Regional Deprivation, Stroke Incidence, and Stroke Care

BACKGROUND

Regional deprivation can increase the risk of illness and adversely affect care outcomes. In this study, we investigated for the German state of Rhineland-Palatinate whether spatial-structural disadvantages are associated with an increased frequency of ischemic stroke and with less favorable care outcomes.

METHODS

We compared billing data from DRG statistics (2008-2017) and quality assurance data (2017) for acute ischemic stroke with the German Index of Multiple Deprivation 2010 (GIMD 2010) for the 36 districts (Landkreise) and independent cities (i.e., cities not belonging to a district) in Rhineland-Palatinate using correlation analyses, a Poisson regression analysis, and logistic regression analyses.

RESULTS

The age-standardized stroke rates (ASR) ranged from 122 to 209 per 100 000 inhabitants, while the GIMD 2010 ranged from 4.6 to 47.5; the two values were positively correlated (Spearman's ρ = 0.47; 95% confidence interval [0.16; 0.85]). In 2017, mechanical thrombectomies were performed more commonly (5.7%) in the first GIMD 2010 quartile of the regional areas (i.e., in the least deprived areas) than in the remaining quartiles (4.2-4.6%). The intravenous thrombolysis rates showed no differences from one GIMD 2010 quartile to another. Severe neurological deficits (National Institutes of Health Stroke Scale ≥ 5) on admission to the hospital were slightly more common in the fourth quartile (i.e., in the most deprived areas), while antiplatelet drugs and statins were somewhat less commonly ordered on discharge in those areas than in the first quartile.

CONCLUSION

These findings document a relationship between regional deprivation and the occurrence of acute ischemic stroke. Poorer GIMD 2010 scores were associated with worse care outcomes in a number of variables, but the absolute differences were small.

Nachuntersuchung 90 Tage nach Schlaganfall und transitorisch ischämischer Attacke im Qualitätssicherungsprojekt Rheinland-Pfalz

Hintergrund In Deutschland liefern Qualitätssicherungsprojekte zahlreiche Informationen zum akuten Schlaganfall, Daten aus Nachuntersuchungen liegen hingegen kaum vor. Ziel des Nachuntersuchungsprojekts war die Erhebung von Daten zu Lebenssituation, Rezidivereignissen, Medikation und Risikofaktoreneinstellung 3 Monate nach Schlaganfall oder TIA.

Material und Methoden Im zweiten Halbjahr 2012 wurden alle im Qualitätssicherungsprojekt „Akuter Schlaganfall“ in Rheinland-Pfalz erfassten Patienten zu einer Nachuntersuchung nach 90 Tagen mittels eines Fragebogens eingeladen.

Ergebnisse Von 8153 Patienten nahmen 3214 (39,4 %) an der Nachuntersuchung teil (Tod im Krankenhaus: n = 370, 4,5 %; dokumentierter Tod zwischen Entlassung und Tag 90: n = 268, 3,3 %; Widerspruch im stationären Aufenthalt n = 1423, 17,5 %; keine Teilnahme n = 2878; 35,3 %). Erneute TIAs/Schlaganfälle wurden bei 5,6 % der Patienten mit ischämischen Hirninfarkten (n = 2050) und bei jeweils 5,4 % der Patienten mit TIA (n = 934) oder intrazerebraler Blutung (ICB; n = 112) diagnostiziert; 316 (10,2 %) der Patienten gaben Krankenhausaufenthalte aus nicht zerebrovaskulären Gründen an. Mindestens eine Rehabilitationsbehandlung erhielten 64,2 % der Hirninfarkt-, 19,0 % der TIA- und 75,9 % der ICB-Patienten. Hilfe im Alltag benötigten 50,3 % der Hirninfarkt- und 63,4 % der ICB-Patienten, die überwiegend von Familienangehörigen geleistet wurde. In einem Alten-/Pflegeheim untergebracht waren 8,5 % der Patienten mit ischämischem Insult und 13,4 % der ICB-Patienten. Regelmäßige Blutdruckkontrollen berichteten 74,9 % und eine zielgerechte Blutdruckeinstellung (< 140 /90 mmHg) 52,7 % der Patienten. Unter den Rauchern gaben 51,7 % eine Beendigung des Nikotinkonsums an. Die Einnahmequote sank zwischen Entlassung und Tag 90 bei den Vitamin K-Antagonisten von 22,2 auf 12,8 %, bei Antihypertensiva von 82,4 % auf 72,9 % und bei Cholesterinsenkern von 74,8 % auf 54,5 %; 20,6 % aller Patienten nahmen an Tag 90 kein Antithrombotikum mehr ein. Bei den Patienten in Krankenhäusern mit überregionaler Stroke Unit (n = 6) lag im Vergleich zu Patienten in Krankenhäusern mit regionaler Stroke Unit (n = 22) oder ohne Stroke Unit (n = 45) (Strukturgruppen) die Teilnahmequote höher, das Durchschnittsalter, der Anteil an Frauen, die Prävalenz von arterieller Hypertonie und von Vorhofflimmern waren hingegen niedriger. Bei Entlassung und nach 90 Tagen erreichten die überregionalen Stroke Units bei einer Reihe von Endpunktparametern ein besseres Ergebnis, nach Adjustierung für Kovariablen fanden sich hingegen keine signifikanten Unterschiede

Diskussion Die Ergebnisse legen ein deutliches Verbesserungspotenzial bez. Therapieadhärenz, Risikofaktorkontrollen und der Vermeidung von Rezidivereignissen und Rehospitalisierungen nach Schlaganfällen nahe, wenngleich unsere Ergebnisse v. a. durch die Quote an nicht teilnehmenden Patienten limitiert sind. Unterschiede in den Ergebnisparametern zwischen den Strukturgruppen sind im Wesentlichen durch Differenzen bei demografischen Faktoren und Vorerkrankungen bedingt.

Risk of Ischemic Stroke and Transient Ischemic Attack Is Increased up to 90 Days after Non-Carotid and Non-Cardiac Surgery

Background: The risk of stroke after cardiac and carotid surgery is well established. In contrast, stroke risk in association with non-cardiac and non-carotid surgery and its time course are insufficiently known. We investigated the prevalence of recent and planned surgery among patients with stroke and transient ischemic attack (TIA), time dependency of stroke risk, stroke etiology, and interruption of antithrombotic medication in association with surgery. Methods: Data on type and date of surgery and similar interventions within the last year or planned for the next 2 weeks were anonymously collected together with demographic data, vascular risk factors, stroke severity, handicap before stroke and stroke etiology within a state-wide, mandatory, hospital-based acute stroke care quality monitoring project (Rhineland-Palatinate, Germany) for 1 year (2010). Results: Non-carotid and non-cardiothoracic surgery was reported as performed within 1 year before the index event or as planned for the next 2 weeks thereafter in 532 out of 12,120 patients with ischemic stroke/TIA (4.4%). Compared to 91-365 days before stroke/TIA as reference period, risk of cerebral ischemia (per day analysis) was increased for surgery within 61-90 days before ischemia (rate ratio 2.0, 95% CI 1.5-2.8) and continuously increased along shorter intervals between stroke and surgery (31-60 days: rate ratio 3.6, 95% CI 2.9-4.5; 15-30 days: rate ratio 8.2, 95% CI 6.7-10.1; 8-14 days: rate ratio 13.2, 95% CI 10.3-16.8; 4-7 days: rate ratio 16.5, 95% CI 12.2-22.1) peaking at an interval of 1-3 days before ischemia (rate ratio 34.0, 95% CI 26.9-42.8). On the day of surgery, rate ratio was 14.8 (95% CI 7.8-27.9) and for planned surgery it was 2.7 (95% CI 1.8-4.0). Results were similar for first-ever and for recurrent ischemic stroke. Perioperative stroke/TIA was positively associated with atrial fibrillation and cardioembolic stroke etiology, higher mortality, more severe neurological deficits at discharge, and longer hospital stay; and it was inversely associated with microangiopathic etiology and discharge at home. In 34.5% of patients with recent/planned surgery, prior antithrombotic or anticoagulant medication had been interrupted. Conclusions: Recent or planned surgery imposes a considerable short-term stroke risk particularly by cardioembolism with cessation of medication as an important contributor. Stroke after surgery is associated with poor outcome and high mortality. Better strategies to reduce the burden of perioperative stroke are urgently required.

Quality Monitoring of Acute Stroke Care in Rhineland-Palatinate, Germany, 2001–2006

Background and Purpose— Quality monitoring projects are useful tools to improve the quality and to assess temporal trends of stroke care in larger populations.

Methods— In Rhineland-Palatinate, Germany, a statewide, hospital-based, acute stroke care quality monitoring project was started in 2001. Initially, participation was mandatory for all hospitals with dedicated stroke units and from 2006 onward was mandatory for all hospitals. Quality monitoring included a structured data assessment and quality indicators for procedural measures.

Results— Between 2001 and 2006, the numbers of patients registered annually (N=6389 vs N=10 610), admission <3 hours after stroke onset (28.2% vs 34.6%), admission via emergency medical systems (38.1% vs 50.3%), and treatment in stroke units (44.3% vs 59.5%) increased significantly ( P <0.0001, respectively). In ischemic stroke, use of thrombolytic therapy increased (for patients admitted <3 hours after onset, 6.5% vs 14.1%), whereas therapy with high-dose heparin declined (24.5% vs 6.0%, P <0.0001). Several quality indicators (performance of neuroimaging and Doppler/duplex sonography, neuroimaging <3 hours after admission) showed stable results at a high level; more patients received echocardiography (62.2% vs 74.0%), but fewer patients were rapidly examined by extracranial Doppler/duplex sonography (68.7% vs 62.8%, P <0.0001). Diagnosis and treatment of hypertension and hyperlipidemia, use of aspirin and combined aspirin/dipyridamole, and diagnosis of atrial fibrillation increased ( P <0.0001, respectively). Use of oral anticoagulation remained stable at ≈38% of patients with cardioembolism.

Conclusions— Although these results reflect high standards of acute stroke care and improvements regarding early admission, thrombolytic therapy, and several secondary preventive measures, there is still the potential for further improvement regarding thrombolysis, use of oral anticoagulation and statins, and admission to stroke units, for example.