The primary exposure was the social vulnerability index (SVI), a metric of social vulnerability for every ZIP Code Tabulation Area ranging from 0.0 to 1.0. RESULTS Of 750 336 patients, 149 145 met inclusion criteria. The mean age was 73 years, and 51% were female. The median time to hospital arrival was 140 minutes (Q1: 60 minutes, Q3: 458 minutes). The geospatial map revealed that many zones of delay overlapped with socially vulnerable areas (https://harvard-cga.maps.arcgis.com/apps/webappviewer/index.html?id=08f6e885c71b457f83cefc71013bcaa7). Cox models (aHR, 95% CI) confirmed that higher SVI, including quartiles 3 (aHR, 0.96 [95% CI, 0.93-0.98]) and 4 (aHR, 0.93 [95% CI, 0.91-0.95]), was associated with delay. Patients from SVI quartile 4 neighborhoods arrived 15.6 minutes [15-16.2] slower than patients from SVI quartile 1. Specific SVI themes associated with delay were a community's socioeconomic status (aHR, 0.80 [95% CI, 0.74-0.85]) and housing type and transportation (aHR, 0.89 [95% CI, 0.84-0.94]). CONCLUSIONS This map of acute stroke presentation times shows areas with a high incidence of delay. Increased social vulnerability characterizes these areas. Such places should be systematically targeted to improve population-level stroke presentation times.
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Affiliation(s)
- Amar Dhand
- Harvard Medical School Boston, MA (A.D., Z.R.R.-W., V.A.D., M.J., R.W.B., R.S.S., L.H.S.)
- Department of Neurology (A.D., Z.R.R.-W., V.A.D.), Brigham and Women's Hospital, Boston, MA
- Network Science Institute, Northeastern University, Boston, MA (A.D.)
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
| | - Yi Mu
- Department of Biostatistics, Channing Laboratory, Harvard T.H. Chan School of Public Health, Boston, MA (Y.M., B.A.R.)
| | - Bernard A Rosner
- Department of Biostatistics, Channing Laboratory, Harvard T.H. Chan School of Public Health, Boston, MA (Y.M., B.A.R.)
| | - Zachary R Rothfeld-Wehrwein
- Harvard Medical School Boston, MA (A.D., Z.R.R.-W., V.A.D., M.J., R.W.B., R.S.S., L.H.S.)
- Department of Neurology (A.D., Z.R.R.-W., V.A.D.), Brigham and Women's Hospital, Boston, MA
| | - Amber Nieves
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (A.N.)
| | - Vrushali A Dhongade
- Harvard Medical School Boston, MA (A.D., Z.R.R.-W., V.A.D., M.J., R.W.B., R.S.S., L.H.S.)
- Department of Neurology (A.D., Z.R.R.-W., V.A.D.), Brigham and Women's Hospital, Boston, MA
| | - Molly Jarman
- Harvard Medical School Boston, MA (A.D., Z.R.R.-W., V.A.D., M.J., R.W.B., R.S.S., L.H.S.)
- Department of Otolaryngology-Head and Neck Surgery (M.J., R.W.B.), Brigham and Women's Hospital, Boston, MA
| | - Regan W Bergmark
- Harvard Medical School Boston, MA (A.D., Z.R.R.-W., V.A.D., M.J., R.W.B., R.S.S., L.H.S.)
- Center for Surgery and Public Health (R.W.B., R.S.S.), Brigham and Women's Hospital, Boston, MA
- Department of Otolaryngology-Head and Neck Surgery (M.J., R.W.B.), Brigham and Women's Hospital, Boston, MA
| | - Robert S Semco
- Harvard Medical School Boston, MA (A.D., Z.R.R.-W., V.A.D., M.J., R.W.B., R.S.S., L.H.S.)
- Center for Surgery and Public Health (R.W.B., R.S.S.), Brigham and Women's Hospital, Boston, MA
| | - Jeremy Ader
- Department of Neurology, Columbia University Irving Medical Center, New York, NY (J.A.)
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, RI (B.D.L.M., W.C.G.)
| | - William C Goedel
- Department of Epidemiology, Brown University School of Public Health, Providence, RI (B.D.L.M., W.C.G.)
| | - Gregg C Fonarow
- Department of Cardiology (G.C.F.), University of California, Los Angeles David Geffen School of Medicine
| | - Eric E Smith
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, AB, Canada (E.E.S.)
| | - Jeffrey L Saver
- Department of Neurology (J.L.S.), University of California, Los Angeles David Geffen School of Medicine
| | - Lee H Schwamm
- Harvard Medical School Boston, MA (A.D., Z.R.R.-W., V.A.D., M.J., R.W.B., R.S.S., L.H.S.)
- Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.)
| | - Kevin N Sheth
- Department of Neurology & Neurosurgery, Yale School of Medicine, New Haven, CT (K.N.S.)
- Yale Center for Brain & Mind Health, New Haven, CT (K.N.S.)
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Nguyen MTH, Sakamoto Y, Maeda T, Woodward M, Anderson CS, Catiwa J, Yazidjoglou A, Carcel C, Yang M, Wang X. Influence of Socioeconomic Status on Functional Outcomes After Stroke: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2024; 13:e033078. [PMID: 38639361 PMCID: PMC11179939 DOI: 10.1161/jaha.123.033078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/06/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND This review aimed to quantify the impact of socioeconomic status on functional outcomes from stroke and identify the socioeconomic status indicators that exhibit the highest magnitude of association. METHODS AND RESULTS We performed a systematic literature search across Medline and Embase from inception to May 2022, to identify observational studies (n≥100, and in English). Risk of bias was assessed using the modified Newcastle Ottawa Scale. Random effects meta-analysis was used to pool data. We included 19 studies (157 715 patients, 47.7% women) reporting functional outcomes measured with modified Rankin Scale or Barthel index, with 10 assessed as low risk of bias. Measures of socioeconomic status reported were education (11 studies), income (8), occupation (4), health insurance status (3), and neighborhood socioeconomic deprivation (3). Pooled data suggested that low socioeconomic status was significantly associated with poor functional outcomes, including incomplete education or below high school level versus high school attainment and above (odds ratio [OR], 1.66 [95% CI, 1.40-1.95]), lowest income versus highest income (OR, 1.36 [95% CI, 1.02-1.83]), a manual job/being unemployed versus a nonmanual job/working (OR, 1.62 [95% CI, 1.29-2.02]), and living in the most disadvantaged socioeconomic neighborhood versus the least disadvantaged (OR, 1.55 [95% CI, 1.25-1.92]). Low health insurance status was also associated with an increased risk of poor functional outcomes (OR, 1.32 [95% CI, 0.95-1.84]), although this was association was not statistically significant. CONCLUSIONS Despite great strides in stroke treatment in the past decades, social disadvantage remains a risk factor for poor functional outcome after an acute stroke. Further research is needed to better understand causal mechanisms and disparities.
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Affiliation(s)
- Mai T. H. Nguyen
- The George Institute for Global Health, The University of New South WalesSydneyNew South WalesAustralia
- Centre of Epidemiology for Policy and Practice, National Centre for Epidemiology and Population HealthAustralian National UniversityCanberraAustralian Capital TerritoryAustralia
| | - Yuki Sakamoto
- The George Institute for Global Health, The University of New South WalesSydneyNew South WalesAustralia
- Department of NeurologyGraduate School of Medicine, Nippon Medical SchoolTokyoJapan
| | - Toshiki Maeda
- The George Institute for Global Health, The University of New South WalesSydneyNew South WalesAustralia
- Department of Preventive Medicine and Public Health, Faculty of MedicineFukuoka UniversityFukuokaJapan
| | - Mark Woodward
- The George Institute for Global Health, The University of New South WalesSydneyNew South WalesAustralia
- The George Institute for Global Health, School of Public Health, Imperial College LondonLondonUnited Kingdom
| | - Craig S. Anderson
- The George Institute for Global Health, The University of New South WalesSydneyNew South WalesAustralia
- Prince of Wales Clinical SchoolUniversity of New South WalesSydneyNew South WalesAustralia
- The George Institute ChinaRegistered Office of The George Institute for Global Health AustraliaBeijingChina
| | - Jayson Catiwa
- The George Institute for Global Health, The University of New South WalesSydneyNew South WalesAustralia
| | - Amelia Yazidjoglou
- Centre of Epidemiology for Policy and Practice, National Centre for Epidemiology and Population HealthAustralian National UniversityCanberraAustralian Capital TerritoryAustralia
| | - Cheryl Carcel
- The George Institute for Global Health, The University of New South WalesSydneyNew South WalesAustralia
| | - Min Yang
- Department of NeurologyFirst Affiliated Hospital of Chengdu Medical CollegeChengduChina
| | - Xia Wang
- The George Institute for Global Health, The University of New South WalesSydneyNew South WalesAustralia
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4
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Stein LK, Maillie L, Erdman J, Loebel E, Mayman N, Sharma A, Wolmer S, Tuhrim S, Fifi JT, Jette N, Mocco J, Dhamoon MS. Variation in US acute ischemic stroke treatment by hospital regions: limited endovascular access despite evidence. J Neurointerv Surg 2024; 16:151-155. [PMID: 37068938 PMCID: PMC11192062 DOI: 10.1136/jnis-2023-020128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/02/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Although national organizations recognize the importance of regionalized acute ischemic stroke (AIS) care, data informing expansion are sparse. We assessed real-world regional variation in emergent AIS treatment, including growth in revascularization therapies and stroke center certification. We hypothesized that we would observe overall growth in revascularization therapy utilization, but observed differences would vary greatly regionally. METHODS A retrospective cross-sectional analysis was carried out of de-identified national inpatient Medicare Fee-for-Service datasets from 2016 to 2019. We identified AIS admissions and treatment with thrombolysis and endovascular thrombectomy (ET) with International Classification of Diseases, 10th Revision, Clinical Modification codes. We grouped hospitals in Dartmouth Atlas of Healthcare Hospital Referral Regions (HRR) and calculated hospital, demographic, and acute stroke treatment characteristics for each HRR. We calculated the percent of hospitals with stroke certification and AIS cases treated with thrombolysis or ET per HRR. RESULTS There were 957 958 AIS admissions. Relative mean (SD) growth in percent of AIS admissions receiving revascularization therapy per HRR from 2016 to 2019 was 13.4 (31.7)% (IQR -6.1-31.7%) for thrombolysis and 28.0 (72.0)% (IQR 0-56.0%) for ET. The proportion of HRRs with decreased or no difference in ET utilization was 38.9% and the proportion of HRRs with decreased or no difference in thrombolysis utilization was 32.7%. Mean (SD) stroke center certification proportion across HRRs was 45.3 (31.5)% and this varied widely (IQR 18.3-73.4%). CONCLUSIONS Overall growth in AIS treatment has been modest and, within HRRs, growth in AIS treatment and the proportion of centers with stroke certification varies dramatically.
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Affiliation(s)
- Laura K Stein
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Luke Maillie
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Erdman
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Emma Loebel
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Naomi Mayman
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Akarsh Sharma
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Stanley Tuhrim
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Johanna T Fifi
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nathalie Jette
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Forman R, Okumu R, Mageid R, Baker A, Neu D, Parker R, Peyravi R, Schindler JL, Sansing LH, Sheth KN, de Havenon A, Jasne A, Narula R, Wira C, Warren J, Sharma R. Association of Neighborhood-Level Socioeconomic Factors With Delay to Hospital Arrival in Patients With Acute Stroke. Neurology 2024; 102:e207764. [PMID: 38165368 PMCID: PMC10834135 DOI: 10.1212/wnl.0000000000207764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/03/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Delivery of acute ischemic stroke (AIS) therapies is contingent on the duration from last known well (LKW) to emergency department arrival time (EDAT). One reason for treatment ineligibility is delay in presentation to the hospital. We evaluate patient and neighborhood characteristics associated with time from LKW to EDAT. METHODS This was a retrospective observational study of patients presenting to the Yale New Haven Hospital in the AIS code pathway from 2010 to 2020. Patients presenting within 4.5 hours from LKW who were recorded in the institutional Get With the Guidelines Stroke registry were classified as early while those presenting beyond 4.5 hours were designated as late. Temporal trends in late presentation were explored by univariate logistic regression. Using variables significant in univariate analysis at p < 0.05, we developed a mixed-effect logistic regression model to estimate the probability of late presentation as a function of patient-level and neighborhood (ZIP)-level characteristics (area deprivation index [ADI] derived from the Health Resources and Services Administration), adjusted for calendar year and geographic distance from the centroid of the ZIP code to the hospital. RESULTS A total of 2,643 patients with AIS from 2010 to 2020 were included (63.4% presented late and 36.6% presented early). The frequency of late presentation increased significantly from 68% in 2010 to 71% in 2020 (p = 0.002) and only among non-White patients. Patients presenting late were more likely to be non-White (37.1% vs 26.9%, p < 0.0001), arrive by means other than emergency medical services (EMS) (32.7% vs 16.1%, p < 0.0001), have an NIHSS <6 (68.7% vs 55.2%, p < 0.0001), and present from a neighborhood with a higher ADI category (p = 0.0001) that was nearer to the hospital (median 5.8 vs 7.7 miles, p = 0.0032). In the mixed model, the ADI by units of 10 (odds ratio [OR] 1.022, 95% confidence interval [CI] 1.020-1.024), non-White race (OR 1.083, 95% CI 1.039-1.127), arrival by means other than EMS (OR 1.193, 95% CI 1.145-1.124), and an NIHSS <6 (OR 1.085, 95% CI 1.041-1.129) were associated with late presentation. DISCUSSION In addition to patient-level factors, socioeconomic deprivation of neighborhood of residence contributes to delays in hospital presentation for AIS. These findings may provide opportunities for targeted interventions to improve presentation times in at-risk communities.
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Affiliation(s)
- Rachel Forman
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Rita Okumu
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Razaz Mageid
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Anna Baker
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Dalton Neu
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Ranisha Parker
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Reza Peyravi
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Joseph L Schindler
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Lauren H Sansing
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Kevin N Sheth
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Adam de Havenon
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Adam Jasne
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Reshma Narula
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Charles Wira
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Joshua Warren
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Richa Sharma
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
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Kim KH, Ro YS, Shin SD, Kim SJ. Association between neighborhood socioeconomic status and mechanical thrombectomy for acute ischemic stroke: A nationwide multilevel observational study. Acad Emerg Med 2023; 30:918-926. [PMID: 37013692 DOI: 10.1111/acem.14731] [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: 01/12/2023] [Revised: 03/24/2023] [Accepted: 03/28/2023] [Indexed: 04/05/2023]
Abstract
OBJECTIVE Acute ischemic stroke is a major health burden worldwide and mechanical thrombectomy is the treatment of choice for large-vessel occlusion stroke. This study aimed to evaluate the association between neighborhood socioeconomic status (SES) and the likelihood of receiving mechanical thrombectomy in patients with acute ischemic stroke. METHODS A nationwide cross-sectional study was conducted using the National Emergency Department Information System database. Patients who were diagnosed with ischemic stroke in the emergency department (ED) within 24 h of symptom onset between 2018 and 2021 were included. The neighborhood SES index was measured at the county level using property tax per capita, education level, and the proportions of single families and single-parent households. The study population was divided into quartiles based on the neighborhood SES index. The study outcome was mechanical thrombectomy. Multilevel multivariable logistic regression was performed. An interaction analysis between mental status at the ED triage and neighborhood SES was also performed. RESULTS Among the 196,007 patients, 8968 (4.6%) underwent mechanical thrombectomy. Compared with the affluent group, the deprived-middle and deprived groups were less likely to receive mechanical thrombectomy; the adjusted ORs (95% CIs) were 1.00 (0.92-1.09), 0.82 (0.74-0.91), and 0.82 (0.72-0.93) for the affluent-middle, deprived-middle, and deprived groups, respectively. Altered mental status at the ED triage strengthened the association between neighborhood SES and the likelihood of receiving mechanical thrombectomy (adjusted ORs [95% CIs] 0.85 [0.81-0.89] for the affluent-middle to deprived-middle group and 0.66 [0.65-0.66] for deprived groups, p-value for interaction < 0.05). CONCLUSIONS For patients diagnosed with acute ischemic stroke at the ED, low neighborhood SES is associated with low odds of receiving mechanical thrombectomy. Public health strategies should be developed to resolve these disparities and to decrease the health care burden of acute ischemic stroke.
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Affiliation(s)
- Ki Hong Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Young Sun Ro
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
- National Emergency Medical Center, National Medical Center, Seoul, Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Seong Jung Kim
- National Emergency Medical Center, National Medical Center, Seoul, Korea
- Department of Emergency Medicine, Chosun University Hospital, Gwangju, Korea
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7
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Fukuda H, Hyohdoh Y, Ninomiya H, Ueba Y, Ohta T, Kawanishi Y, Kadota T, Hamada F, Fukui N, Nonaka M, Kawada K, Fukuda M, Nishimoto Y, Matsushita N, Nojima Y, Kida N, Hayashi S, Izumidani T, Nishimura H, Moriki A, Ueba T. Impact of areal socioeconomic status on prehospital delay of acute ischaemic stroke: retrospective cohort study from a prefecture-wide survey in Japan. BMJ Open 2023; 13:e075612. [PMID: 37620264 PMCID: PMC10450073 DOI: 10.1136/bmjopen-2023-075612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/09/2023] [Indexed: 08/26/2023] Open
Abstract
OBJECTIVES To examine whether the Areal Deprivation Index (ADI), an indicator of the socioeconomic status of the community the patient resides in, is associated with delayed arrival at the hospital and poor outcomes in patients with acute ischaemic stroke from a prefecture-wide stroke database in Japan. DESIGN Retrospective study. SETTING Twenty-nine acute stroke hospitals in Kochi prefecture, Japan. PARTICIPANTS Nine thousand and six hundred fifty-one patients with acute ischaemic stroke who were urgently hospitalised, identified using the Kochi Acute Stroke Survey of Onset registry. Capital and non-capital areas were analysed separately. PRIMARY AND SECONDARY OUTCOME MEASURES Prehospital delay defined as hospital arrival ≥4-hour after stroke onset, poor hospital outcomes (in-hospital mortality and discharge to a nursing facility) and the opportunities of intravenous recombinant tissue plasminogen activator (rt-PA) and endovascular reperfusion therapy. RESULTS In the overall cohort, prehospital delay was observed in 6373 (66%) patients. Among individuals residing in non-capital areas, those living in municipalities with higher ADI (more deprived) carried a significantly higher risk of prehospital delay (per one-point increase, OR (95% CI) 1.45 (1.26 to 1.66)) by multivariable logistic regression analysis. In-hospital mortality (1.45 (1.02 to 2.06)), discharge to a nursing facility (1.31 (1.03 to 1.66)), and delayed candidate arrival ≥2-hour of intravenous rt-PA (2.04 (1.30 to 3.26)) and endovascular reperfusion therapy (2.27 (1.06 to 5.00)), were more likely to be observed in the deprived areas with higher ADI. In the capital areas, postal-code-ADI was not associated with prehospital delay (0.97 (0.66 to 1.41)). CONCLUSIONS Living in socioeconomically disadvantaged municipalities was associated with prehospital delays of acute ischaemic stroke in non-capital areas in Kochi prefecture, Japan. Poorer outcomes of those patients may be caused by delayed treatment of intravenous rt-PA and endovascular reperfusion therapy. Further studies are necessary to determine social risk factors in the capital areas. TRIAL REGISTRATION NUMBER This article is linked to a clinical trial to UMIN000050189, No.: R000057166 and relates to its Result stage.
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Affiliation(s)
- Hitoshi Fukuda
- Department of Neurosurgery, Kochi Medical School Hospital, Nankoku, Japan
| | - Yuki Hyohdoh
- Centre of Medical Information Science, Kochi University, Kochi, Japan
| | - Hitoshi Ninomiya
- Department of Integrated Centre for Advanced Medical Technologies, Kochi Medical School Hospital, Nankoku, Japan
| | - Yusuke Ueba
- Department of Neurosurgery, Kochi Medical School Hospital, Nankoku, Japan
| | - Tsuyoshi Ohta
- Department of Neurosurgery, Kochi Health Sciences Centre, Kochi, Japan
| | - Yu Kawanishi
- Department of Neurosurgery, Kochi Medical School Hospital, Nankoku, Japan
| | - Tomohito Kadota
- Department of Neurosurgery, Kochi Medical School Hospital, Nankoku, Japan
| | - Fumihiro Hamada
- Department of Neurosurgery, Kochi Medical School Hospital, Nankoku, Japan
| | - Naoki Fukui
- Department of Neurosurgery, Kochi Medical School Hospital, Nankoku, Japan
| | - Motonobu Nonaka
- Department of Neurosurgery, Kochi Medical School Hospital, Nankoku, Japan
| | - Kei Kawada
- Department of Pharmacy, Kochi Medical School Hospital, Nankoku, Japan
| | - Maki Fukuda
- Department of Neurosurgery, Kochi Health Sciences Centre, Kochi, Japan
| | - Yo Nishimoto
- Department of Neurosurgery, Chikamori Hospital, Kochi, Japan
| | | | - Yuji Nojima
- Department of Neurosurgery, Hata Kenmin Hospital, Sukumo, Japan
| | - Namito Kida
- Department of Neurosurgery, Aki General Hospital, Kochi, Japan
| | - Satoru Hayashi
- Department of Neurosurgery, Chikamori Hospital, Kochi, Japan
| | | | | | - Akihito Moriki
- Department of Neurosurgery, Mominoki Hospital, Kochi, Japan
| | - Tetsuya Ueba
- Department of Neurosurgery, Kochi Medical School Hospital, Nankoku, Japan
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8
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Stamm B, Royan R, Giurcanu M, Messe SR, Jauch EC, Prabhakaran S. Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke. JAMA 2023; 330:636-649. [PMID: 37581671 PMCID: PMC10427946 DOI: 10.1001/jama.2023.12739] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 06/22/2023] [Indexed: 08/16/2023]
Abstract
Importance Treatments for time-sensitive acute stroke are not available at every hospital, often requiring interhospital transfer. Current guidelines recommend hospitals achieve a door-in-door-out time of no more than 120 minutes at the transferring emergency department (ED). Objective To evaluate door-in-door-out times for acute stroke transfers in the American Heart Association Get With The Guidelines-Stroke registry and to identify patient and hospital factors associated with door-in-door-out times. Design, Setting, and Participants US registry-based, retrospective study of patients with ischemic or hemorrhagic stroke from January 2019 through December 2021 who were transferred from the ED at registry-affiliated hospitals to other acute care hospitals. Exposure Patient- and hospital-level characteristics. Main Outcomes and Measures The primary outcome was the door-in-door-out time (time of transfer out minus time of arrival to the transferring ED) as a continuous variable and a categorical variable (≤120 minutes, >120 minutes). Generalized estimating equation (GEE) regression models were used to identify patient and hospital-level characteristics associated with door-in-door-out time overall and in subgroups of patients with hemorrhagic stroke, acute ischemic stroke eligible for endovascular therapy, and acute ischemic stroke transferred for reasons other than endovascular therapy. Results Among 108 913 patients (mean [SD] age, 66.7 [15.2] years; 71.7% non-Hispanic White; 50.6% male) transferred from 1925 hospitals, 67 235 had acute ischemic stroke and 41 678 had hemorrhagic stroke. Overall, the median door-in-door-out time was 174 minutes (IQR, 116-276 minutes): 29 741 patients (27.3%) had a door-in-door-out time of 120 minutes or less. The factors significantly associated with longer median times were age 80 years or older (vs 18-59 years; 14.9 minutes, 95% CI, 12.3 to 17.5 minutes), female sex (5.2 minutes; 95% CI, 3.6 to 6.9 minutes), non-Hispanic Black vs non-Hispanic White (8.2 minutes, 95% CI, 5.7 to 10.8 minutes), and Hispanic ethnicity vs non-Hispanic White (5.4 minutes, 95% CI, 1.8 to 9.0 minutes). The following were significantly associated with shorter median door-in-door-out time: emergency medical services prenotification (-20.1 minutes; 95% CI, -22.1 to -18.1 minutes), National Institutes of Health Stroke Scale (NIHSS) score exceeding 12 vs a score of 0 to 1 (-66.7 minutes; 95% CI, -68.7 to -64.7 minutes), and patients with acute ischemic stroke eligible for endovascular therapy vs the hemorrhagic stroke subgroup (-16.8 minutes; 95% CI, -21.0 to -12.7 minutes). Among patients with acute ischemic stroke eligible for endovascular therapy, female sex, Black race, and Hispanic ethnicity were associated with a significantly higher door-in-door-out time, whereas emergency medical services prenotification, intravenous thrombolysis, and a higher NIHSS score were associated with significantly lower door-in-door-out times. Conclusions and Relevance In this US registry-based study of interhospital transfer for acute stroke, the median door-in-door-out time was 174 minutes, which is longer than current recommendations for acute stroke transfer. Disparities and modifiable health system factors associated with longer door-in-door-out times are suitable targets for quality improvement initiatives.
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Affiliation(s)
- Brian Stamm
- Department of Neurology, University of Michigan, Ann Arbor
- Department of Neurology, Northwestern University, Chicago, Illinois
| | - Regina Royan
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Emergency Medicine, Northwestern University, Chicago, Illinois
- Assistant Editor, JAMA Network Open
| | - Mihai Giurcanu
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Steven R. Messe
- Department of Neurology, University of Pennsylvania, Philadelphia
| | - Edward C. Jauch
- Department of Research, Mountain Area Health Education Center, Asheville, North Carolina
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9
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Stamm B, Royan R, Trifan G, Alvarado-Dyer R, Velez FGS, Taylor W, Pinna P, Reish NJ, Vargas A, Goldenberg FD, Schneck MJ, Biller J, Testai F, Caprio FZ, Chou SH, Gorelick PB, Liotta EM, Batra A. Household income is associated with functional outcomes in a multi-institutional cohort of patients with ischemic stroke and COVID-19. J Stroke Cerebrovasc Dis 2023; 32:107059. [PMID: 36842351 PMCID: PMC9939399 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107059] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
OBJECTIVES The COVID-19 pandemic has heightened awareness of health disparities associated with socioeconomic status (SES) across the United States. We examined whether household income is associated with functional outcomes after stroke and COVID-19. MATERIALS AND METHODS This was a multi-institutional, retrospective cohort study of consecutively hospitalized patients with SARS-CoV-2 and radiographically confirmed stroke presenting from March through November 2020 to any of five comprehensive stroke centers in metropolitan Chicago, Illinois, USA. Zip-code-derived household income was dichotomized at the Chicago median. Logistic regression was used to examine the relationship between household income and good functional outcome (modified Rankin Scale 0-3 at discharge, after ischemic stroke). RESULTS Across five hospitals, 159 patients were included. Black patients comprised 48.1%, White patients 38.6%, and Hispanic patients 27.7%. Median household income was $46,938 [IQR: $32,460-63,219]. Ischemic stroke occurred in 115 (72.3%) patients (median NIHSS 7, IQR: 0.5-18.5) and hemorrhagic stroke in 37 (23.7%). When controlling for age, sex, severe COVID-19, and NIHSS, patients with ischemic stroke and household income above the Chicago median were more likely to have a good functional outcome at discharge (OR 7.53, 95% CI 1.61 - 45.73; P=0.016). Race/ethnicity were not included in final adjusted models given collinearity with income. CONCLUSIONS In this multi-institutional study of hospitalized patients with stroke, those residing in higher SES zip codes were more likely to have better functional outcomes, despite controlling for stroke severity and COVID-19 severity. This suggests that area-based SES factors may play a role in outcomes from stroke and COVID-19.
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Affiliation(s)
- Brian Stamm
- Ken & Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Regina Royan
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Gabriela Trifan
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine at Chicago, Chicago, IL
| | | | - Faddi G. Saleh Velez
- Department of Neurology, University of Chicago, Chicago, IL,Department of Neurology, The University of Oklahoma College of Medicine, Oklahoma City, OK
| | - William Taylor
- Ascension Medical Group, Milwaukee, WI,Department of Neurology, Loyola University Medical Center, Chicago, IL
| | - Pranusha Pinna
- Department of Neurology, Rush University Medical Center, Chicago, IL,National Institute of Neurological Disorders and Stroke, National Institute of Health, Bethesda, MD
| | - Nicholas J. Reish
- Ken & Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Alejandro Vargas
- Department of Neurology, Rush University Medical Center, Chicago, IL
| | | | - Michael J Schneck
- Department of Neurology, Loyola University Medical Center, Chicago, IL
| | - José Biller
- Department of Neurology, Loyola University Medical Center, Chicago, IL
| | - Fernando Testai
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine at Chicago, Chicago, IL
| | - Fan Z. Caprio
- Ken & Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sherry H. Chou
- Ken & Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Philip B. Gorelick
- Ken & Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Eric M. Liotta
- Ken & Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ayush Batra
- Ken & Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL,Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL
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10
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Tran PM, Warren JL, Leifheit EC, Goldstein LB, Lichtman JH. Associations Between Long-Term Air Pollutant Exposure and 30-Day All-Cause Hospital Readmissions in US Patients With Stroke. Stroke 2023; 54:e126-e129. [PMID: 36729388 PMCID: PMC11059199 DOI: 10.1161/strokeaha.122.042265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/01/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND Long-term exposure to air pollutants is associated with increased stroke incidence, morbidity, and mortality; however, research on the association of pollutant exposure with poststroke hospital readmissions is lacking. METHODS We assessed associations between average annual carbon monoxide (CO), nitrogen dioxide (NO2), ozone (O3), particulate matter 2.5, and sulfur dioxide (SO2) exposure and 30-day all-cause hospital readmission in US fee-for-service Medicare beneficiaries age ≥65 years hospitalized for ischemic stroke in 2014 to 2015. We fit Cox models to assess 30-day readmissions as a function of these pollutants, adjusted for patient and hospital characteristics and ambient temperature. Analyses were then stratified by treating hospital performance on the Centers for Medicare and Medicaid Services risk-standardized 30-day poststroke all-cause readmission measure to determine if the results were independent of performance: low (Centers for Medicare and Medicaid Services rate for hospital <25th percentile of national rate), high (>75th percentile), and intermediate (all others). RESULTS Of 448 148 patients with stroke, 12.5% were readmitted within 30 days. Except for tropospheric NO2 (no national standard), average 2-year CO, O3, particulate matter 2.5, and SO2 values were below national limits. Each one SD increase in average annual CO, NO2, particulate matter 2.5, and SO2 exposure was associated with an adjusted 1.1% (95% CI, 0.4-1.9%), 3.6% (95% CI, 2.9%-4.4%), 1.2% (95% CI, 0.2%-2.3%), and 2.0% (95% CI, 1.1%-3.0%) increased risk of 30-day readmission, respectively, and O3 with a 0.7% (95% CI, 0.0%-1.5%) decrease. Associations between long-term air pollutant exposure and increased readmissions persisted across hospital performance categories. CONCLUSIONS Long-term air pollutant exposure below national limits was associated with increased 30-day readmissions after stroke, regardless of hospital performance category. Whether air quality improvements lead to reductions in poststroke readmissions requires further research.
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Affiliation(s)
| | | | - Erica C. Leifheit
- Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | | | - Judith H. Lichtman
- Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
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11
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Chari SV, Cui ER, Fehl HE, Fernandez AR, Brice JH, Patel MD. Community socioeconomic and urban-rural differences in emergency medical services times for suspected stroke in North Carolina. Am J Emerg Med 2023; 63:120-126. [PMID: 36370608 PMCID: PMC10425758 DOI: 10.1016/j.ajem.2022.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/19/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Our objectives were to describe time intervals of EMS encounters for suspected stroke patients in North Carolina (NC) and evaluate differences in EMS time intervals by community socioeconomic status (SES) and rurality. METHODS This cross-sectional study used statewide data on EMS encounters of suspected stroke in NC in 2019. Eligible patients were adults requiring EMS transport to a hospital following a 9-1-1 call for stroke-like symptoms. Incident street addresses were geocoded to census tracts and linked to American Community Survey SES data and to rural-urban commuting area (RUCA) codes. Community SES was defined as high, medium, or low based on tertiles of an SES index. Urban, suburban, and rural tracts were defined by RUCA codes 1, 2-6, and 7-10, respectively. Multivariable quantile regression was used to estimate how the median and 90th percentile of EMS time intervals varied by community SES and rurality, adjusting for each other; patient age, gender, and race/ethnicity; and incident characteristics. RESULTS We identified 17,117 eligible EMS encounters of suspected stroke from 2028 census tracts. The population was 65% 65+ years old; 55% female; and 69% Non-Hispanic White. Median response, scene, and transport times were 8 (interquartile range, IQR 6-11) min, 16 (IQR 12-20) min, and 14 (IQR 9-22) minutes, respectively. In quantile regression adjusted for patient demographics, minimal differences were observed for median response and scene times by community SES and rurality. The largest median differences were observed for transport times in rural (6.7 min, 95% CI 5.8, 7.6) and suburban (4.7 min, 95% CI 4.2, 5.1) tracts compared to urban tracts. Adjusted rural-urban differences in 90th percentile transport times were substantially greater (16.0 min, 95% CI 14.5, 17.5). Low SES was modesty associated with shorter median (-3.3 min, 95% CI -3.8, -2.9) and 90th percentile (-3.0 min, 95% CI -4.0, -2.0) transport times compared to high SES tracts. CONCLUSIONS While community-level factors were not strongly associated with EMS response and scene times for stroke, transport times were significantly longer rural tracts and modestly shorter in low SES tracts, accounting for patient demographics. Further research is needed on the role of community socioeconomic deprivation and rurality in contributing to delays in prehospital stroke care.
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Affiliation(s)
- Srihari V Chari
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Eric R Cui
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Haylie E Fehl
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Antonio R Fernandez
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA; ESO, Austin, TX, USA
| | - Jane H Brice
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Mehul D Patel
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
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12
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Nantais J, Larsen K, Skelhorne-Gross G, Beckett A, Nolan B, Gomez D. Potential Access to Emergency General Surgical Care in Ontario. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13730. [PMID: 36360609 PMCID: PMC9653868 DOI: 10.3390/ijerph192113730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/13/2022] [Accepted: 10/20/2022] [Indexed: 06/16/2023]
Abstract
Limited access to timely emergency general surgery (EGS) care is a probable driver of increased mortality and morbidity. Our objective was to estimate the portion of the Ontario population with potential access to 24/7 EGS care. Geographic information system-based network-analysis was used to model 15-, 30-, 45-, 60-, and 90-min land transport catchment areas for hospitals providing EGS care, 24/7 emergency department (ED) access, and/or 24/7 operating room (OR) access. The capabilities of hospitals to provide each service were derived from a prior survey. Population counts were based on 2016 census blocks, and the 2019 road network for Ontario was used to determine speed limits and driving restrictions. Ninety-six percent of the Ontario population (n = 12,933,892) lived within 30-min's driving time to a hospital that provides any EGS care. The availability of 24/7 EDs was somewhat more limited, with 95% (n = 12,821,747) having potential access at 30-min. Potential access to all factors, including 24/7 ORs, was only possible for 93% (n = 12,471,908) of people at 30-min. Populations with potential access were tightly clustered around metropolitan centers. Supplementation of 24/7 OR capabilities, particularly in centers with existing 24/7 ED infrastructure, is most likely to improve access without the need for new hospitals.
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Affiliation(s)
- Jordan Nantais
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON M5B 1T8, Canada
- Department of Surgery, Section of General Surgery, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
| | - Kristian Larsen
- CAREX Canada, Faculty of Health Sciences, Simon Fraser University, Vancouver, BC V6T 1Z3, Canada
- Department of Geography and Planning, University of Toronto, Toronto, ON M5S 3G3, Canada
- Department of Geography and Environmental Studies, Ryerson University, Toronto, ON M5B 2K3, Canada
| | - Graham Skelhorne-Gross
- Department of Surgery, Division of General Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Andrew Beckett
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON M5B 1T8, Canada
- Department of Surgery, Division of General Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Brodie Nolan
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON M5B 1T8, Canada
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada
| | - David Gomez
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON M5B 1T8, Canada
- Department of Surgery, Division of General Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada
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13
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Drip and ship and mothership models of mechanical thrombectomy result in similar outcomes in acute ischemic stroke of the anterior circulation. J Stroke Cerebrovasc Dis 2022; 31:106733. [PMID: 36030578 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106733] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 08/05/2022] [Accepted: 08/14/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Stroke therapy has been transformed in recent years due to the availability of thrombolysis and mechanical thrombectomy (MT). Whether transferring the patient directly to a comprehensive stroke center (CSC, mothership model) is better than taking them to a primary stroke center (PSC) and then to a CSC for MT (drip and ship) is unclear but has important implications. We compared the performance of both models in a district of the Basque country, Spain. METHODS This is a retrospective analysis of prospectively collected data of all acute ischemic stroke patients consecutively admitted to the Neurology Department of two institutions and eligible for MT over a 36-month period with anterior circulation large vessel occlusion (LVO). One center applied the mothership model and the other the drip-and-ship. The two models were compared in terms of mortality and functional status assessed by modified Rankin (mRS) scale at 90 days. As a surrogate of the effectiveness of the two models, all times pertinent to stroke therapy were recorded. RESULTS A total of 187 patients were evaluated subjected to MT with the drip-and-ship model and 188 with mothership, with a median NIHSS of 15. Prior to MT, 17% of the drip-and-ship patients received thrombolysis and 26% in the mothership. Neither mortality rate nor mRS showed statistically significant differences 90 days after stroke. The time lapse from stroke to MT was optimal in both models; albeit being 10 minutes longer in the drip-and-ship model, it had no impact on patients' outcomes. CONCLUSIONS Drip-and-ship and mothership models can provide optimal and similar results in acute stroke patients in terms of mortality and functional status at 90 days. Their coexistence may alleviate the burden of CSC thus facilitating the access of more stroke patients to advanced therapies in an equitable manner.
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14
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Kurogi A, Onozuka D, Hagihara A, Nishimura K, Kada A, Hasegawa M, Higashi T, Kitazono T, Ohta T, Sakai N, Arai H, Miyamoto S, Sakamoto T, Iihara K. Influence of hospital capabilities and prehospital time on outcomes of thrombectomy for stroke in Japan from 2013 to 2016. Sci Rep 2022; 12:3252. [PMID: 35228551 PMCID: PMC8885934 DOI: 10.1038/s41598-022-06074-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 01/24/2022] [Indexed: 11/30/2022] Open
Abstract
To determine whether increasing thrombectomy-capable hospitals with moderate comprehensive stroke center (CSC) capabilities is a valid alternative to centralization of those with high CSC capabilities. This retrospective, nationwide, observational study used data from the J-ASPECT database linked to national emergency medical service (EMS) records, captured during 2013–2016. We compared the influence of mechanical thrombectomy (MT) use, the CSC score, and the total EMS response time on the modified Rankin Scale score at discharge among patients with acute ischemic stroke transported by ambulance, in phases I (2013–2014, 1461 patients) and II (2015–2016, 3259 patients). We used ordinal logistic regression analyses to analyze outcomes. From phase I to II, MTs increased from 2.7 to 5.5%, and full-time endovascular physicians per hospital decreased. The CSC score and EMS response time remained unchanged. In phase I, higher CSC scores were associated with better outcomes (1-point increase, odds ratio [95% confidence interval]: 0.951 [0.915–0.989]) and longer EMS response time was associated with worse outcomes (1-min increase, 1.007 [1.001–1.013]). In phase II, neither influenced the outcomes. During the transitional shortage of thrombectomy-capable hospitals, increasing hospitals with moderate CSC scores may increase nationwide access to MT, improving outcomes.
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Affiliation(s)
- Ai Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Daisuke Onozuka
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akihito Hagihara
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akiko Kada
- Department of Clinical Research Planning and Management, Clinical Research Center, National Hospital Organization Nagoya Medical Centre, Nagoya, Japan
| | - Manabu Hasegawa
- Immunization Office, Health Service Division, Health Service Bureau, Ministry of Health, Labor and Welfare, Tokyo, Japan
| | - Takahiro Higashi
- Division of Health Services Research, Center for Cancer Control and Information Services, National Cancer Center, Tokyo, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Science, Kyushu University, Fukuoka, Japan
| | - Tsuyoshi Ohta
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Centre General Hospital, Kobe, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. .,Department of Neurosurgery, Director General of the Hospital, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shimmmachi, Suita, Osaka, 564-8565, Japan.
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15
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Xin Y, Ren X. Predicting depression among rural and urban disabled elderly in China using a random forest classifier. BMC Psychiatry 2022; 22:118. [PMID: 35168579 PMCID: PMC8845343 DOI: 10.1186/s12888-022-03742-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 01/27/2022] [Indexed: 12/18/2022] Open
Abstract
With global aging, the number of elderly with physical disabilities is also increasing. Compared with the ordinary elderly, the elderly who lose their independence are more likely to have the symptoms of depression. Reducing depression may help to alleviate the disability process of those who find themselves in the disabled stages. Therefore, the purpose of this study is to explore the predictive effects of demographic characteristics, health behavior, health status, family relations, social relations, and subjective attitude on depression in rural and urban disabled elderly to improve early depression symptom recognition.A total of 1460 older adults aged 60 and disabled were selected from China Family Panel Studies (CFPS). Depression was assessed according to The Center for Epidemiologic Studies Depression Scale (CES-D). This paper used the random forest classifier to predict the depression of the disabled elderly from six aspects: demographic characteristics, health status, health behavior, family relationship, and social relationship. The prediction model was established based on 70% of the training set and 30% of the test set. The depression rate of rural disabled elderly was 57.67%, and that of urban disabled elderly was 44.59%. The mean values of the 10-k cross-validated results were 0.71 in rural areas and 0.70 in urban areas. AUC:0.71, specificity: 65.3%, sensitivity: 80.6% for rural disabled elderly with depression; AUC:0.78, specificity: 78.1%, sensitivity: 64.2% for urban disabled elderly with depression, respectively. There are apparent differences in the top ten predictors between rural and urban disabled elderly. The common predictors were self-rated health, changing in perceived health, disease or accidence experience within the past 2 weeks, life satisfaction, trusting people, BMI, and having trust in the future. Non-common predictors were chronic diseases, neighborly relations, total medical expenses within 1 year, community emotion, sleep duration, and family per capita income. Using random forest data to predict the depression of the disabled elderly may lead to early detection of depression.
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Affiliation(s)
- Yu Xin
- grid.13291.380000 0001 0807 1581West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan China
| | - Xiaohui Ren
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China.
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Walton NT, Mohr NM. Concept review of regionalized systems of acute care: Is regionalization the next frontier in sepsis care? J Am Coll Emerg Physicians Open 2022; 3:e12631. [PMID: 35024689 PMCID: PMC8733842 DOI: 10.1002/emp2.12631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/21/2021] [Accepted: 11/23/2021] [Indexed: 11/10/2022] Open
Abstract
Regionalization has become a buzzword in US health care policy. Regionalization, however, has varied meanings, and definitions have lacked contextual information important to understanding its role in improving care. This concept review is a comprehensive primer and summation of 8 common core components of the national models of regionalization informed by text-based analysis of the writing of involved organizations (professional, regulatory, and research) guided by semistructured interviews with organizational leaders. Further, this generalized model of regionalized care is applied to sepsis care, a novel discussion, drawing on existing small-scale applications. This discussion highlights the fit of regionalization principles to the sepsis care model and the actualized and perceived potential benefits. The principal aim of this concept review is to outline regionalization in the United States and provide a roadmap and novel discussion of regionalized care integration for sepsis care.
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Affiliation(s)
| | - Nicholas M. Mohr
- Departments of Emergency Medicine, Anesthesia‐Critical Care Medicine, and EpidemiologyUniversity of Iowa–Carver College of MedicineIowa CityIowaUSA
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Bender MT, Mattingly TK, Rahmani R, Proper D, Burnett WA, Burgett JL, LEsperance J, Cushman JT, Pilcher WH, Benesch CG, Kelly AG, Bhalla T. Mobile stroke care expedites intravenous thrombolysis and endovascular thrombectomy. Stroke Vasc Neurol 2021; 7:209-214. [PMID: 34952889 PMCID: PMC9240459 DOI: 10.1136/svn-2021-001119] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/16/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The number of mobile stroke programmes has increased with evidence, showing they expedite intravenous thrombolysis. Outstanding questions include whether time savings extend to patients eligible for endovascular therapy and impact clinical outcomes. OBJECTIVE Our mobile stroke unit (MSU), based at an academic medical centre in upstate New York, launched in October 2018. We reviewed prospective observational data sets over 26 months to identify MSU and non-MSU emergency medical service (EMS) patients who underwent intravenous thrombolysis or endovascular thrombectomy for comparison of angiographic and clinical outcomes. RESULTS Over 568 days in service, the MSU was dispatched 1489 times (2.6/day) and transported 300 patients (20% of dispatches). Intravenous tissue plasminogen activator (tPA) was administered to 57 MSU patients and the average time from 911 call-to-tPA was 42.5 min (±9.2), while EMS transported 73 patients who received tPA at 99.4 min (±35.7) (p<0.001). Seven MSU patients (12%) received tPA from 3.5 hours to 4.5 hours since last known well and would likely have been outside the window with EMS care. Endovascular thrombectomy was performed on 21 MSU patients with an average 911 call-to-groin puncture time of 99.9 min (±18.1), while EMS transported 54 patients who underwent endovascular thrombectomy (ET) at 133.0 min (±37.0) (p=0.0002). There was no difference between MSU and traditional EMS in modified Rankin score at 90-day clinic follow-up for patients undergoing intravenous thrombolysis or endovascular thrombectomy, whether assessed as a dichotomous or ordinal variable. CONCLUSIONS Mobile stroke care expedited both intravenous thrombolysis and endovascular thrombectomy. There is an ongoing need to show improved functional outcomes with MSU care.
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Affiliation(s)
- Matthew T Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Thomas K Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Diana Proper
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Walter A Burnett
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Jason L Burgett
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Joshua LEsperance
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Jeremy T Cushman
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Webster H Pilcher
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Curtis G Benesch
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
| | - Adam G Kelly
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
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18
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de Havenon A, Sheth K, Johnston KC, Delic A, Stulberg E, Majersik J, Anadani M, Yaghi S, Tirschwell D, Ney J. Acute Ischemic Stroke Interventions in the United States and Racial, Socioeconomic, and Geographic Disparities. Neurology 2021; 97:e2292-e2303. [PMID: 34649872 PMCID: PMC8665433 DOI: 10.1212/wnl.0000000000012943] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/27/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In patients with ischemic stroke (IS), IV alteplase (tissue plasminogen activator [tPA]) and endovascular thrombectomy (EVT) reduce long-term disability, but their utilization has not been fully optimized. Prior research has also demonstrated disparities in the use of tPA and EVT specific to sex, race/ethnicity, socioeconomic status, and geographic location. We sought to determine the utilization of tPA and EVT in the United States from 2016-2018 and if disparities in utilization persist. METHODS This is a retrospective, longitudinal analysis of the 2016-2018 National Inpatient Sample. We included adult patients who had a primary discharge diagnosis of IS. The primary study outcomes were the proportions who received tPA or EVT. We fit a multivariate logistic regression model to our outcomes in the full cohort and also in the subset of patients who had an available baseline National Institutes of Health Stroke Scale (NIHSS) score. RESULTS The full cohort after weighting included 1,439,295 patients with IS. The proportion who received tPA increased from 8.8% in 2016 to 10.2% in 2018 (p < 0.001) and who had EVT from 2.8% in 2016 to 4.9% in 2018 (p < 0.001). Comparing Black to White patients, the odds ratio (OR) of receiving tPA was 0.82 (95% confidence interval [CI] 0.79-0.86) and for having EVT was 0.75 (95% CI 0.70-0.81). Comparing patients with a median income in their zip code of ≤$37,999 to >$64,000, the OR of receiving tPA was 0.81 (95% CI 0.78-0.85) and for having EVT was 0.84 (95% CI 0.77-0.91). Comparing patients living in a rural area to a large metro area, the OR of receiving tPA was 0.48 (95% CI 0.44-0.52) and for having EVT was 0.92 (95% CI 0.81-1.05). These associations were largely maintained after adjustment for NIHSS, although the effect size changed for many of them. Contrary to prior reports with older datasets, sex was not consistently associated with tPA or EVT. DISCUSSION Utilization of tPA and EVT for IS in the United States increased from 2016 to 2018. There are racial, socioeconomic, and geographic disparities in the accessibility of tPA and EVT for patients with IS, with important public health implications that require further study.
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Affiliation(s)
- Adam de Havenon
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA.
| | - Kevin Sheth
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - Karen C Johnston
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - Alen Delic
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - Eric Stulberg
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - Jennifer Majersik
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - Mohammad Anadani
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - Shadi Yaghi
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - David Tirschwell
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
| | - John Ney
- From the University of Utah (A.d.H., A.D., E.S., J.M.), Salt Lake City; Yale University (K.S.), New Haven, CT; University of Virginia (K.C.J.), Charlottesville; Washington University (M.A.), St. Louis, MO; Brown University (S.Y.), Providence, RI; University of Washington (D.T.), Seattle; and Boston University (J.N.), MA
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Abstract
Neurologic health disparities are created and perpetuated by structural and social determinants of health. These factors include, but are not limited to, interpersonal bias, institutional factors that lead to disparate access to care, and neighborhood-level factors, such as socioeconomic status, segregation, and access to healthy food. Effects of these determinants of health can be seen throughout neurology, including in stroke, epilepsy, headache, amyotrophic lateral sclerosis, multiple sclerosis, and dementia. Interventions to improve neurologic health equity require multilayered approaches to address these interdependent factors that create and perpetuate disparate neurologic health access and outcomes.
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Affiliation(s)
- Nicole Rosendale
- Neurohospitalist Division, Department of Neurology, University of California San Francisco, 1001 Potrero Avenue, Building 1, Room 101, Box 0870, San Francisco, CA 94110, USA.
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Characterizing the performance of emergency medical transport time metrics in a residentially segregated community. Am J Emerg Med 2021; 50:111-119. [PMID: 34340164 DOI: 10.1016/j.ajem.2021.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/03/2021] [Accepted: 07/05/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To derive and characterize the performance of various metrics of emergency transport time in assessing for sociodemographic disparities in the setting of residential segregation. Secondarily to characterize racial disparities in emergency transport time of suspected stroke patients in Austin, Texas. DATA SOURCES We used a novel dataset of 2518 unique entries with detailed spatial and temporal information on all suspected stroke transports conducted by a public emergency medical service in Central Texas between 2010 and 2018. STUDY DESIGN We conducted one-way ANOVA tests with post-hoc pairwise t-tests to assess how mean hospital transport times varied by patient race. We also developed a spatially-independent metric of emergency transport urgency, the ratio of expected duration of self-transport to a hospital and the measured transport time by an ambulance. DATA COLLECTION/EXTRACTION We calculated ambulance arrival and destination times using sequential temporospatial coordinates. We excluded any entries in which patient race was not recorded. We also excluded entries in which ambulances' routes did not pass within 100 m of either the patient's location or the documented hospital destination. PRINCIPAL FINDINGS We found that mean transport time to a hospital was 2.5 min shorter for black patients compared to white patients. However, white patients' transport times to a hospital were found to be, on average, 4.1 min shorter than expected compared to 3.4 min shorter than expected for black patients. One-way ANOVA testing for the spatially-independent index of emergency transport urgency was not statistically significant, indicating that average transport time did not vary significantly across racial groups when accounting for variations in transport distance. CONCLUSIONS Using a novel transport urgency index, we demonstrate that these findings represent race-based variation in spatial distributions rather than racial bias in emergency medical transport. These results highlight the importance of closely examining spatial distributions when utilizing temporospatial data to investigate geographically-dependent research questions.
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21
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Clough RH, Ince J, Minhas JS. Evolving the Proposed HEMS Stroke Triaging Tool. J Emerg Med 2021; 60:812-813. [PMID: 34147229 DOI: 10.1016/j.jemermed.2020.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/02/2020] [Accepted: 12/14/2020] [Indexed: 11/20/2022]
Affiliation(s)
- Rebecca H Clough
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Jonathan Ince
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Jatinder S Minhas
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; University Hospitals of Leicester NHS Trust, Leicester, UK
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22
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Rauch S, Taubenböck H, Knopp C, Rauh J. Risk and space: modelling the accessibility of stroke centers using day- & nighttime population distribution and different transportation scenarios. Int J Health Geogr 2021; 20:31. [PMID: 34187473 PMCID: PMC8243862 DOI: 10.1186/s12942-021-00284-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/16/2021] [Indexed: 12/12/2022] Open
Abstract
Purpose Rapid accessibility of (intensive) medical care can make the difference between life and death. Initial care in case of strokes is highly dependent on the location of the patient and the traffic situation for supply vehicles. In this methodologically oriented paper we want to determine the inequivalence of the risks in this respect. Methods Using GIS we calculate the driving time between Stroke Units in the district of Münster, Germany for the population distribution at day- & nighttime. Eight different speed scenarios are considered. In order to gain the highest possible spatial resolution, we disaggregate reported population counts from administrative units with respect to a variety of factors onto building level. Results The overall accessibility of urban areas is better than in less urban districts using the base scenario. In that scenario 6.5% of the population at daytime and 6.8% at nighttime cannot be reached within a 30-min limit for the first care. Assuming a worse traffic situation, which is realistic at daytime, 18.1% of the population fail the proposed limit. Conclusions In general, we reveal inequivalence of the risks in case of a stroke depending on locations and times of the day. The ability to drive at high average speeds is a crucial factor in emergency care. Further important factors are the different population distribution at day and night and the locations of health care facilities. With the increasing centralization of hospital locations, rural residents in particular will face a worse accessibility situation. Supplementary Information The online version contains supplementary material available at 10.1186/s12942-021-00284-y.
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Affiliation(s)
- S Rauch
- Institute for Geography and Geology, Julius-Maximilians-Universitat Würzburg, 97074, Würzburg, Germany.
| | - H Taubenböck
- Institute for Geography and Geology, Julius-Maximilians-Universitat Würzburg, 97074, Würzburg, Germany.,German Aerospace Center (DLR), German Remote Sensing Data Center (DFD), Oberpfaffenhofen, 82234, Wessling, Germany
| | - C Knopp
- German Aerospace Center (DLR), German Remote Sensing Data Center (DFD), Oberpfaffenhofen, 82234, Wessling, Germany
| | - J Rauh
- Institute for Geography and Geology, Julius-Maximilians-Universitat Würzburg, 97074, Würzburg, Germany
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Kharbach A, Obtel M, Achbani A, Aasfara J, Hassouni K, Lahlou L, Razine R. Ischemic stroke in Morocco: Prehospital delay and associated factors. Rev Epidemiol Sante Publique 2021; 69:345-359. [PMID: 34148762 DOI: 10.1016/j.respe.2021.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/28/2021] [Accepted: 03/30/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES This study aimed to estimate prehospital delay and to identify the factors associated with the late arrival of patients with ischemic stroke at the Souss Massa Regional Hospital Center in Morocco. PATIENTS AND METHODS An observational, prospective, cross-sectional study was conducted from March 2019 to September 2019 in the Souss Massa regional hospital center, which is a public hospital structure. A questionnaire was administered to patients with ischemic stroke and to bystanders (family or others), while clinical and paraclinical data were collected from medical records. Univariate and multivariate logistic regression analyses were used to identify the factors associated with delayed arrival at emergency department. RESULTS A total of 197 patients and 197 bystanders who fulfilled the criteria for the study were included. The median time from symptom onset to hospital arrival was 6hours (IQR, 4-16). Multiple regression analysis showed that illiteracy (OR 38.58; CI95%: 3.40-437.27), waiting for symptoms to disappear (patient behavior) (OR 11.24; CI95%: 1.57-80.45), deciding to go directly to the hospital (patient behavior) (OR 0.07; CI95%: 0.01-0.57), bystander's knowledge that stroke is a disease requiring urgent care within a limited therapeutic window (OR 0.005; CI95%: 0.00-0.36), and direct admission without reference (OR 0.005; CI95%: 0.00-0.07), were independently associated with late arrival (>4.5hours) of patients with acute ischemic stroke. In addition, illiteracy (OR 24.62; CI95%: 4.37-138.69), vertigo and disturbance of balance or coordination (OR 0.14; CI95%: 0.03-0.73), the relative's knowledge that stroke is a disease requiring urgent care and within a limited therapeutic window (OR 0.03; CI95%: 0.00-0.22), calling for an ambulance (relative's behavior) (OR 0.16; CI95%: 0.03-0.80), distance between 50 and 100km (OR 10.16; CI95%: 1.16-89.33), and direct admission without reference (OR 0.03; CI95%: 0.00-0.14), were independently associated with late arrival (>6hours) of patients with acute ischemic stroke. CONCLUSION Patient behavior, bystander knowledge and direct admission to the competent hospital for stroke care are modifiable factors potentially useful for reducing onset-to-door time, and thereby increasing the implementation rates of acute stroke therapies.
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Affiliation(s)
- A Kharbach
- Laboratory of Biostatistics, Clinical Research and Epidemiology (LBRCE), Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco.
| | - M Obtel
- Laboratory of Biostatistics, Clinical Research and Epidemiology (LBRCE), Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco; Laboratory of Social Medicine (Public Health, Hygiene and Preventive Medicine), Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco.
| | - A Achbani
- Laboratory of Cell Biology and Molecular Genetics (LBCGM), Department of Biology, Faculty of Sciences, University Ibn Zohr Agadir, Rabat, Morocco.
| | - J Aasfara
- Department of Neurology, International Cheikh Khalifa University Hospital, Mohammed VI University of Health Sciences (UM6SS) Casablanca, Rabat, Morocco.
| | - K Hassouni
- International School of Public Health, Mohammed VI University of Health Sciences (UM6SS) Casablanca, Rabat, Morocco.
| | - L Lahlou
- Laboratory of Biostatistics, Clinical Research and Epidemiology (LBRCE), Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco; Faculty of Medicine and Pharmacy of Agadir, University Ibn Zohr, Agadir, Morocco.
| | - R Razine
- Laboratory of Biostatistics, Clinical Research and Epidemiology (LBRCE), Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco; Laboratory of Social Medicine (Public Health, Hygiene and Preventive Medicine), Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco.
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Mullen MT, Williams OA. Going the Extra Mile: Disparities in Access to Specialized Stroke Care. Stroke 2021; 52:2580-2582. [PMID: 34107736 DOI: 10.1161/strokeaha.121.035128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michael T Mullen
- Department of Neurology, University of Pennsylvania, Philadelphia (M.T.M.)
| | - Olajide A Williams
- Department of Neurology, Columbia University, New York, NY (O.A.W.).,Department of Neurology, New York Presbyterian Hospital (O.A.W.)
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25
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Yu CY, Blaine T, Panagos PD, Kansagra AP. Demographic Disparities in Proximity to Certified Stroke Care in the United States. Stroke 2021; 52:2571-2579. [PMID: 34107732 DOI: 10.1161/strokeaha.121.034493] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Cathy Y Yu
- Washington University School of Medicine (C.Y.Y.)
| | - Timothy Blaine
- Mallinckrodt Institute of Radiology (T.B., A.P.K.), Washington University School of Medicine, St. Louis, MO
| | - Peter D Panagos
- Department of Emergency Medicine (P.D.P.), Washington University School of Medicine, St. Louis, MO.,Department of Neurology (P.D.P., A.P.K.), Washington University School of Medicine, St. Louis, MO
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology (T.B., A.P.K.), Washington University School of Medicine, St. Louis, MO.,Department of Neurology (P.D.P., A.P.K.), Washington University School of Medicine, St. Louis, MO.,Department of Neurological Surgery (A.P.K.), Washington University School of Medicine, St. Louis, MO
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26
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Choi JC, Kim JG, Kang CH, Bae HJ, Kang J, Lee SJ, Park JM, Park TH, Cho YJ, Lee KB, Lee J, Kim DE, Cha JK, Kim JT, Lee BC, Lee JS, Kim AS. Effect of Transport Time on the Use of Reperfusion Therapy for Patients with Acute Ischemic Stroke in Korea. J Korean Med Sci 2021; 36:e77. [PMID: 33754510 PMCID: PMC7985286 DOI: 10.3346/jkms.2021.36.e77] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 01/11/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND We investigated the association between geographic proximity to hospitals and the administration rate of reperfusion therapy for acute ischemic stroke. METHODS We identified patients with acute ischemic stroke who visited the hospital within 12 hours of symptom onset from a prospective nationwide multicenter stroke registry. Reperfusion therapy was classified as intravenous thrombolysis (IVT), endovascular therapy (EVT), or combined therapy. The association between the proportion of patients who were treated with reperfusion therapy and the ground transport time was evaluated using a spline regression analysis adjusted for patient-level characteristics. We also estimated the proportion of Korean population that lived within each 30-minute incremental service area from 67 stroke centers accredited by the Korean Stroke Society. RESULTS Of 12,172 patients (mean age, 68 ± 13 years; men, 59.7%) who met the eligibility criteria, 96.5% lived within 90 minutes of ground transport time from the admitting hospital. The proportion of patients treated with IVT decreased significantly when stroke patients lived beyond 90 minutes of the transport time (P = 0.006). The proportion treated with EVT also showed a similar trend with the transport time. Based on the residential area, 98.4% of Korean population was accessible to 67 stroke centers within 90 minutes. CONCLUSION The use of reperfusion therapy for acute stroke decreased when patients lived beyond 90 minutes of the ground transport time from the hospital. More than 95% of the South Korean population was accessible to 67 stroke centers within 90 minutes of the ground transport time.
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Affiliation(s)
- Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Korea
- Institute of Medical Science, Jeju National University, Jeju, Korea.
| | - Joong Goo Kim
- Department of Neurology, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Korea
| | - Chul Hoo Kang
- Department of Neurology, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Korea
| | - Hee Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jihoon Kang
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Daejeon, Korea
| | - Jong Moo Park
- Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Yong Jin Cho
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Hospital, Daegu, Korea
| | - Dong Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jae Kwan Cha
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Joon Tae Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Byung Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Korea
| | - Anthony S Kim
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
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27
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Zheng S, Lyu TJ, Li Z, Gu H, Yang X, Wang C, Li H, Jiang Y, Shen H, Wang Y. GRP per capita and hospital characteristics associated with intravenous tissue plasminogen activator adherence rate: evidence from the Chinese Stroke Center Alliance. Stroke Vasc Neurol 2021; 6:337-343. [PMID: 33431514 PMCID: PMC8485228 DOI: 10.1136/svn-2020-000633] [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: 09/16/2020] [Revised: 11/22/2020] [Accepted: 12/01/2020] [Indexed: 11/30/2022] Open
Abstract
Background Timely delivery of intravenous tissue plasminogen activator (IV-rt PA) is pivotal to eligible patients who had a stroke while achieving higher rates of IV-rt PA has been problematic. This paper focuses on investigating influential factors associated with the administration of IV-rt PA, primarily per capita gross regional product (GRP) and healthcare system factors. Methods The study included 980 hospitals in the Chinese Stroke Center Alliance where 158 003 patients who had an acute ischaemic stroke received IV-rt PA between August 2015 and August 2019. The adherence rate to IV-rt PA within 4.5 hours time window in each hospital was the primary outcome. Influential factors were grouped into two categories: macroeconomic status and hospital characteristics. The outcome was analysed using multivariable linear regression. Results GRP per capita (β=2.37, p<0.001), hospital stroke centre certification (β=3.77, p<0.001), number of neurologists (β=0.12, p<0.001), existence of emergency services for neurological treatment (β=7.43, p=0.014), presence of emergency department (β=10.03, p=0.019) and cooperating with emergency centre (β=4.65, p=0.029) were significantly positively associated with the adherence rate to IV-rt PA. Conclusions Higher GRP per capita, affluent neurological personnel, well-equipped emergency services for neurological treatment and routine cooperation with the emergency centre were important for enhancing the adherence rate to IV-rt PA among patients who had an acute ischaemic stroke in China.
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Affiliation(s)
- Suxi Zheng
- Innvotion and Information Management, HKU Business School, The University of Hong Kong, Hong Kong, China
| | - Tian Jie Lyu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zixiao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Chinese Institute for Brain Research, Beijing, China
| | - Hongqiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Yang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chunjuan Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haipeng Shen
- Innvotion and Information Management, HKU Business School, The University of Hong Kong, Hong Kong, China .,Shenzhen Institute of Research and Innovation, The University of Hong Kong, Shenzhen, China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China .,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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28
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Hsu KC, Lin CH, Johnson KR, Fann YC, Hsu CY, Tsai CH, Chen PL, Chang WL, Yeh PY, Wei CY. Comparison of outcome prediction models post-stroke for a population-based registry with clinical variables collected at admission vs. discharge. VESSEL PLUS 2021; 5:2. [PMID: 35356047 PMCID: PMC8963213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
AIM The ability to predict outcomes can help clinicians to better triage and treat stroke patients. We aimed to build prediction models using clinical data at admission and discharge to assess predictors highly relevant to stroke outcomes. METHODS A total of 37,094 patients from the Taiwan Stroke Registry (TSR) were enrolled to ascertain clinical variables and predict their mRS outcomes at 90 days. The performances (i.e., the area under the curves (AUCs)) of these independent predictors identified by logistic regression (LR) based on clinical variables were compared. RESULTS Several outcome prediction models based on different patient subgroups were evaluated, and their AUCs based on all clinical variables at admission and discharge were 0.85-0.88 and 0.92-0.96, respectively. After feature selections, the input features decreased from 140 to 2-18 (including age of onset and NIHSS at admission) and from 262 to 2-8 (including NIHSS at discharge and mRS at discharge) at admission and discharge, respectively. With only a few selected key clinical features, our models can provide better performance than those previously reported in the literature. CONCLUSION This study proposed high performance prognostics outcome prediction models derived from a population-based nationwide stroke registry even with reduced LR-selected clinical features. These key clinical features can help physicians to better focus on stroke patients to triage for best outcome in acute settings.
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Affiliation(s)
- Kai-Cheng Hsu
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan,Artificial Intelligence Center for Medical Diagnosis, China Medical University Hospital, Taichung, Taiwan,Department of Neurology, China Medical University Hospital, Taichung, Taiwan
| | - Ching-Heng Lin
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Kory R. Johnson
- Bioinformatics Section, National Institute of Neurological Disorder and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Yang C. Fann
- Bioinformatics Section, National Institute of Neurological Disorder and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Chung Y. Hsu
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
| | - Chon-Haw Tsai
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan
| | - Po-Lin Chen
- Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wei-Lun Chang
- Department of Neurology, Show Chwan Memorial Hospital, Changhua County, Taiwan
| | - Po-Yen Yeh
- Department of Neurology, St. Martin De Porres Hospital, Chiayi, Taiwan
| | - Cheng-Yu Wei
- Department of Neurology, Chang Bing Show Chwan Memorial Hospital, Changhua County, Taiwan
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29
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Yuan EJ, Hsu CA, Lee WC, Chen TJ, Chou LF, Hwang SJ. Where to buy face masks? Survey of applications using Taiwan's open data in the time of coronavirus disease 2019. J Chin Med Assoc 2020; 83:557-560. [PMID: 32304508 PMCID: PMC7199767 DOI: 10.1097/jcma.0000000000000325] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) had spread rapidly since late December 2019. Personal protective equipment was essential to prevent transmission. Owing to shortage of face masks, Taiwan government began to implement quasi rationing on February 6, 2020, by allowing each resident to purchase two masks in seven days. Taiwan National Health Insurance Administration offered online data with real-time updates on face mask availability in all contracted pharmacies and selected local health centers. Based on the open data, numerous software applications quickly emerged to assist the public in finding sales locations efficiently. METHODS Up until March 15, 2020, the Public Digital Innovation Space of Taiwan government had recorded 134 software applications of face mask availability, and 24 software applications were excluded due to defect, duplicate, and unavailability. These applications were analyzed according to platform, developer type, and display mode. RESULTS Of the 110 valid software applications, 67 (60.9%) applications were deployed on websites, followed by 21 (19.1%) on social networking sites, 19 (17.3%) as mobile applications, and 3 (2.7%) in other modes. Nearly two thirds (n = 70) of applications were developed by individuals, one third (n = 37) by commercial companies, only two applications by central and local governments, and one by a nongovernmental organization. With respect to the display mode, 47 (42.7%) applications adopted map-view only, 41 (37.3%) adopted table-view only, and 19 (17.3%) adopted both modes. Of the remaining three applications, two offered voice user interfaces and one used augmented reality. CONCLUSION Taiwan's open data strategy facilitated rapid development of software applications for information dissemination to the public during the COVID-19 crisis. The transparency of real-time data could help alleviate the panic of the public. The collaborative contributions from the grassroots in disasters were priceless treasures.
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Affiliation(s)
- Eunice J. Yuan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chia-An Hsu
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Wui-Chiang Lee
- Department of Medical Affairs and Planning, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Tzeng-Ji Chen
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Big Data Center, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- *Address correspondence: Dr. Tzeng-Ji Chen, Department of Family Medicine, Taipei Veterans General Hospital, 201, Section 2, Shi-Pai Road, Taipei 112, Taiwan, ROC. E-mail address: (T.-J. Chen)
| | - Li-Fang Chou
- Department of Public Finance, National Chengchi University, Taipei, Taiwan, ROC
| | - Shinn-Jang Hwang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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