Alert on elongated in-hospital acute stroke management delays. An Aquitain cohort study

The objectives were to analyze changes from 2012 to 2017 in different management times of stroke patients included in the Aquitaine stroke Observatory (ObA2). The studied times (onset-to-needle time-ONT, onset-to-door time-ODT, door-to-imaging time-DIT, door-to-needle time-DNT and imaging-to-needle time-INT) were described as median, interquartile ranges and proportion of patients within the recommended median time goals (ODT under 4hours, DIT within 20min; for thrombolyzed patients, DIT under 20min and a ONT under 4:30) to be compared with an objective of 50% of patients within said time goal. Globally, ODT was 160min, with 43.6% to 59.6% of patients within the ODT goal along the study period. With no improvement over time, the proportion of patients within the DIT goal stayed stable and at a low level (range: 5.5-7.0%) for all patients, decreasing from 25.2% to 11.4% for thrombolyzed patients. The proportion of thrombolyzed patients within the DNT goal varied from 15.1% to 30.3% during study period. These results highlight the urgent need for action to improve in-hospital management of stroke patients, focusing on delays between admission and imaging.

273 - Vulnérabilité, COVID-19 et qualité des prises en charge cardio-neuro-vasculaires en aigu

Contexte

La pandémie COVID-19 faisait craindre une détérioration des prises en charge hors COVID, notamment des infarctus du myocarde et accidents vasculaires cérébraux, tout particulièrement chez les personnes vulnérables. L'objectif était d'étudier l'effet de la première vague de COVID-19 sur la prise en charge des personnes vulnérables victimes d'un infarctus du myocarde ou d'un accident vasculaire cérébral.

Méthodes

Les données étaient issues de deux cohortes de patients hospitalisés pour « infarctus du myocarde » et « accident vasculaire cérébral » entre janvier 2019 et août 2020 inclus dans les registres aquitains cardio-neuro-vasculaires. Les associations entre vulnérabilités (cliniques : âge supérieur à 65 ans, antécédents cardiovasculaires; socio-économiques : indice de défavorisation) et délais de prise en charge ont été analysées par des modèles mixtes de régression linéaire multivariée, avec une interaction sur la période (pré, per, post-confinement).

Résultats

Au total, 9218 patients ont été inclus (6436 accidents vasculaires cérébraux, 2782infarctus du myocarde). Dans la cohorte « infarctus du myocarde », le délai premier contact médical/revascularisation était plus long chez les personnes âgées (p<0,001) et les personnes « très défavorisées » (p=0,003) sans modification significative liée à la première vague COVID-19 (interaction : p=0,541 pour l’âge, p=0,642 pour l'indice de défavorisation). Dans la cohorte « accident vasculaire cérébral », aucune différence significative du délai admission/imagerie n'a été mise en évidence liée aux vulnérabilités étudiées et à la période COVID-19.

Discussion/Conclusion

Les mesures mises en place pendant la crise COVID-19 n'ont pas eu d'impact sur les délais de prise en charge des populations vulnérables pour les filières structurées de l'infarctus du myocarde ou de l'accident vasculaire cérébral. En particulier, les disparités de prise en charge préexistantes n'ont été ni accentuées ni réduites.

Déclaration de liens d'intérêts

Les auteurs déclarent ne pas avoir de liens d'intérêts.

[Linking Interventional Cardiology clinical registry data with French hospital administrative data: Development and validation of deterministic record linkage]

BACKGROUND

To recreate the in-hospital healthcare pathway for patients treated with coronary angiography or percutaneous coronary intervention, we linked the interventional cardiology registry (ACIRA) and the pseudonymized French hospital medical information system database (PMSI) in the Aquitaine region. The objective of this study was to develop and validate a deterministic merging algorithm between these exhaustive and complementary databases.

METHODS

After a pre-treatment phase of the databases to standardize the 11 identified linking variables, a deterministic linking algorithm was developed on ACIRA hospital stays between December 2011 and December 2014 in nine interventional cardiology centers as well as the data from the consolidated PMSI databases of the Aquitaine region from 2011 to 2014. Merging was carried out through 12 successive steps, the first consisting in strict linking of the 11 variables. The performance of the algorithm was analyzed in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Strategies complementary to the initial algorithm (change in the order of variables and base preprocessing) were tested. Comparative analysis of merged/unmerged patients explored potential causes of mismatch.

RESULTS

The algorithm found 97.2% of the 31,621 ACIRA stays to have sensitivity of 99.9% (95% CI [99.9; 99.9]), specificity of 97.9% (95% CI [97.7; 98.1]), PPV of 99.9% (95% CI [99.9; 99.9]) and NPV of 96.9% (95% CI [96.7; 97.1]). Complementary strategies did not yield better results. The unmerged patients were older, and hospitalized mostly in 2012 in two interventional cardiology centers.

CONCLUSION

This study underscored the feasibility and validity of an indirect deterministic pairing to routinely link a registry of practices using hospital data to pseudonymized medico-administrative databases. This method, which can be extrapolated to other health events leading to hospitalization, renders it possible to effectively reconstruct patients' hospital healthcare pathway.

Socioeconomic status influences delays in the management of acute ST-elevation myocardial infarction

Background

A prompt diagnosis to initiate the appropriate reperfusion therapy is crucial to improve clinical outcomes in acute ST-elevation myocardial infarction (STEMI) patients. Socio-economic status (SES) refers to parameters like income, educational status and occupation. A low SES negatively interferes with the prognosis of STEMI patients. However, the impact of SES on delay time in acute STEMI remains matter of debate.

Methods

We used databases from two French multicentric and prospective registries: ACIRA (patients undergoing coronary angiography in any catheterization laboratories of Aquitaine) and REANIM (acute STEMI patients supported by emergency medical system (EMS) in Aquitaine). An ecological indicator of social deprivation Fdep09 was calculated to describe geographical inequalities in health based on municipality of residence. The higher the value, the more disadvantaged the population. Low SES was defined as Fdep09 &gt; median value.

Results

Two-thousand-eight-hundred-and-forty consecutive patients with acute STEMI undergoing coronary angiography from January 2017 to December 2018 in Aquitaine were included. Patients with lower SES were more often initially referred to emergency departments of non-percutaneous coronary intervention capable centers whereas patients with higher SES were more often directly transferred to PCI centers by the mobile emergency care units as recommended by the most recent European guidelines (p&lt;10–4). Patients with low SES had longer delays from symptom onset to first medical contact (FMC) (116 [60–119] vs 98 [55–233] min, p=0.0078) and were more likely to receive fibrinolysis (9.9 vs 5.2%, p&lt;10–4). Linear regression modeling showed that each point of the Fdep09 index was associated with increase in the delay from symptom onset to FMC by a factor 1.1 (95% CI: 1.04–1.17, p&lt;10–3) after adjusting for potential confounders.

Conclusion

SES inequality has negative influence on the delays in the management of acute STEMI patients. Efforts to raise awareness of suspicious signs of acute MI among individuals in lower SES could be valuable.

FDep09 distribution

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): ARS Nouvelle-Aquitaine

Post-stroke pathway analysis and link with one year sequelae in a French cohort of stroke patients: the PAPASePA protocol study

Background

Stroke is a health problem with serious consequences, both in terms of mortality, and after-effects affecting patient quality of life. Stroke requires both urgent and chronic management involving the entire health care system. Although large variability in the management of stroke patients have been noticed, knowledge of the diversity and the scalability of post-stroke pathways, whether it is the care pathway or the life pathway, is currently not sufficient. Moreover the link between post-stroke pathways and patients sequelae have not been yet clearly defined. All this information would be useful to better target the needs to improve stroke patient management.

The purposes are to identify the post-stroke life pathways components associated with sequelae (activity limitations – main purpose, cognitive disorders, anxio-depressive disorders, fatigue, participation restrictions) at 3 months and 1 year post-stroke, to define a typology of life pathways of patients during the post-stroke year and to analyze the social and geographical inequalities in the management of stroke.

Methods

Design: a prospective multicenter comparative cohort study with a follow up to 1 year after the acute episode.

Participant centers: 13 hospitals in the Aquitaine region (France).

Study population: patients diagnosed with a confirmed ischemic or hemorrhagic stroke included in the Aquitaine Observatory of Stroke (ObA2) cohort and voluntary to participate.

Data sources are existing databases (ObA2 database and the French National Health Data System - SNDS) to collect information about care pathways, patient characteristics and stroke characteristics and Ad hoc surveys to collect information about life pathways and post-stroke sequelae. The endpoints of the study are post-stroke activity limitations evaluated by the modified Rankin score, other post-stroke sequelae (Cognitive disorders, anxio-depressive disorders, fatigue, restriction of participation) assessed by standardized and validated scales and Clusters of patients responding to pathways with common or similar characteristics.;

Discussion

By integrating a longitudinal dimension and relying on a large cohort, the project will make it possible to identify the sources of disturbances and the factors favorable to the outcome of the life pathways, important for the planning of the offer and the management of the public policies concerning stroke pathways.

Trial registration

ClinicalTrials.gov ID: NCT03865173, March 6th, 2019.

[One hundred and fifteen cases of imported falciparum malaria admitted at the Bordeaux teaching hospital Emergency Unit]

OBJECTIVES

The authors had for objective to evaluate the management of a Plasmodium falciparum malaria in a Bordeaux teaching hospital EU.

METHODS

One hundred and fifteen patients with falciparum malaria admitted between January 2004 and October 2006 were retrospectively studied and those with ambulatory treatment were questioned by phone.

RESULTS

Fifty per cent of patients had consulted a community physician prior to admission, and a parasitic test was made for 50 % of these. In seven (27 %) cases the test was wrong. Twenty-seven (87 %) of ambulatory patients were contacted by phone. Eleven (41 %) of these said they were not aware of the potential disease severity. Patients initially treated in ambulatory care and later hospitalized because of their evolution have either insisted to go back home or have been sent home because there was not enough room in the hospital. Hospitalization for at least 24 hours had been indicated for 83 patients (72 %). Twelve patients (10 %) have presented with symptoms of severe malaria. Atovaquone-proguanil was the main therapeutic regimen for inpatients and outpatients (n=93, 81 %). Twelve (10 %) patients did not undergo follow-up parasitological assessment, 10 ambulatory patients (32 %) and two hospitalized patients (2 %).

CONCLUSION

An efficient hospital-community network and recent protocols are the best tools to rapidly refer patients to an adapted structure with available trained staff and referent specialist.