Abstract T MP96: Trends and Variation in Inpatient Discharge to Hospice Among High Stroke Volume Hospitals

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Benjamin P George ◽  
Adam G Kelly ◽  
Eric B Schneider ◽  
Robert G Holloway
Keyword(s):  
Ischemic Stroke ◽  
Stroke Volume ◽  
Acute Ischemic Stroke ◽  
Hospice Care ◽  
Average Rate ◽  
High Volume ◽  
Absolute Number ◽  
Annual Growth Rate ◽  
Compound Annual Growth Rate ◽  
Hospital Variation

Background: In recent years, individuals with acute ischemic stroke accounted for approximately 4% of all inpatients discharged to hospice, yet little is known about current practices and trends in discharge to hospice care for stroke admissions within US hospitals. Methods: We examined rates of hospice discharge for adult acute ischemic stroke patients admitted to acute care facilities in the top quartile of annual stroke volume between 2001 and 2010 in the Nationwide Inpatient Sample. These high volume hospitals account for nearly 75% of stroke admissions in the dataset. Only those with available information on hospice discharge were considered. Compound annual growth rate was used to examine changes in utilization over time. Hospice trends were evaluated using the Cochran-Armitage test. Results: Among 1,935 high volume hospitals there were 455,372 hospitalizations for acute ischemic stroke from 2001 to 2010, 12,036 (2.6%) of which were discharged to hospice (30% to home; 70% to medical facility). The absolute number of discharges to hospice care grew at 29% per year over the ten-year period (P Trend<0.001). Discharge rates to hospice care per 100 stroke admissions increased from an average of 0.5 (SD=1.3) in 2001 to 4.3 (SD=3.0) in 2010 (P Trend<0.001). Inter-hospital variation in rates of hospice discharge remained large from year to year, and ranged from zero to 15.6 per 100 stroke admissions (Median=3.8; Interquartile Range=3.7) in 2010. Conclusions: The average rate of discharge to hospice care for acute ischemic stroke inpatients admitted to high volume hospitals has grown substantially in the past decade; variation in this practice across these hospitals remains large.

Abstract 2825: History of Cancer Predicts Mortality After Acute Endovascular Treatment for Ischemic Stroke

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Karl Meisel ◽  
Mahesh Jayaraman ◽  
Jonathan Grossberg ◽  
Anthony Kim
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Hospice Care ◽  
Exploratory Analysis ◽  
Endovascular Intervention ◽  
Consecutive Series ◽  
History Of ◽  
History Of Cancer

Introduction: Endovascular treatment is an emerging therapy for acute ischemic stroke. There is no clear consensus about how best to select patients that may benefit from intervention. We conducted an exploratory analysis of clinical risk factors to predict mortality after endovascular intervention in order to better understand how to improve outcomes for patients with acute ischemic stroke. Methods: We identified consecutive series of patients treated with endovascular therapy for acute ischemic stroke at two academic hospitals between 2005 to 2010. Key clinical data elements and clinical outcomes at the time of discharge were abstracted from medical records. We evaluated univariate and multivariable associations using logistic regression and compared mean NIH Stroke Scale between those with and without a history of cancer using the t-test. Results: We identified 88 patients who received endovascular intervention with intra-arterial tissue plasminogen activator (t-PA) and/or mechanical thrombectomy. The mean age of the cohort was 68.2 (SD 16.6) and 44 (55%) were female. A total of 23 (26.1%) patients died during the index hospitalization or were discharged to hospice care. A history of cancer was documented in 20 (22.7%) patients. A history of cancer was associated with a 3.2-fold (95% CI 1.1-9.1) higher odds of mortality. This association persisted after adjusting for age greater than 80 years and hypertension (OR of 4.0, 95% CI 1.3-12). The average NIH Stroke Scale was 15.6 in those with cancer compared to 14.6 without (p=0.53). A history of cancer was not associated with parenchymal hemorrhagic transformation (OR 1.2, 95% CI 0.3-4.9), IV tPA (OR 0.5, 95% CI 0.1-2.3), a TIMI score of 2b or 3 (OR 0.5, 95% CI 0.2-1.3), or an internal carotid artery occlusion (OR 1.7, 95% CI 0.5-5.1). Conclusions: In an exploratory analysis of consecutive patients with acute ischemic stroke treated with endovascular therapy, a history of cancer was strongly associated with significantly increased odds of mortality. One possible explanation could be that patients with cancer may have earlier withdrawal of care but the reasons for this observed association are unclear. Further investigation is necessary to verify and explain the reasons for this observation in order to improve outcomes for acute ischemic stroke patients.

Abstract 203: Emergent Brain Imaging for Acute Ischemic Stroke in Veterans Health Administration Hospitals

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Kori Sauser ◽  
Dawn M Bravata ◽  
Rodney A Hayward ◽  
Deborah A Levine
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Brain Imaging ◽  
Veterans Health Administration ◽  
Primary Objective ◽  
Veterans Health ◽  
Health Administration ◽  
Linear Regression Models ◽  
Patient Level ◽  
Hospital Variation

Objective: Tissue plasminogen activator (tPA) is under-utilized in Veterans Health Administration medical centers (VAMCs); delays in brain imaging may be a significant barrier. Our primary objective was to describe door-to-imaging time (DIT) patterns among veterans with acute ischemic stroke (IS). We identified patient-level predictors of faster imaging times and decomposed variation in DIT attributable to hospital and patient-level factors. Methods: Detailed medical record reviews were done on 5,000 acute IS patients admitted to any VAMC in 2007; this analysis included those with emergent brain imaging (CT/MRI within 6 hours). We used descriptive statistics to report DIT patterns and a series of random-intercept hierarchical linear regression models to identify predictors of DIT and to decompose variation in DIT. Results: Among the 2,681 acute IS patients emergently imaged in a VAMC, median DIT was 67.7 minutes (min) (IQR, 37.1-115.8 min). Among the 83 patients who were eligible for tPA, the median DIT was 45.9 min (IQR, 28.4-72.1 min) and 22% met the DIT<25 min guideline. Arrival from clinic and increased onset-to-arrival time were independently associated with slower DIT, whereas blood pressure on arrival >185/110 mm Hg was associated with faster DIT (Table). In the model without patient-level factors, 7.2% of variation in DIT was attributable to hospital. Adding patient-level predictors to the model explained 18.8% of the variation in DIT, but 6.4% of the variation remained attributable to case-mix-adjusted hospital variation. Despite this clinical substantial hospital variation, the low IS caseload at most hospitals made it impossible to reliably identify high- and low-performing facilities. Conclusion: There remains room for improvement in DIT for VAMC acute IS patients. Variation is attributable to patient and hospital factors, however, low case IS loads at most hospitals prevented reliable discrimination between high and low-performing centers.

Abstract 4: Variation and Temporal Trends in the Characteristics of US Hospitals Treating Acute Ischemic Stroke Patients with IV-tPA: Findings from GWTG-Stroke

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Lee H Schwamm ◽  
Syed F Ali ◽  
Mathew J Reeves ◽  
Eric E Smith ◽  
Jeffrey L Saver ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Systems Of Care ◽  
Team Building ◽  
Temporal Trends ◽  
High Volume ◽  
Wilcoxon Test ◽  
Chi Square ◽  
Over Time ◽  
Iv Tpa

Introduction: Utilization of IV tPA is challenging for many hospitals. Using data from the national Get With The Guidelines-Stroke program, we analyzed changes over time in the characteristics of the hospitals that treated patients with tPA. Methods: We analyzed patient-level data from 2003-2011 at 1600 GWTG hospitals that joined the program at any time during the study period and admitted any acute ischemic stroke (AIS) patients arriving ≤ 2 hr of onset and eligible for tPA. Descriptive trends by time were analyzed by chi-square or Wilcoxon test for continuous data. Results: IV tPA was given within 3 hr at 1394 sites to 50,798/ 75,115 (67.6%) eligible AIS patients arriving ≤ 2 hr; 206 (14.8%) sites had a least one eligible patients but no tPA use. IV tPA treatment rates varied substantially across hospitals (median 61.2%, range 0-100%), with > 200 hospitals providing tPA < 10% of the time (Figure). Over time, more patients and a larger proportion of patients were treated at smaller (median bed size 407 vs. 372, p< 0.001), non-academic, Southern hospitals, and those with lower annualized average ischemic stroke volumes (252.4 vs. 235.2, p< 0.001) (Table). While more than half of all tPA patients were treated at Primary Stroke Centers, this proportion did not change over time. The proportion of patients treated at high volume tPA treatment sites (average > 20/year) increased over time (31.9 vs. 34.5, p< 0.007). Conclusion: Over the past decade, while primary stroke centers still account for more than half of all treatments, tPA has been increasingly delivered in smaller, non-academic hospitals. These data support the continued emphasis on stroke team building and systems of care at US hospitals.

scholarly journals Catheter based selective hypothermia reduces stroke volume during focal cerebral ischemia in swine

2015 ◽  
Vol 8 (4) ◽  
pp. 418-422 ◽  
Author(s):  
Thomas K Mattingly ◽  
Lynn M Denning ◽  
Karen L Siroen ◽  
Barb Lehrbass ◽  
Pablo Lopez-Ojeda ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Cerebral Ischemia ◽  
Stroke Volume ◽  
Acute Ischemic Stroke ◽  
Brain Mri ◽  
Global Cerebral Ischemia ◽  
Moderate Hypothermia ◽  
Stroke Model ◽  
Stroke Treatment ◽  
Endovascular Cooling

BackgroundTotal body hypothermia is an established neuroprotectant in global cerebral ischemia. The role of hypothermia in acute ischemic stroke remains uncertain. Selective application of hypothermia to a region of focal ischemia may provide similar protection with more rapid cooling and elimination of systemic side effects. We studied the effect of selective endovascular cooling in a focal stroke model in adult domestic swine.MethodsAfter craniotomy under general anesthesia, a proximal middle cerebral artery branch was occluded for 3 h, followed by 3 h of reperfusion. In half of the animals, selective hypothermia was induced during reperfusion using a dual lumen balloon occlusion catheter placed in the ipsilateral common carotid artery. Following reperfusion, the animals were sacrificed. Brain MRI and histology were evaluated by experts who were blinded to the intervention.Results25 animals were available for analysis. Using selective hypothermia, hemicranial temperature was successfully cooled to a mean of 26.5°C. Average time from start of perfusion to attainment of moderate hypothermia (<30°C) was 25 min. Mean MRI stroke volumes were significantly reduced by selective cooling (0.050±0.059 control, 0.005±0.011 hypothermia (ratio stroke:hemisphere volume) (p=0.046). Stroke pathology volumes were reduced by 42% compared with controls (p=0.256).ConclusionsSelective moderate hypothermia was rapidly induced using endovascular techniques in a clinically realistic swine stroke model. A significant reduction in stroke volume on MRI was observed. Endovascular selective hypothermia can provide neuroprotection within time frames relevant to acute ischemic stroke treatment.

scholarly journals Hospital Variation in Home-Time After Acute Ischemic Stroke

Stroke ◽  
2016 ◽  
Vol 47 (10) ◽  
pp. 2627-2633 ◽  
Author(s):  
Emily C. O’Brien ◽  
Ying Xian ◽  
Haolin Xu ◽  
Jingjing Wu ◽  
Jeffrey L. Saver ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Hospital Variation

scholarly journals Motorization and Under-Reported Road Accidents: Spatial Evidence from Pakistan

2021 ◽  
Vol 40 (3) ◽  
pp. 482-495
Author(s):  
Farrukh Baig ◽  
Sajan Shaikh ◽  
Mir Aftab Hussain Talpur
Keyword(s):  
Road Safety ◽  
Average Rate ◽  
Transportation Policy ◽  
World Health ◽  
Annual Growth Rate ◽  
Road Accidents ◽  
Compound Annual Growth Rate ◽  
Potential Impact ◽  
Health Organization ◽  
Spatial Maps

Considering the importance of road safety, as discussed in the agenda of World Health Organization-2030; this study folds motorization and under-reporting of road accidents in Punjab, Pakistan. The objectives of the study are selected as 1) identifying the motorization in Punjab; 2) synthesizing the vehicles dominance by preparing spatial maps on the basis of their types; 3) identifying the evidence of under-reporting of road accidents. Compound Annual Growth Rate (CAGR) of different vehicles were estimated, and spatial maps were generated using ArcGIS to demonstrate the spatial distribution of vehicles (CAGR). Results indicated the potential impact of geographical locations on the CAGR of vehicles. The CAGR of registered vehicles was recorded as: 2.73% to 9.93% for Cars; 12.63% to 18.94% for Motorcycles; 9.35% to 24.1% for Rickshaws; 0.74% to 7.29% for Trucks and 5.25% to 14.42% for Vans. On the other hand, the CAGR of road length varied from 0.35% to 12.03% that illustrated the alarming situation of increased motorization. Sluggish infrastructural development and the huge recorded difference in CAGR can be categorized as the possible causes of immense road accidents. By comparing reported road accidents with Punjab Emergency Service (PES) estimations; the average rate of annual under-reported road accidents was found as 62.6% that also showed variations, according to different administrative regions of the Punjab province. Study findings suggests that the development of effective transportation policy, focusing road safety may help Pakistan to curtail road accidents and induce free-flow of traffic.

scholarly journals Trends in hospital procedure volumes for intra-arterial treatment of acute ischemic stroke: results from the paul coverdell national acute stroke program

2020 ◽  
Vol 12 (11) ◽  
pp. 1076-1079
Author(s):  
Ganesh Asaithambi ◽  
Xin Tong ◽  
Kamakshi Lakshminarayan ◽  
Sallyann M Coleman King ◽  
Mary G George
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Patient Outcomes ◽  
High Volume ◽  
Favorable Outcome ◽  
Stroke Registry ◽  
The Usa ◽  
Low Volume ◽  
The Impact

BackgroundRates of intra-arterial revascularization treatments (IAT) for acute ischemic stroke (AIS) are increasing in the USA. Using a multi-state stroke registry, we studied the trend in IAT use among patients with AIS over a period spanning 11 years. We examined the impact of IAT rates on hospital procedure volumes and patient outcome after stroke.MethodsWe used data from the Paul Coverdell National Acute Stroke Program (PCNASP) and explored trends in IAT between 2008 and 2018. Patient outcomes were examined by rates of IAT procedures across hospitals. Specifically, outcomes were compared across low-volume (<15 IAT per year), medium-volume (15–30 IAT per year), and high-volume hospitals (>30 IAT per year). Favorable outcome was defined as discharge to home.ResultsThere were 612 958 patients admitted with AIS to 687 participating hospitals within the PCNASP during this study. Only 2.9% of patients (mean age 68.5 years, 49.3% women) received IAT. The percent of patients with AIS receiving IAT increased from 1% in 2008 to 5.3% in 2018 (p<0.001). The proportion of low-volume hospitals decreased over time (p<0.001), and the proportions of medium-volume (p=0.007) and high-volume hospitals (p<0.001) increased between 2008 and 2018. When compared with medium-volume hospitals, high-volume hospitals had a higher (p<0.0001) and low-volume hospitals had a lower (p<0.0001) percent of patients discharged to home.ConclusionHigh-volume hospitals were associated with a higher rate of favorable outcome. With the increased use of IAT among patients with AIS, the proportion of low-volume hospitals performing IAT significantly decreased.

Stroke Volume Predicts Nocturnal Hypoxemia in the Acute Ischemic Stroke after Intravenous Thrombolysis

2019 ◽  
Vol 28 (9) ◽  
pp. 2481-2487 ◽  
Author(s):  
Jaana K. Huhtakangas ◽  
Tarja Saaresranta ◽  
Michaela K. Bode ◽  
Risto Bloigu ◽  
Juha Huhtakangas
Keyword(s):  
Ischemic Stroke ◽  
Stroke Volume ◽  
Acute Ischemic Stroke ◽  
Intravenous Thrombolysis ◽  
Nocturnal Hypoxemia

Abstract WMP5: Predictors and Clinical Relevance of Hemorrhagic Transformation after Endovascular Therapy for Acute Ischemic Stroke: a Multicenter Retrospective Analysis of 1122 Patients

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Raul G Nogueira ◽  
Rishi Gupta ◽  
Tudor G Jovin ◽  
Elad I Levy ◽  
David Liebeskind ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Retrospective Analysis ◽  
Endovascular Therapy ◽  
High Volume ◽  
Artery Occlusion ◽  
Large Artery ◽  
Anterior Circulation

Background and Purpose: Endovascular techniques are frequently employed to treat large artery occlusion in acute ischemic stroke (AIS). We sought to determine the predictors and clinical impact of intracranial hemorrhage (ICH) after endovascular therapy. Methods: Retrospective analysis of consecutive patients presenting to 13 high-volume stroke centers with AIS due to proximal occlusion in the anterior circulation who underwent endovascular treatment within 8 hours from symptom onset. Logistic regression was performed to determine the variables associated with ICH, hemorrhagic infarction (HI), and parenchymal hematomas (PH) as well as 90-day poor outcome (mRS≥3), and mortality. Results: A total of 1122 patients (mean age, 67±15 years; median NIHSS, 17 [IQR13-20]) were studied. Independent predictors for HI included diabetes mellitus (OR 2.27, 95%CI [1.58-3.26], p<0.0001), pre-procedure IV tPA (1.43[1.03-2.08], p<0.037), Merci thrombectomy (1.47[1.02-2.12], p<0.032), and longer time to puncture (1.001[1.00-1.002], p<0.026). Patients with atrial fibrillation (1.61[1.01-2.55], p<0.045) had a higher risk of parenchymal hematomas (PH) while the use of intra-arterial tPA (0.57[0.35-0.90], p<0.008) was associated with lower chances of PH. Both the presence of HI (2.23[1.53-3.25], p< 0.0001) and PH (6.24[3.06-12.75], p< 0.0001) were associated with poor functional outcomes; however, only PH was associated with higher mortality (3.53[2.19-5.68], p<0.0001). Conclusions: In AIS patients undergoing endovascular therapy, diabetes mellitus, longer time to treatment, and Merci thrombectomy appear to be associated with a higher risk for HI while atrial fibrillation appears to result in a higher risk for PH. While both HI and PH are associated with poor outcomes only PH is associated with higher mortality.

Abstract 17: Hospital Variation in Thrombolysis Times in Acute Ischemic Stroke Patients: the Contributions of Door-to-Imaging Time and Imaging-to-Needle Time

2014 ◽  
Vol 7 (suppl_1) ◽  
Author(s):  
Kori Sauser ◽  
Deborah A Levine ◽  
Adrienne V Nickles ◽  
Mathew J Reeves
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Cohort Analysis ◽  
Random Effect ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Patient Factors ◽  
Hospital Variation ◽  
Imaging Time ◽  
Multi Level

Background: Given the limited time window available for treatment with tPA in acute ischemic stroke patients, guidelines recommend door-to-imaging time within 25 minutes of hospital arrival and a door-to-needle time (DTN) within 60 minutes. Despite temporal improvements in door-to-image and DTN, tPA treatment times remain suboptimal. Objectives: To examine the contributions of door-to-image and imaging-to-needle times to delays in timely delivery of tPA to ischemic stroke patients, and to examine between-hospital variation in DTN. Methods: A cohort analysis of 1,193 ischemic stroke patients treated with intravenous tPA from 2009-2012 at 25 Michigan hospitals participating in the Paul Coverdell National Acute Stroke Registry. The primary outcome was DTN (time in minutes from emergency department arrival to tPA delivery). Multi-level linear regression models included hospital-specific random effects. Results: Mean patient age was 68 years, median NIHSS score was 11 (IQR 6-17), 51% were female, and 37% were nonwhite. Mean DTN was 82.9 ±35.4 minutes, mean door-to-imaging time was 22.8 ±15.9 minutes and mean imaging-to-needle time was 60.1 ±32.3 minutes. A majority of patients had door-to-imaging within 25 minutes (68.4%) but only a minority had DTN within 60 minutes (28.7%). At the patient level door-to-imaging time was only modestly correlated with DTN (r= 0.41), conversely image-to-needle time was strongly correlated with DTN (r= 0.89) (figure). In the multi-level model the hospital random effect accounted for only 12.7% of variability in door-to-needle time. Neither annual stroke volume nor primary stroke center designation was a significant predictor of better DTN. Patient factors (age, race, sex, arrival mode, onset-to-arrival time, and stroke severity) explained 15.4% of the between-hospital variation in DTN. After adjustment for patient factors, door-to-imaging time explained only 10.8% of the variation in hospital risk-adjusted DTN, while imaging-to-needle time explained 64.6%. Conclusion: Compared to door-to-imaging time, imaging-to-needle time was more closely correlated with DTN and a much greater contributor to variability in hospital door-to-needle times. More attention to systems changes that can decrease imaging-to-needle time for acute ischemic stroke patients is now needed.

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