Emergency department utilization among patients who receive outpatient specialty care for headache: A retrospective cohort study analysis

OBJECTIVES

To compare clinical characteristics among outpatient headache clinic patients who do and do not self-report visiting the emergency department for headache.

BACKGROUND

Headache is the fourth most common reason for emergency department visits, compromising 1%-3% of visits. Limited data exist about patients who are seen in an outpatient headache clinic but still opt to frequent the emergency department. Clinical characteristics may differ between patients who self-report emergency department use and those who do not. Understanding these differences may help identify which patients are at greatest risk for emergency department overutilization.

METHODS

This observational cohort study included adults treated at the Cleveland Clinic Headache Center between October 12, 2015 and September 11, 2019, who completed self-reported questionnaires. Associations between self-reported emergency department utilization and demographics, clinical characteristics, and patient-reported outcome measures (PROMs: Headache Impact Test [HIT-6], headache days per month, current headache/face pain, Patient Health Questionnaire-9 [PHQ-9], Patient-Reported Outcomes Measurement Information System [PROMIS] Global Health [GH]) were evaluated.

RESULTS

Of the 10,073 patients (mean age 44.7 ± 14.9, 78.1% [7872/10,073] female, 80.3% [8087/10,073] White patients) included in the study, 34.5% (3478/10,073) reported visiting the emergency department at least once during the study period. Characteristics significantly associated with self-reported emergency department utilization included younger age (odds ratio = 0.81 [95% CI = 0.78-0.85] per decade), Black patients (vs. White patients) (1.47 [1.26-1.71]), Medicaid (vs. private insurance) (1.50 [1.29-1.74]), and worse area deprivation index (1.04 [1.02-1.07]). Additionally, worse PROMs were associated with greater odds of emergency department utilization: higher (worse) HIT-6 (1.35 [1.30-1.41] per 5-point increase), higher (worse) PHQ-9 (1.14 [1.09-1.20] per 5-point increase), and lower (worse) PROMIS-GH Physical Health T-scores (0.93 [0.88-0.97]) per 5-point increase.

CONCLUSION

Our study identified several characteristics associated with self-reported emergency department utilization for headache. Worse PROM scores may be helpful in identifying which patients are at greater risk for utilizing the emergency department.

Abstract WMP50: Lesion-symptom Mapping For Post-stroke Depression

Background: Post-stroke depression poses an important challenge for patients and delays reintegration to societal roles. Earlier identification of patients at higher risk for depression based on clinical imaging would allow a tailored treatment approach.

Methods: We conducted machine-learning based lesion-symptom mapping (LSM) using a retrospective cohort of 477 patients with first-ever acute ischemic stroke (AIS) presenting to a large cerebrovascular center from 2013-2019 with mild motor impairment defined by mRS 0-2. Patient Health Questionnaire (PHQ-9) depression scale was collected within 60 days of index stroke. The location and volume of AIS lesions on brain MRI were analyzed using a machine-learning based algorithm coupled with the FreeSurfer parcellation package. LSM after random field theory-based multiple comparison correction was conducted to examine the association of AIS location and volume with PHQ-9 scale, adjusting for patient age, sex and NIHSS.

Results: AIS in the right temporal, parietal, occipital lobes and the right basal ganglia were associated with depressive symptoms (Figure A). Sensitivity analysis excluding those with significant sleep disturbance (n=24) demonstrated that strokes in the right frontal and parietal lobes were associated with severe depression measured by PHQ-9>10 (Figure B).

Conclusions: This hypothesis generating study was suggestive of a neuroanatomic basis for the development of post-stroke depression. Further studies in a larger dataset are needed to confirm these associations. The methods will help to predict those patients at higher risk for post-stroke depression, allowing for earlier intervention and recovery.

Patient Versus Clinician Proxy Reliability of the AM-PAC "6-Clicks" Basic Mobility and Daily Activity Short Forms

OBJECTIVE

The purpose of this study was to test the reliability of the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" mobility and activity short forms between patients and therapist proxies. As a secondary aim, reliability was examined when patients completed their self-report before versus after the therapist evaluation.

METHODS

Patients being seen for an initial physical therapist (N = 70) or occupational therapist (N = 71) evaluation in the acute care hospital completed the "6-Clicks" mobility short form (if a physical therapist evaluation) or activity short form (if an occupational therapist evaluation). Whether patients completed their self-assessment before or after the evaluation was randomized. Patient- and therapist-rated "6-Clicks" raw scores were converted to AM-PAC T-scores for comparison. Reliability was assessed with intraclass correlation coefficients (ICCs) and Bland-Altman plots, and agreement was assessed with weighted kappa values.

RESULTS

The ICCs for the "6-Clicks" mobility and daily activity short forms were 0.57 (95% CI = 0.42-0.69) and 0.45 (95% CI = 0.28-0.59), respectively. For both short forms, reliability was higher when the patient completed the self-assessment after versus before the therapist evaluation (ICC = 0.67, 95% CI = 0.47-0.80 vs ICC = 0.50, 95% CI = 0.26-0.67 for the mobility short form; and ICC = 0.52, 95% CI = 0.29-0.70 vs ICC = 0.34, 95% CI = 0.06-0.56 for the activity short form).

CONCLUSION

Reliability of the "6-Clicks" total scores was moderate for both the mobility and activity short forms, though higher for the mobility short form and when patients' self-report occurred after the therapist evaluation.

IMPACT

Reliability of the AM-PAC "6-Clicks" short forms is moderate when comparing scores from patients with those of therapists responding as proxies. The short forms are useful for measuring participants' function in the acute care hospital; however, it is critical to recognize limitations in reliability between clinician- and patient-reported AM-PAC scores when evaluating longitudinal change and recovery.

0735 Sleep Disturbances in Post-Acute Sequelae of COVID-19 (PASC)

Introduction

Sleep difficulties and fatigue are highly prevalent, pervasive symptoms reported in patients with Post-Acute Sequelae of COVID-19 (PASC). As little is known of the predictors and severity of PASC-related sleep disturbance and intersection with fatigue, we leverage systematic data collected from the Cleveland Clinic ReCOVer Clinic for further elucidation

Methods

Analysis of data collected from Cleveland Clinic ReCOVer Clinic patients (February-November 2021) who completed the Patient-Reported Outcomes Measurement (PROMIS) Sleep Disturbance and PROMIS Fatigue questionnaires was performed. Data were extracted from the Cleveland Clinic COVID-19 registry and the electronic health record.PROMIS scores are standardized to the general U.S. adult population on a T-scale with mean 50±10. PROMIS sleep disturbance and fatigue T-scores ≥60 indicates at least moderate disturbance and ≥70 indicate severe disturbance. T-test and Chi-square tests were used to examine cross-group differences. Multivariable logistic regression adjusted for age, race, sex, and body mass index(kg/m2) was performed to investigate factors associated with sleep disturbance severity.

Results

Out of 1321, 682 patients completed the PROMIS Sleep Disturbance questionnaire with age 49.8±13.6, 75.2% female and 12.3% black race. Average T-scores were 57.7±8.3, 281 (41.2%) patients reported at least moderate sleep disturbance and 50 (7.3%) reported severe sleep disturbances. Average PROMIS Fatigue T-score was 63.0±9.2; 68.6% patients reported at least moderate fatigue, 22.6% reported severe fatigue. Patients with moderate-severe compared to normal-to-mild sleep disturbances respectively had higher BMI (32.3±8.7 vs 30.9±7.5, p=0.049), were more likely of black race (40.0±10.0 vs 41.0±15.7,p=0.010), had worse eneral Anxiety Disorder (GAD)-2 questionnaires scores (2.8±2.1 vs 1.6±1.7,p<0.001), Patient Health Questionnaire (PHQ)-2 scores (2.8±2.0 vs 1.6±1.7,p<0.001) and PROMIS fatigue scores (66.7±7.8 vs 60.4±9.1,p<0.001) with no difference in age, sex, or hospitalization due to COVID-19. In the adjusted model, black race was associated with moderate-severe sleep disturbance (OR=3.42, 95%CI:1.64-7.13).

Conclusion

The prevalence of moderate to severe sleep disturbances reported by patients presenting for PASC was very high i.e.>40% and associated with obesity, black race and mood symptoms. Notably, after adjustment for demographics, black race conferred a 3-fold higher odds of moderate-severe sleep disturbance emphasizing the need to characterize race-specific determinants and disparities in COVID-19 survivors.

Support (If Any)

 

Long-term continuation of anti-seizure medications after acute stroke

Objective

To investigate the factors associated with the long‐term continuation of anti‐seizure medications (ASMs) in acute stroke patients.

Methods

We performed a retrospective cohort study of stroke patients with concern for acute symptomatic seizures (ASySs) during hospitalization who subsequently visited the poststroke clinic. All patients had continuous EEG (cEEG) monitoring. We generated a multivariable logistic regression model to analyze the factors associated with the primary outcome of continued ASM use after the first poststroke clinic visit.

Results

A total of 507 patients (43.4% ischemic stroke, 35.7% intracerebral hemorrhage, and 20.9% aneurysmal subarachnoid hemorrhage) were included. Among them, 99 (19.5%) suffered from ASySs, 110 (21.7%) had epileptiform abnormalities (EAs) on cEEG, and 339 (66.9%) had neither. Of the 294 (58%) patients started on ASMs, 171 (33.7%) were discharged on them, and 156 (30.3% of the study population; 53.1% of patients started on ASMs) continued ASMs beyond the first poststroke clinic visit [49.7 (±31.7) days after cEEG]. After adjusting for demographical, stroke‐ and hospitalization‐related variables, the only independent factors associated with the primary outcome were admission to the NICU [Odds ratio (OR) 0.37 (95% CI 0.15–0.9)], the presence of ASySs [OR 20.31(95% CI 9.45–48.43)], and EAs on cEEG [OR 2.26 (95% CI 1.14–4.58)].

Interpretation

Almost a third of patients with poststroke ASySs concerns may continue ASMs for the long term, including more than half started on them acutely. Admission to the NICU may lower the odds, and ASySs (convulsive or electrographic) and EAs on cEEG significantly increase the odds of long‐term ASM use.

795 Real World Challenges and Barriers for Positive Airway Pressure Therapy Use in Acute Ischemic Stroke Patients

Introduction

Untreated obstructive sleep apnea (OSA) in patients with acute ischemic stroke (AIS) increases morbidity and mortality post-stroke. However, diagnosing and treating OSA in AIS is challenging. As such, we aimed to determine the feasibility of portable monitoring (PM) for diagnosis and positive airway pressure (PAP) therapy for treatment of OSA in an inpatient stroke population.

Methods

We recruited inpatients with AIS from the Cleveland Clinic. Those who consented underwent PM; participants with a respiratory event (REI) ≥10 were offered auto-titrating positive airway pressure therapy (APAP). Ease-of-use questionnaires were completed. We summarized categorical variables using n(%) and continuous variables using mean±SD or median [IQR].

Results

27 participants (age 59.8±11.8, 51.9% female, 51.9% African American, BMI 33.3±11.4) enrolled. The study ended early due to Medicare contracting that forced most patients to complete stroke rehabilitation outside the Cleveland Clinic health system. 69.6% had large vessel occlusions and 52% had moderate/severity disability (Modified Rankin score ≥2). PM was attempted in 23 participants and successful in 19. Nursing and patients rated the PM device as highly easy to use. 11 of 14 patients who had an REI ≥10 consented to APAP titration, but only 5 continued APAP after discharge. Four patients who initially said APAP was easy to use noted that their stroke interfered with their APAP use at home.

Conclusion

This study demonstrates the challenges in the assessment and treatment of OSA in an acute ischemic stroke population, highlighting the necessity for further research into timely and feasible screening and treatment.

Support (if any)

ResMed

Physical Activity Monitoring Using a Fitbit Device in Ischemic Stroke Patients: Prospective Cohort Feasibility Study

Background

Continuous tracking of ambulatory activity in real-world settings using step activity monitors has many potential uses. However, feasibility, accuracy, and correlation with performance measures in stroke patients have not been well-established.

Objective

The primary study objective was to determine adherence with wearing a consumer-grade step activity monitor, the Fitbit Charge HR, in home-going ischemic stroke patients during the first 90 days after hospital discharge. Secondary objectives were to (1) determine accuracy of step counts of the Fitbit Charge HR compared with a manual tally; (2) calculate correlations between the Fitbit step counts and the mobility performance scores at discharge and 30 days after stroke; (3) determine variability and change in weekly step counts over 90 days; and (4) evaluate patient experience with using the Fitbit Charge HR poststroke.

Methods

A total of 15 participants with recent mild ischemic stroke wore a Fitbit Charge HR for 90 days after discharge and completed 3 mobility performance tests from the National Institutes of Health Toolbox at discharge and Day 30: (1) Standing Balance Test, (2) 2-Minute Walk Endurance Test, and (3) 4-Meter Walk Gait Speed Test. Accuracy of step activity monitors was assessed by calculating differences in steps recorded on the step activity monitor and a manual tally during 2-minute walk tests.

Results

Participants had a mean age of 54 years and a median modified Rankin scale score of 1. Mean daily adherence with step activity monitor use was 83.6%. Mean daily step count in the first week after discharge was 4376. Daily step counts increased slightly during the first 30 days after discharge (average increase of 52.5 steps/day; 95% CI 32.2-71.8) and remained stable during the 30-90 day period after discharge. Mean step count difference between step activity monitor and manual tally was –4.8 steps (–1.8%). Intraclass correlation coefficients for step counts and 2-minute walk, standing balance, and 4-meter gait speed at discharge were 0.41 (95% CI –0.14 to 0.75), –0.12 (95% CI –0.67 to 0.64), and 0.17 (95% CI –0.46 to 0.66), respectively. Values were similarly poor at 30 days.

Conclusions

The use of consumer-grade Fitbit Charge HR in patients with recent mild stroke is feasible with reasonable adherence and accuracy. There was poor correlation between step counts and gait speed, balance, and endurance. Further research is needed to evaluate the association between step counts and other outcomes relevant to patients, including patient-reported outcomes and measures of physical function.

The influence of collecting patient-reported outcome measures on visit satisfaction in rheumatology clinics

Objectives

Patient-reported outcome measures (PROMs) can direct patient-centred care and increase patient satisfaction with the visit. The objective of this study was to assess the relationship between the collection of PROMs and visit satisfaction, as measured by the Clinician and Group Practice Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey.

Methods

An electronic platform for collection of patient-reported information was implemented in rheumatology clinics between August and September 2016. Adult patients were included in the study if they completed CG-CAHPS after an ambulatory visit. The pre-implementation cohort consisted of patients seen between January and June 2016; the post-implementation cohort consisted of patients seen between January and June 2017. The CG-CAHPS scores were compared between cohorts. Mixed effect models were constructed to identify predictors of visit satisfaction.

Results

Characteristics were similar between the 2117 pre- and 2380 post-implementation patients. Visit satisfaction was high in both cohorts but did not differ [odds ratio = 0.97 (95% CI: 0.79, 1.19)]. Predictors of improved satisfaction included being an established patient, being male, older age and reporting higher quality of life. However, sensitivity analyses in the post-implementation cohort suggested that implementing PROMs might convey benefits for new patients, in particular.

Conclusion

Collection of PROMs had no effect on visit satisfaction in rheumatology clinics, although there might be benefits for new patients. These largely null findings might be attributable to high satisfaction levels in our cohorts or to lack of provider review of PROM data with patients. Further research is indicated to determine the impact of provider communication of PROM results to patients on different domains of visit satisfaction.

Use of the Activity Measure for Post-Acute Care "6 Clicks" Basic Mobility Inpatient Short Form and National Institutes of Health Stroke Scale to Predict Hospital Discharge Disposition After Stroke

OBJECTIVE

Therapists in the hospital are charged with making timely discharge recommendations to improve access to rehabilitation after stroke. The objective of this study was to identify the predictive ability of the Activity Measure for Post-Acute Care "6 Clicks" Basic Mobility Inpatient Short Form (6 Clicks mobility) score and the National Institutes of Health Stroke Scale (NIHSS) score for actual hospital discharge disposition after stroke.

METHODS

In this retrospective cohort study, data were collected from an academic hospital in the United States for 1543 patients with acute stroke and a 6 Clicks mobility score. Discharge to home, a skilled nursing facility (SNF), or an inpatient rehabilitation facility (IRF) was the primary outcome. Associations among these outcomes and 6 Clicks mobility and NIHSS scores, alone or together, were tested using multinomial logistic regression, and the predictive ability of these scores was calculated using concordance statistics.

RESULTS

A higher 6 Clicks mobility score alone was associated with a decreased odds of actual discharge to an IRF or an SNF. The 6 Clicks mobility score alone was a strong predictor of discharge to home versus an IRF or an SNF. However, predicting discharge to an IRF versus an SNF was stronger when the 6 Clicks mobility score was considered in combination with the NIHSS score, age, sex, and race.

CONCLUSION

The 6 Clicks mobility score alone can guide discharge decision making after stroke, particularly for discharge to home versus an SNF or an IRF. Determining discharge to an SNF versus an IRF could be improved by also considering the NIHSS score, age, sex, and race. Future studies should seek to identify which additional characteristics improve predictability for these separate discharge destinations.

IMPACT

The use of outcome measures can improve therapist confidence in making discharge recommendations for people with stroke, can enhance hospital throughput, and can expedite access to rehabilitation, ultimately affecting functional outcomes.

Patient-Reported Outcomes (PROs) in Acute Symptomatic Seizure (ASyS) Versus Patients With Established Epilepsy

Purpose

Acute symptomatic seizures (ASyS) are common in critically ill patients. It is unknown how ASyS affect posthospitalization self-reported health compared to patients with established epilepsy.

Methods

This is a retrospective cohort study from 2010 to 2018. Patients were identified by an institutional epilepsy database (Ebase). Patient-reported outcome measures (PROMs) were completed as part of standard of care and included the number of seizures in the prior 4 weeks, Liverpool Seizure Severity Scale (LSSS) ictal score, quality of life in epilepsy (QOLIE)-10, Patient Health Questionnaire-9 scales, and the PROM Information System Global Health (PROMIS-GH) scale. Mixed-effects models were created to adjust for age, sex, and race and to examine score trajectory over the 1 year after baseline.

Results

A total of 15 311 established epilepsy patients and 317 patients with ASyS were identified. When compared to patients with epilepsy, patients with ASyS were older, mostly male, more often black, and had worse baseline scores on the QOLIE-10 (P < .001), PROMIS-GH Physical Health (P = .037), and LSSS Ictal (P = .006) scales. Patient-Reported Outcomes Measurement Information System Mental and Physical Health T-scores were worse than the general population (T-score = 50) for patients with both ASyS (44 and 42.5, respectively) and epilepsy (44.2 and 44.6, respectively). After adjusting for age, sex, and race, patients with ASyS reported 38% fewer seizures (P = .006) yet worse QOLIE-10 score (P = .034). We found that scores improved over time for all PROMs except for PROMIS-GH Mental Health.

Conclusion

Compared to patients with epilepsy, patients with ASyS had fewer seizures but worse epilepsy-specific quality of life. Independent of group status, scores generally improved over time.

Psychological correlates of patients with postural orthostatic tachycardia syndrome (POTS)

Psychological symptoms are frequently reported in patients with Postural Orthostatic Tachycardia Syndrome (POTS); however, the nature of these symptoms is not well understood. The current study described baseline psychological symptoms in patients with POTS, and examined associations between psychological and self-report autonomic symptoms. Participants reported mild anxiety symptoms, moderate depressive symptoms, severe somatization, and elevated anxiety sensitivity. Depressive symptoms and pain catastrophizing were significantly associated with autonomic symptoms. The current study adds to the literature by documenting elevated levels of anxiety sensitivity, and relationships between psychological and autonomic symptoms.

Satisfaction with Care and Satisfaction with Decision Making are Similar Regardless of Staffing Model in a Neurocritical Care Unit

Introduction

Patient-centered care, particularly shared medical decision making, is difficult to measure in critically ill patients where decisions are often made by a designated surrogate, often receiving information from multiple providers with varying degrees of training. The purpose of this study was to compare short-term satisfaction with care and decision making in patients or surrogates between two neurocritical care units [one staffed by a neurocritical care attending and advanced practice providers (APPs) and one staffed by a neurocritical care attending and resident/fellow trainees] using the Family Satisfaction in the ICU (FS-ICU) survey.

Methods

Over a 6-month period, the FS-ICU was administered on a tablet device to patients or surrogates at least 24 h after admission and stored on REDCap database.

Results

One hundred and thirty-four patients or surrogates completed the FS-ICU. The response rates were 59.97% and 46.58% in the APP and trainee units, respectively. There were no differences in patient age, sex, ventilator days or ICU length of stay. Overall, there were no differences in satisfaction with care or perceived shared medical making between the units. Respondents who identified their relationship with the patient as “other” (not a spouse, parent, nor a sibling) were less satisfied with care. Additionally, surrogates who identified as parents of the patient were more satisfied with degree of shared medical decision making.

Conclusion

This study showed that: (1) collecting FS-ICU in a neurocritical care unit is feasible, (2) overall there is no difference in short-term satisfaction with care or shared decision making between a NICU staffed with trainees compared to one staffed with APPs, and (3) parents of patients have a higher short-term satisfaction with degree of shared medical decision making.

Effect of Positive Airway Pressure Therapy on Drowsy Driving in a Large Clinic-Based Obstructive Sleep Apnea Cohort

STUDY OBJECTIVES

Drowsy driving related to obstructive sleep apnea (OSA) represents an important public health problem with limited data on the effect of positive airway pressure (PAP) therapy. We hypothesize that PAP therapy will reduce self-reported drowsy driving in a large clinic-based OSA cohort.

METHODS

Drowsy driving (self-reported near-accidents/accidents) incidents from baseline to after PAP therapy (stratified by adherence) were compared in a cohort of 2,059 patients with OSA who initiated PAP therapy from January 1, 2010 to December 31, 2014. Multivariable logistic regression models evaluated the dependence of change in drowsy driving incidents on other factors, including change in Epworth Sleepiness Scale (ESS) and Patient Health Questionnaire-9 (PHQ9) scores.

RESULTS

In the entire cohort (age 56.0 ± 13.1 years, 45.4% female, 76.0% white, average follow-up 124.4 ± 67.3 days), drowsy driving incidents reduced from 14.2 to 6.9% after PAP therapy (P < .001). In subgroups, drowsy driving incidents reduced from 14% to 5.3% (P < .001) in patients who self-reported adherence to PAP therapy and 14.1% to 5.3% (P < .001) in patients objectively adherent to PAP therapy. For each one-point improvement in Epworth Sleepiness Scale score, the odds of drowsy driving decreased by about 14% (odds ratio 0.86, 95% confidence interval 0.82 to 0.90).

CONCLUSIONS

In this clinic-based cohort, drowsy driving improved after adherent PAP usage, with greater drowsy driving risk for those with greater sleep propensity. This highlights the importance of and need for routine drowsy driving assessments and careful clinical attention to PAP adherence and sleep propensity in this population. Our findings should be confirmed and may be used to provide support for initiatives to address the public health issue of drowsy driving.

Institutional care paths: Development, implementation, and evaluation

PURPOSE

The Cleveland Clinic experience with care paths, including their creation and implementation, challenges overcome during development and testing, and outcomes of selected care path evaluations, is described.

SUMMARY

Care paths are tools to assist healthcare professionals in practicing evidence-based medicine. The Cleveland Clinic health system has implemented or is developing approximately 100 care paths, including care paths designed to optimize management of sepsis and septic shock and to promote timely use of i.v. tissue plasminogen activator and correct dosing of antithrombotics and statins in patients with stroke. Key steps in successful care path initiatives include (1) identifying key stakeholders, (2) achieving stakeholder consensus on a standardized approach to disease or condition management, (3) cultivating provider awareness of care paths, (4) incorporating care path tools into the electronic health record and workflow processes, and (5) securing the resources to develop, implement, and maintain care paths. Electronic health records facilitate the use of and adherence to care paths. After care path implementation, revisions are typically needed due to unexpected issues not initially identified and to optimize care path features and support resources for clinical practice. Ongoing evaluation is required to determine whether an implemented care path is producing the intended patient and quality performance outcomes.

CONCLUSION

Care paths provide a standardized approach to treatment or prevention of a disease or condition, reducing unnecessary variability and expense while promoting optimal, cost-effective patient care.

Abstract WP486: Do Social Determinants of Health Predict Recovery in the First 90 Days After Stroke?

Background: Understanding the factors impacting recovery after stroke is a critical step in developing interventions to optimize stroke outcomes. Previous work from Ohio Coverdell Program suggested that race may be independently associated with reduced odds of improvement in the first 30 days after stroke.

Purpose: To determine if race, household income, and insurance status are independently associated with improvement in disability in the first 90 days after hospital discharge in patients admitted to comprehensive stroke centers (CSC) who received acute intervention.

Methods: Retrospective cohort study of patients entered into the GWTG-Stroke from 7 Ohio Coverdell CSCs from 1/1/2015 to 7/16/2018 who received IV tPA and/or acute catheter-based intervention and had a mRS score at discharge and 90 days. Multivariable linear regression was performed to examine the association of race, household income estimated by ZIP code, and insurance on improvement in mRS between discharge and 90 days after adjusting for discharge mRS, clinical characteristics and hospital management.

Results: There were 1,140 patients in the cohort who had mean age 66.7 yrs (SD 15.0). Estimated median income was $51,190 (SD $18,050); 18.3% were nonwhite. Of the socioeconomic variables assessed, only Medicaid insurance was associated with less recovery in the first 90 days post-discharge (β = -0.40; 95% CI -0.67, -0.14).Other variables associated with recovery were discharge mRS, hospital, premorbid ambulatory status, admission NIHSS, discharge destination, and length of stay. (see Table)

Conclusion: Race and household income were not associated with recovery in the first 90 days post-discharge in stroke patients admitted to CSCs receiving acute interventions. Patients with Medicaid insurance had reduced probability of improvement. Further evaluation is indicated to determine if the worse recovery in Medicaid patients is due to socioeconomic status or premorbid health status.

Characterization of Patient Interest in Provider-Based Consumer Health Information Technology: Survey Study

BACKGROUND

Consumer health information technology can improve patient engagement in their health care and assist in navigating the complexities of health care delivery. However, the consumer health information technology offerings of health systems are often driven by provider rather than patient perspectives and inadequately address patient needs, thus limiting their adoption by patients. Consideration given to patients as stakeholders in the development of such technologies may improve adoption, efficacy, and consumer health information technology resource allocation.

OBJECTIVE

The aims of this paper were to measure patient interest in different health system consumer health information technology apps and determine the influence of patient characteristics on consumer health information technology interest.

METHODS

Patients seen at the Cleveland Clinic Neurological Institute were electronically surveyed on their interest in using different consumer health information technology apps. A self-efficacy scale, Patient Health Questionnaire-9 depression screen, and EuroQol 5 dimensions health-related quality of life scale were also completed by patients. Logistic regression was used to determine the influence of patient characteristics on interest in consumer health information technology in the categories of self-management, education, and communication.

RESULTS

The majority of 3852 patient respondents had an interest in all technology categories assessed in the survey. The highest interest was in apps that allow patients to ask questions of providers (3476/3852, 90.24%) and to schedule appointments (3211/3839, 83.64%). Patient interest in consumer health information technology was significantly associated with greater depression symptoms, worse quality of life, greater health self-efficacy, and smartphone ownership (P<.001 for all listed).

CONCLUSIONS

Patients should be viewed as active stakeholders in consumer health information technology development and their perspectives should consistently guide development efforts. Health systems should consider focusing on consumer health information technologies that assist patients in scheduling appointments and asking questions of providers. Patients with depression should also be considered for targeted consumer health information technology implementation. Health self-efficacy is a valid predictor of consumer health information technology interest and may play a role in the utilization of consumer health information technologies. Health systems, broadly, should put forth greater effort to understand the needs and interests of patients in the consumer health information technology development process. Consumer health information technology design and implementation may be improved by understanding which technologies patients want.

Impact of Sleep-Disordered Breathing Treatment on Quality of Life Measures in a Large Clinic-Based Cohort

STUDY OBJECTIVES

This study aims to report the effect of positive airway pressure (PAP) therapy on quality of life (QoL) measures in the clinical sleep-disordered breathing (SDB) population.

METHODS

We examined general QoL measures assessed by European Quality of Life-5D (EQ-5D) and sleep-specific QoL by examining Functional Outcomes of Sleep Questionnaire (FOSQ) scores before and after PAP therapy retrospectively in a clinical SDB population using paired and two-sample t tests. Age and socioeconomic status (SES) effect modification on pre-PAP QoL measures were investigated utilizing the interaction terms.

RESULTS

A total of 2,027 patients with SDB initiated PAP therapy between January 1, 2010 and December 31, 2014. The mean age of the cohort was 56.2 years (standard deviation = 13.2), with 45.8% female and 76.9% Caucasians. EQ-5D change after exclusion of those with normal QoL was 0.042 (0.152) in all patients, 0.051 (0.150) in patients who were PAP adherent by self-report, and 0.050 (0.132) in patients who were objectively PAP adherent (n = 704 of 1,011 with available objective adherence data, 69.6%). Change in FOSQ after excluding those with normal FOSQ was 1.9 (2.9) in all patients, 2.2 (2.9) in patients who were PAP adherent by self-report, and 2.3 (2.9) in patients who were objectively PAP adherent. Those with (1) worse QoL at baseline and younger age and (2) worse QoL at baseline and residing in lower SES strata had worse outcomes after PAP therapy (P < .05).

CONCLUSIONS

We found consistent improvement in global and sleep-specific QoL measures after PAP therapy, hence providing evidence of PAP benefit in the clinical population and rationale for targeted efforts to optimize QoL in younger and lower SES subgroups.

Failed Removal of Indwelling Urinary Catheters in Patients With Acute Stroke: Incidence and Risk Factors

BACKGROUND

Reducing the incidence of indwelling urinary catheter (IUC) use and early removal of the devices that are inserted are appropriate priorities for quality patient care. Just like symptomatic bacteriuria, failed catheter removal as a complication of IUC use is associated with considerable morbidity. In the ideal setting, patients who need IUCs have them, and patients who do not need them will have them removed safely, with the goal of reducing medical complications and facilitating the rehabilitation phase of care.

OBJECTIVE

To determine the incidence of failed removal of IUCs and the factors associated with failed removal in persons hospitalized with acute stroke.

DESIGN

Retrospective review of medical records and associated clinical data collection platforms.

SETTING

Comprehensive stroke center at a tertiary care hospital.

PATIENTS

The study cohort included 175 stroke patients admitted to the hospital and managed with IUCs. Mean age was 66.1 years (standard deviation = 15), 55% were female.

METHODS

Univariable and multiple logistic regression analyses were performed. Variables assessed included age, gender, race, duration of hospital stay, stroke subtype, National Institutes of Health Stroke Scale, and 6-Clicks Scale, which is a measure of functional status.

MAIN OUTCOME MEASUREMENTS

The dependent variable was occurrence of a failed attempt at removal of an IUC, defined as removal followed by a catheter reinsertion.

RESULTS

During the study period, 175 of 432 patients with acute hospital admission for new stroke had an IUC removal event. Of these patients, 46 (26%) experienced a failed catheter removal. On univariate analysis, factors significantly associated with failed removal included presence of a hemorrhagic stroke (P = .005), lower level of physical function (by 6-Clicks and NIHSS scores), hospital length of stay (P < .001), and discharge location (P = .005). Bedside bladder ultrasound testing by nursing staff was used more frequently in the group of patients who had unsuccessful IUC removals (95% confidence interval 4.56-21.67, P < .001). Length of stay (P < .001), white race (P = .001), and hemorrhagic stroke (P = .009) were associated independently with failed catheter removal after adjustment for other clinical variables.

CONCLUSIONS

This single-site study identified a high incidence of failed urinary catheter removal in patients with stroke, along with factors associated with failed removal. This is the first step in developing a predictive model that could reduce the incidence of this adverse event. Policies, penalties, and protocols designed to reduce catheter days must be sensitive to the special situations in which IUCs are medically necessary and equal consideration given to identifying the patients for which catheter removal poses a greater risk than continued catheter use.

LEVEL OF EVIDENCE

III.

A mixed methods study of multiple health behaviors among individuals with stroke

Background

Individuals with stroke often have multiple cardiovascular risk factors that necessitate promoting engagement in multiple health behaviors. However, observational studies of individuals with stroke have typically focused on promoting a single health behavior. Thus, there is a poor understanding of linkages between healthy behaviors and the circumstances in which factors, such as stroke impairments, may influence a single or multiple health behaviors.

Methods

We conducted a mixed methods convergent parallel study of 25 individuals with stroke to examine the relationships between stroke impairments and physical activity, sleep, and nutrition. Our goal was to gain further insight into possible strategies to promote multiple health behaviors among individuals with stroke. This study focused on physical activity, sleep, and nutrition because of their importance in achieving energy balance, maintaining a healthy weight, and reducing cardiovascular risks. Qualitative and quantitative data were collected concurrently, with the former being prioritized over the latter. Qualitative data was prioritized in order to develop a conceptual model of engagement in multiple health behaviors among individuals with stroke. Qualitative and quantitative data were analyzed independently and then were integrated during the inference stage to develop meta-inferences. The 25 individuals with stroke completed closed-ended questionnaires on healthy behaviors and physical function. They also participated in face-to-face focus groups and one-to-one phone interviews.

Results

We found statistically significant and moderate correlations between hand function and healthy eating habits (r = 0.45), sleep disturbances and limitations in activities of daily living (r =  − 0.55), BMI and limitations in activities of daily living (r =  − 0.49), physical activity and limitations in activities of daily living (r = 0.41), mobility impairments and BMI (r =  − 0.41), sleep disturbances and physical activity (r =  − 0.48), sleep disturbances and BMI (r = 0.48), and physical activity and BMI (r =  − 0.45). We identified five qualitative themes: (1) Impairments: reduced autonomy, (2) Environmental forces: caregivers and information, (3) Re-evaluation: priorities and attributions, (4) Resiliency: finding motivation and solutions, and (5) Negative affectivity: stress and self-consciousness. Three meta-inferences and a conceptual model described circumstances in which factors could influence single or multiple health behaviors.

Discussion

This is the first mixed methods study of individuals with stroke to elaborate on relationships between multiple health behaviors, BMI, and physical function. A conceptual model illustrates addressing sleep disturbances, activity limitations, self-image, and emotions to promote multiple health behaviors. We discuss the relevance of the meta-inferences in designing multiple behavior change interventions for individuals with stroke.

Abstract 165: What Domains of Health Are Most Impacted After Ischemic Stroke?

Background: Multiple domains of health are impacted in patients with ischemic stroke, which may vary by degree of disability. The objective of this study was to examine patient-reported health for 6 domains across levels of disability compared to the U.S. general population.

Methods: Observational cohort study of 811 ischemic stroke patients (937 visits) seen in a cerebrovascular clinic 2/17/15 - 8/8/16 who completed the routinely collected PROMIS patient-reported outcome measures (PROMs): Physical Function (PF), Satisfaction with Social Roles (SatSocRol), Fatigue, Anxiety, Sleep Disturbance, and Pain Interference. PROMIS scores are standardized to the U.S. population (mean score = 50). Providers completed the NIHSS and modified Rankin (mRS). Distribution of PROMIS scores were calculated across mRS levels. Multivariable regression was performed to evaluate the association of the following factors with PROM scores: age, sex, race, mRS, and time from stroke (0-90 d, 91-365 d, >365 d).

Results: Patients with no-minimal disability (mRS 0-1) had PROMIS scores that were similar to the general population. PROMIS scores increased at higher mRS levels, although correlation between scores and mRS level varied (Sleep ρ= 0.172 to PF ρ=0.483). Within each mRS level > 1, highest (worst) scores were in PF, SatSocRol, and Cognition domains (Graph). Female sex was associated with higher Fatigue (p=0.003), Anxiety (p<0.0001), PF (p=0.021), and Cognition (p=0.001) scores. Age was associated with higher PF (p<0.0001) and lower Anxiety (p=0.023) scores.

Conclusion: Patients with ischemic stroke reported symptoms in multiple health domains that increase to varying degrees at higher levels of disability. PF, SatSocRol, and Cognition were most impacted at all disability levels. This information improves our understanding of stroke’s impact on patients compared to the general population and brings attention to the importance of social roles and cognition to stroke survivors.

Abstract TMP41: High-sensitivity C-Reactive Protein and Depression in Patients With Ischemic Stroke

Background: Depression is common in patients after stroke and is associated with worse outcomes Recognition of the causal factors contributing to post-stroke depression may lead to new treatment interventions. Ischemic stroke produces inflammatory responses and there is data to suggest that inflammation may promote depression. The objective of this analysis is to determine the association of hsCRP levels with depression in patients with ischemic stroke.

Methods: We performed a retrospective cohort study of patients with ischemic stroke seen in a cerebrovascular clinic who completed a PHQ-9 depression screen and had a hsCRP level drawn between 28 days before or within 7 days after the PHQ-9 screen. Multivariate linear regression was performed:- the dependent variable was PHQ-9 score, the independent variable was log-transformed hsCRP. Additional covariates included age, sex, race (White vs. Black/Other), time since stroke (≤ 3 months vs. > 3 months), mRS score (0-2 vs. 3-5) and statin use at time of hsCRP draw (yes vs. no).

Results: Between Feb 3, 2009 and March 14, 2014, 803 patients were seen in the cerebrovascular clinic with a diagnosis of ischemic stroke who had hscrp level. Of these, 220 patients had a hSCRP drawn within the prespecified time interval from PHQ9 screen. Mean age was 60.7 years, 43.2% were female and 78.6% were White. There was a significant independent association between hsCRP value and PHQ-9 score; For each 5-fold increase in hsCRP, the average PHQ-9 score increased by 1.22 points (95% CI 0.38 - 2.06, P = 0.005). Other variables independently associated with PHQ-9 score were: mRS > 2 (OR = 3.39, 95% CI 1.40 - 5.38), female (OR=-1.72 95% CI -3.11 - -0.32), and statin use (OR=-1.91, 95% CI -3.34 - -0.47).

Conclusions: hsCRP level was independently associated with depressive symptoms. Understanding the association between inflammatory markers and depression following ischemic stroke may lead to the development of improved methods to predict post-stroke depression and new treatment interventions

Abstract WP144: Ultrasound Criteria for Assessment of Vertebral Artery Origins

Introduction: We sought to validate ultrasound as a reliable means of assessing vessel stenosis of vertebral artery origins.

Methods: We reviewed 1135 patient charts with ultrasound of the posterior circulation performed 2008-2015 in our Neurovascular Laboratory Imaging Institute. Inclusion criteria consisted of ultrasound and digital subtraction angiography (DSA) performed within three months as well as absence of prior stent placement, resulting in 218 vessels in 133 patients. Using DSA as the gold standard, we determined sensitivity and specificity of ultrasound in detecting occlusion at vertebral artery origin. All patients with non-occluded vertebral artery origins without stent were evaluated for degree of stenosis on DSA, and compared to mean flow velocity (MFV) on ultrasound.

Results: Among 218 vertebral artery origins evaluated, ultrasound showed sensitivity of 85.7% (95% confidence interval (CI) 69.7-95.2%) for occlusion and specificity of 99. 5% (95%CI 96.9-99.9%). Among 126 arteries without occlusion, <50% stenosis had average MFV 39.5 cm/s (SD 19.9), 50-69% stenosis had average MFV 69.2 cm/s (SD 34.7), and severe 70-99% stenosis had average MFV 129 cm/s (SD 30.65), p<0.001 by Kruskal-Wallis test. For detecting ≥70% stenosis, c-statistic of ROC curve was 0.81, and MFV of 70 cm/s has 82% sensitivity and 88% specificity of ≥70% stenosis.

Conclusion: Ultrasound has good sensitivity and excellent specificity for detecting vertebral origin occlusion. Flow velocity can be used to screen for severe stenosis of vertebral artery at origin.

ASPECTS discrepancies between CT and MR imaging: analysis and implications for triage protocols in acute ischemic stroke

BACKGROUND

Optimal imaging triage for intervention for large vessel occlusions remains unclear. MR-based imaging provides ischemic core volumes at the cost of increased imaging time. CT Alberta Stroke Program Early CT Score (ASPECTS) estimates are faster, but may be less sensitive.

OBJECTIVE

To assesses the rate at which MRI changed management in comparison with CT imaging alone.

METHODS

Retrospective analysis of patients with acute ischemic stroke undergoing imaging triage for endovascular therapy was performed between 2008 and 2013. Univariate and multivariate analyses were performed. Multivariate logistic regression was used to evaluate the effect of time on disagreement in MRI and CT ASPECTS scores.

RESULTS

A total of 241 patients underwent both diffusion-weighted imaging (DWI) and CT. Six patients with DWI ASPECTS ≥6 and CT ASPECTS <6 were omitted, leaving 235 patients. For 47 patients, disagreement between the two modalities resulted in different treatment recommendations. The estimated probability of disagreement was 20.0% (95% CI 15.4% to 25.6%). In a multivariate logistic regression, CT ASPECTS >7 (p=0.004) and admission National Institutes of Health Stroke Scale (NIHSS) score <16 (p=0.008) were simultaneously significant predictors of agreement in ASPECTS. The time between modalities was a marginally significant predictor (p=0.080).

CONCLUSIONS

The study suggests that patients with NIHSS scores at admission of <16 and patients with CT ASPECTS >7 have a higher likelihood of agreement between CT and DWI based on an ASPECTS cut-off value of 6. Additional MRI for triage in patients with NIHSS at admission of >16, and ASPECTS of 6 or 7 may be more likely to change management. Unsurprisingly, patients with low CT ASPECTS had good correlation with MRI ASPECTS.

Abstract WP378: Improving Data Quality for Stroke Performance Measures: a Comprehensive and Systematic Approach to Inter Rater Reliability in Ohio

Background: Ohio has been funded from the Centers for Disease Control and Prevention for the Paul Coverdell National Acute Stroke Prevention Program for over ten years. This data driven program focuses on reducing stroke mortality and morbidity with emphasis on stroke systems of care throughout the continuum. Inter rater reliability is required to confirm reliability and inform quality initiatives. The objective of this study is to determine the annual inter-rater reliability, utilizing Item Specific Percent Agreement (ISPA),after comprehensive abstractor training, in 45 Ohio Coverdell hospitals.

Methods: We developed a comprehensive abstraction training program which included: in-person, all-day training for abstractors and reabstractors; reference binders; Question and Answer webinars; abstraction updates at statewide tri-annual Coverdell meetings and easy access, prompt, technical assistance communications for specific questions. Results are shared with individual hospital identifying specific areas for improvement. We examined 395 randomly selected charts from 45 hospitals to determine the overall state and individual hospital ISPA during 2014 to 2015. Up to 67 national stroke performance measure and Coverdell data elements were reviewed for agreement according to eligibility. Charts were abstracted and reabstracted by hospitals using Get With the Guidelines®-Stroke and securely transmitted for analysis. The number of charts provided by hospitals was determined by the previous year’s stroke volume. The statistical package “Rstudio” was used for analysis.

Results: A total of 13,528 elements were reviewed. The overall state ISPA was 94.9%, compared to 94% during 2013 to 2014. Hospital agreement scores ranged from 78.2% to 99.6%, compared to the previous 83.1% to 99% in the previous year.

Conclusion: The comprehensive abstraction training program developed by Ohio Coverdell has resulted in excellent inter rater reliability scores. ISPA is a feasible method of performing inter-rater reliability.

Abstract WP116: Patterns of Vascular Calcification in Young Patients With Intracranial Stenosis

Introduction: Intravascular calcification is thought to be a marker of atherosclerosis in patients with stenosis and vascular risk factors. Little is known about the utility of quantifying intracranial calcification to help determine mechanism of stenosis. The objective of our study was to compare presence and patterns of intracranial calcification in patients with intracranial stenosis due to atherosclerosis and other etiologies.

Methods: Retrospective cohort study of 89 patients < 50 years with diagnosis of intracranial stenosis who had undergone CT angiogram from 2008-2013; 44 had presumed atherosclerosis as etiology ( > 3 vascular risk factors with no other identified cause). CTAs were reviewed for presence and location of intracranial calcification.

Results: Of patients with atherosclerotic stenosis, 28 (64%) had intravascular calcification compared to 16 (36%) of those with stenosis of other etiologies (P=0.0039). There was no significant difference in pattern or location of stenosis between groups. One-third had calcification outside the region of stenosis in both groups. Distal internal carotid artery and distal vertebral artery were the most common sites of intracranial calcification (Table).

Conclusion: Intracranial calcification is more commonly seen in patients < 50 years old with stenosis secondary to atherosclerosis, but the pattern and location was similar between groups. More research is needed to determine the utility of using the presence of vascular calcification to help determine mechanism of intracranial stenosis in the young.

Chronic cerebrospinal venous insufficiency: pitfalls and perils of sonographic assessment

OBJECTIVES

Duplex sonography has been proposed as a diagnostic modality for detection of chronic cerebrovascular venous insufficiency, a recently proposed hypothesis of multiple sclerosis (MS) pathogenesis. We reviewed potential challenges of duplex sonography for diagnosis of chronic cerebrovascular venous insufficiency and used interim pooled data from a study aimed to apply cerebrovascular venous insufficiency criteria to a group of patients with MS and control patients without MS.

METHODS

Duplex sonography for chronic cerebrovascular venous insufficiency was performed in patients with MS and controls. Extracranial and deep cerebral veins were studied by using a published chronic cerebrovascular venous insufficiency protocol and criteria. Comparative imaging was performed to explore how physiologic factors and imaging techniques could affect key parameters. The effects of varying definitions on fulfilling chronic cerebrovascular venous insufficiency diagnostic criteria were also explored.

RESULTS

Forty-two patients were enrolled. Twenty-five (60%) had a reduction in internal jugular vein cross-sectional area by 50% or more, cross-sectional area of 0.3 cm(2) or less, and/or a B-mode abnormality. No patients had reflux longer than 0.88 seconds in both sitting and supine positions, the presence of duplex sonographic reflux on transcranial Doppler imaging, or a larger internal jugular vein cross-sectional area in the sitting versus supine position. Fourteen patients (33.3%) had either a flap or septum, and 1 had a web. Collateral veins to the vertebral veins were identified in 14 of 42 patients (33.3%). The use of transcranial Doppler imaging versus quality Doppler profiles resulted in fewer patients meeting criteria for chronic cerebrovascular venous insufficiency.

CONCLUSIONS

There are several important variables, including physiologic, technical, and criterion definitions, in the application of sonographic assessment of chronic cerebrovascular venous insufficiency that may affect diagnostic accuracy.

Large deep white matter lesions may predict futile recanalization in endovascular therapy for acute ischemic stroke

OBJECTIVE

This study investigated whether large ischemic lesions in the deep white matter (DWM) on pretreatment diffusion-weighted MRI (DWI) predict futile recanalization.

METHODS

Consecutive acute stroke patients with anterior circulation ischemia who underwent successful arterial recanalization with thrombolysis in cerebral infarction grade 2b or 3 were enrolled. A large DWI-DWM lesion was defined as a hyperintense lesion in the DWM on initial DWI, located mainly between the anterior and posterior horns of the lateral ventricle. The Alberta Stroke Program Early CT score on CT and DWI and stroke volume on initial DWI were recorded. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) score. Futile recanalization was defined as a 30-day modified Rankin scale score of 3-6 despite successful recanalization. Univariate and multivariate regression analyses were performed to identify predictors of futile recanalization.

RESULTS

In 35 of 46 patients (76%) with successful recanalization, futile recanalization was observed in 20 patients (57%). Patients with futile recanalization were older (median age 74 vs. 58 years; p = 0.053), had higher initial NIHSS scores (median 17 vs. 9; p = 0.042), and a higher prevalence of large DWI-DWM lesions (45 vs. 9%; p = 0.022). Logistic regression analysis showed that a large DWI-DWM lesion was an independent predictor of futile recanalization (OR 13.97; 95% CI 1.32-147.73; p = 0.028).

CONCLUSION

Patients with large preintervention DWI-DWM lesions may be poor candidates for endovascular therapy.

Abstract T P287: The Utility of Depression Screening in the Acute Stroke Hospitalization

Background: The importance of early recognition and treatment of post stroke depression (PSD) has led to recommendations for depression screening during the acute stroke admission.

We studied the utility of PSD screening during acute stroke admissions using the 2-item Patient Health Questionnaire (PHQ-2) by (a) determining the prevalence of positive depression screen during admission and (b) calculating the level of agreement between positive screens during admission and outpatient follow-up.

Methods: This was a retrospective cohort study of adult patients discharged 1/2013 - 12/2013 with principal discharge diagnosis of acute ischemic stroke or intracerebral hemorrhage excluding patients who died during admission. PSD screening was systematically performed using the 4-item PHQ (PHQ-4) administered to patients on the stroke service by midlevel providers. Positive screen was defined as PHQ-2 subscore ≥3. At outpatient follow up, the 9-item PHQ (PHQ-9) was administered by patient questionnaire.

Results: Of 718 patients, acute phase PHQ-4 data was available for 50% (358), 14% were not assessed due to drowsiness or aphasia, 2% were both admitted and discharged on weekends, and 21% were admitted to non-stroke services. Demographic characteristics were similar between the groups with and without PHQ data with higher rates of hemorrhagic strokes, longer ICU stay, and worse discharge mRS in the group without PHQ data. The median time from admission to PHQ-4 was 3 days. The screen was positive in 4.7% (17/358, 95% CI 2.8% - 7.5%). Outpatient follow-up occurred in 55% (396/718) patients a median of 34 days postdischarge and 260 had PHQ-9 data. Of these, 20.8% (54/260, 95% CI 16.0% - 26.2%) screened positive using PHQ-2.

There were 158 patients who had PHQ-2 data from both acute and follow up phases, 1.9% (3/158) of these screened positive in the acute phase and an additional 15.8% (25/158) who screened negative in the acute phase converted to positive at follow up.

Conclusion: Systematic screening for PSD using PHQ-2 in acute phase of stroke identified few patients with depression and there was subsequent conversion to a positive screen at follow up. PSD screening in acute in-hospital phase does not appear to be cost efficient utilization of inpatient resources.

Abstract W P121: Patterns Of Vessel Involvement In Patients With Intracranial Atherosclerosis Across Ages

Introduction: Intracranial atherosclerosis has been well studied in the aging population, much less is known about atherosclerotic stenosis in the young. Clinicians seek to control traditional vascular risk factors in this population, but differences in patterns of stenosis may call for varied treatment approaches. This study sought to compare age to the distribution of vessel involvement in patients with moderate-severe intracranial stenosis.

Methods: This is a retrospective cohort study of patients with intracranial stenosis seen in the stroke clinic of a tertiary center from 2008-2013.

Inclusion criteria were moderate-severe intracranial stenosis clinically felt to be due to atherosclerosis with ≥3 traditional vascular risk factors. Patients with other mechanisms of intracranial stenosis were excluded. Stenosis location and severity were based on cerebral angiography, CTA, or MRA. Patients were divided into young (< 50 yr), middle-age (51-64 yr), or older (≥

65 yr). All 69 patients ≤50 yr were included; a random sample of 69 patients > 50 were selected for this analysis.

Results: There were similar rates of vascular risk factors except HTN, which was less common in the young group (81.2% young, 100% middle, 96.8% older, p=0.0006). The location of stenoses varied by age category. Older patients had more posterior circulation involvement compared to the younger groups (p = 0.046), with more frequent involvement of vertebral and basilar arteries (p = 0.012) (Table). The occurrence of stenosis in the distal ICA and MCA vessels were similar among age groups. The frequency of ACA stenosis was highest in the young category (p = 0.026).

Conclusion: There are differences in anatomic locations of presumed intracranial atherosclerosis across age groups with older patients (> 65 yrs) having a higher rate of posterior circulation disease. This suggests potential differences in pathophysiological mechanisms. These findings warrant further investigation.

Abstract W P119: High Resolution MRI Characteristics of Unclassified Intracranial Stenosis Under Age 50

Introduction: Intracranial stenoses in the young have various underlying pathologies, including early atherosclerosis, infectious and inflammatory vasculitis, and Moyamoya disease, but specific diagnosis is challenging in clinical practice. We set out to characterize the unclassified intracranial stenoses and probable atherosclerosis in the young using high-resolution MRI (HR-MR) vessel wall imaging techniques.

Methods: We reviewed the HR-MR database at our hospital with criteria of patients under 50 years with intracranial stenosis. Patients with primary / secondary CNS vasculitis, infectious vasculitis, Moyamoya disease, dissection or cardio embolic strokes were excluded. Imaging protocol included black-blood gadolinium contrast -enhanced T1-weighted sequence with fat suppression and time-of-flight MRA of the circle of willis with 3-Tesla MRI.

Results: Twenty-five patients (9 males, median age 41) met the inclusion criteria. Hyperlipidemia hypertension, history of smoking and diabetes mellitus were noted in 24, 20, 16, and 9 patients respectively. Seventeen had 3 or more vascular risk factors. Twenty-one patients (84 %) had isolated anterior circulation involvement, while 13 patients (52%) had single vessel stenosis. Median time interval between ischemic event and HR-MR was 78 days. Concentric vessel wall enhancement of the culprit stenosis was noted in 18 patients (72%). None had eccentric wall thickening and eccentric enhancement. Vessel wall enhancement was associated with the presence of diabetes (p=0.026) but not associated with other vascular risk factors. Having a risk factor burden of 3 or more (p=0.15), multifocal stenosis (p=0.3), or shorter time to MRI imaging (p=0.6) were not associated with vessel wall enhancement. On follow-up HR-MR imaging after median of 6 months, all 5 patients with early vessel wall enhancement had unchanged findings.

Conclusion: In this cohort, while the risk factor burden suggests “accelerated atherosclerosis,” the vessel wall enhancement patterns are unlike atherosclerotic plaques that have been previously described with HR-MR. The nature of these stenoses needs further investigation.

Abstract W P297: The Electronic Stroke CarePath - An Integrated Approach to Stroke Care

Background: There is a continuous need to improve efficiency and quality of care. In response, the Electronic Stroke CarePath (ESCP) was developed for management of ischemic stroke patients. We describe the development, implementation and outcomes of the first 2 years of this initiative.

Methods: The ESCP consists of care pathways for ischemic stroke that are integrated within the EHR (Epic) and includes systematic collection of patient-reported outcomes (PROs). Main components of the EHR integration included a navigation panel, the use of structured forms with elements that autopopulate templates, and clinical decision support. An external software platform was used to collect PROs. Inpatient mortality and length of stay (LOS) were compared before and after implementation in ischemic stroke patients and in 2 control groups: ICH and SAH patients, after adjustment for case-mix. Postdischarge functional outcomes of ischemic stroke patients were compared between the 1st 3 months of rollout and remainder of the study period.<br

Results: The ESCP was implemented in Sep 2010 and modified over the first 3 months. Data were analyzed from Jan 2011- Dec 2012. There were 1106 patients with mean age 66.2 yrs and admission NIHSS 5; 46.1% were women.

There was a significant reduction in observed/predicted inpatient mortality after implementation of the ESCP in ischemic stroke patients (OR 0.59 [95% CI 0.42-0.83], but not in the control patients with ICH (OR 0.90 [0.59 - 1.38]) or SAH (OR 1.05 [0.67 - 1.65]). . Similarly, a significant increase in the proportion with LOS < predicted after ESCP implementation was seen only in ischemic stroke pts (51.4% vs 56.0%, p=0.047). Compared to those admitted within the 1st 3 mo of ESCP rollout, ischemic pts admitted in the remainder of the study period demonstrated nonsignificant improvements in degree of impairment (NIHSS, 3.9 to 2.7, p=0.059), IADLs (modified Rankin, 2.6 to 2.2, p=0.079) and physical function (SIS16, 67.8 - 76.0, p=0.084) at followup.

Conclusion: Implementation of the ESCP is feasible and may be associated with a benefit in multiple different outcomes after ischemic stroke. This approach, which combines carepaths, HIT, and the systematic collection of PROs, may be an important strategy for optimizing stroke care in the future.

Abstract W P120: Patterns of Vessel Involvement of Intracranial Stenosis in the Young

Introduction: Intracranial stenosis in the young has various etiologies. We sought to identify patterns of vessel involvement of intracranial stenosis.

Methods: This is a retrospective cohort study of young patients (≤50 years old) with intracranial stenosis seen in the stroke clinic of a tertiary center from 2008-2013. Patients were grouped by clinical diagnosis of 1. atherosclerosis (≥ 3 traditional risk factors ) 2. vasculitis ; 3. RCVS; 4. unknown etiology. Stenosis location and severity were compared among these groups based on cerebral angiography, CTA, or MRA.

Results: A total of 128 patients were identified in this cohort. Of this cohort, presumed atherosclerosis (56%) was the most common etiology followed by unknown etiology (21%). Distinct patterns of stenosis were noted among these categories (see table). Atherosclerosis was more commonly identified in the anterior circulation (68.1%, p=.036). Moyamoya disease and the vasculitides had high predilection for MCA stenosis. RCVS showed a more diffuse vessel involvement which includes posterior circulation.

Conclusion: Distinct of patterns of vessel involvement are seen among different etiologies of intracranial stenosis in the young. These patterns may help in determining the etiology of intracranial stenosis in this population.

Abstract 10: The PROMIS Physical Function Scale- a Promising Scale for use in Stroke

Background: Functional status is a critically important outcome measure after stroke. The ability to electronically capture this through self-report is increasing. The Patient Reported Outcomes Measurement Information System (PROMIS) uses computer adaptive testing (CAT), which can increase score precision and reduce patient burden. The number of questions depends on the patient’s responses. The objective of this study was to evaluate the performance of the PROMIS physical function scale (PROMIS PF) compared to the validated Stroke Impact Scale 16 (SIS16) in an ambulatory stroke clinic.

Methods: Patient-reported PROMIS PF (CAT version) and SIS16 were electronically collected on patients seen in the stroke clinic using the Knowledge Program platform. Patient completion rates were > 70%. Distribution of scores was compared to assess ceiling/floor effects. Internal consistency was assessed by calculating the SEM for PROMIS PF and Cronbach’s alpha for SIS16. Correlations with NIHSS were performed to assess convergent validity.

Results: The PROMIS PF and SIS16 were collected on 5,691 patients from Jan 2010 - May 2014. Mean SIS16 score = 81.4 (SD 21.5), mean PROMIS PF score = 42.8 (SD 11.2). The SIS16 had a22% ceiling effect, <1 % ceiling effect was seen with PROMIS PF (Figure). Patients completed 16 SIS16 items and a median of 4 [IQR 4, 5] PROMIS PF items. Cronbach’s alpha for SIS16 = 0.959, SEM for PROMIS PF = 2.3; both values suggest excellent internal consistency. Test-retest correlation was 0.867 for SIS16 and 0.87 for PROMIS PF. Correlations between NIHS and the 2 scales were -0.461 (p<0.001) for PROMIS PF and -0.559 (p<0.0001) for SIS16.

Conclusion: The use of the PROMIS system to obtain electronic patient-reported functional status in ambulatory stroke clinic is feasible. PROMIS PF is an option for measurement of physical function in patients with stroke. It had similar test characteristics as the SIS16 but with lower patient burden and no ceiling effect.

Abstract W P176: Relationship Between Right-to-Left Shunting and Microembolic Signals on Transcranial Doppler Monitoring

Background: Transcranial doppler-monitoring (TCM) has been used to identify patients at risk for embolic stroke and aids in identification of stroke mechanism. Limited data exists on the occurrence of microembolic signals (MES) on TCM and the presence of right-to-left shunting (RLS), most commonly through a patent foramen ovale. Our objective was to determine if a relationship exists between the presence of a RLS on transcranial doppler-bubble (TCB) and MES on TCM, and if the degree of shunting correlated with increased number of MES.

Methods: A retrospective chart review was conducted of 113 inpatients that underwent both TCB for the detection of a RLS and TCM during their admission for ischemic stroke at the Cleveland Clinic between 2011 and 2012. TCM was performed for 20 minutes in all patients. Both TCM and TCB used standardized protocols and machines. Data collected included demographics, presence of a shunt, and stroke mechanism.

Results: Mean age of the study cohort was 57.9 years and 46.9% were female. RLS on TCB was found in 30.1% of patients and MES were seen on TCM in 33.6% of patients. The occurrence of MES was similar in patients with and without RLS (38.2% vs. 31.6% respectively) (p=0.50). In patients with undetermined stroke mechanism and RLS, there was a trend towards higher occurrence of MES (42.9% vs 30.8%, p=0.35). No significant difference was seen between the occurrence of MES and degree of shunting according to Spencer Grades I-IV (p=0.48). Patients with MES and RLS had an insignificantly greater number of MES than patients without RLS (59.8 vs 10.8. p=0.33). This difference in the number of MES was more pronounced in patients with undetermined stroke etiology (73.1 vs 14.4, p=0.42).

Conclusions: There was no overall relationship between RLS and MES on TCM. However, the number of MES in patients with positive TCM was greater in those with a RLS compared to those without RLS, particularly in patients with undetermined stroke mechanism. Although, more data is needed, in patients with strokes of undetermined etiology, the presence of MES on TCD may suggest the presence of a RLS, especially if the number of MES is high.

Abstract T P308: Re-assessment of Lipid Profiles in Stroke Patients Post-hospital Discharge - Room for Improvement

Introduction: According to guidelines patients receiving a lipid-lowering agent at discharge for stroke should receive follow-up lipid profile. Our measure takes the currently collected STK-6, one step further and tries to identify whether these patients receive follow-up lipid testing by comparing non-abstracted electronic health record data to abstracted data.

Methods: Data was extracted from the Cleveland Clinic EMR (Epic Systems, Inc.) utilized by the Cleveland Clinic Health System (10 hospitals and 16 family health centers). The cohort was based on patients with an admission for stroke from 2008 to 2012 utilizing STK-6 criteria. We examined this cohort for whether they received a lipid panel within the 12 months after the discharge date and limited patients to those that received follow up encounters at our healthcare system. Demographic factors including age, gender, race, ethnicity, distance to hospital, primary diagnosis for hospitalization and presence of comorbid conditions were also extracted. This data was compared to our abstracted publically reported STK-6 data which comes from claims data.

Results: Of the 508 patients included in results for STK-6 reporting, only 391 (77%) were also identified through the EMR. Of these, 274 patients had follow up at least one year within the healthcare system. Only 97(35%) patients had lipid panel lab results indicated in the EMR within one year of discharge. Testing was not statistically different based on patient characteristics: patients < 70 yrs vs 70+ (37% vs 30%, p=0.27), whites vs non-whites (35% vs. 36%, p=0.93), males vs. females (39% vs 30%, p=0.12). There was no significant difference in distance to the hospital from patients primary residence either between those without and with follow up lipid testing (mean distance=39 miles vs.17 miles, p=0.22).

Conclusions: Follow up lipid testing following stroke discharge is not consistently performed among patients treated at a large healthcare system. There are not any highly significant differences in testing based on patient demographic characteristics or distance to the hospital. Further understanding of the reasons for poor follow up testing is required as well as evaluating concordance of the data pulled from the EMR when compared to abstracted data.