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Treatment Delays and Worse Outcomes for Patients With In-Hospital Stroke

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Study Authors: Feras Akbik, Haolin Xu, et al.; Amy Y.X. Yu, Michael D. Hill

Target Audience and Goal Statement: Neurologists, hospitalists, emergency department physicians

The goal of this study was to examine trends in the use of intravenous and endovascular reperfusion therapies for treatment of in-hospital stroke.

Question Addressed:

  • What were the trends in the use of intravenous and endovascular reperfusion therapies for treatment of in-hospital stroke?

Study Synopsis and Perspective:

Up to 10.8% of all acute ischemic strokes occur in the hospital. Unlike patients with out-of-hospital stroke onset, those who experience a stroke in the hospital are more likely to have contraindications to systemic thrombolysis because they may have been admitted after major trauma, are recovering from surgery, or a variety of other reasons.

Action Points

  • Patients with in-hospital stroke onset received treatment at slower rates and had worse functional outcomes compared with those with out-of-hospital stroke onset, despite an increase in use of endovascular therapy and intravenous thrombolysis for these patients, according to a retrospective cohort analysis of a national stroke registry.
  • Note that, although patients with in-hospital stroke onset were increasingly recognized and treated with reperfusion therapy, disparities in care persisted, highlighting opportunities to optimize care, including the use of dedicated inpatient stroke protocols.

There have been no large national datasets that have reported on the use of endovascular therapy in patients with acute ischemic stroke onset in the hospital. Therefore, a retrospective cohort analysis of the American Heart Association Get With the Guidelines-Stroke registry was performed to characterize the temporal trends for in-hospital stroke, comparing patient features, process measures of quality, and outcomes, versus out-of-hospital stroke.

In-hospital strokes were increasingly recognized and treated with reperfusion therapy in recent years, though still not on par with out-of-hospital strokes, according to Feras Akbik, MD, PhD, of Emory University Hospital in Atlanta, and colleagues.

The proportion of in-hospital stroke among all stroke hospital discharges rose from 2.7% in 2008 to 3.5% in 2018 (P<0.001), they reported in JAMA Neurology.

For the analysis, the researchers identified more than 2.2 million eligible discharged patients with acute ischemic stroke at 1,355 sites from January 1, 2008 through September 30, 2018.

Patients were included if they were admitted with acute ischemic stroke via the emergency department or if they experienced one while hospitalized. People admitted via interhospital transfer were excluded.

In total, 67,493 patients (3.0%; mean age 72 years, 53.2% women) had in-hospital stroke onset.

People who had in-hospital versus out-of-hospital stroke onset tended to have more comorbidities and vascular risk factors. Age and sex were similar between groups whether people received IV thrombolysis only or underwent endovascular therapy.

Symptomatic intracranial hemorrhage rates were no different between groups receiving IV thrombolysis, whereas the in-hospital onset patients had a reduced risk after endovascular therapy.

The proportion of patients with in-hospital stroke receiving IV thrombolysis increased steadily from 2008 to 2018, from about 9% to 19% (P<0.001). Endovascular therapy also increased, from 2.5% to 6.4% (P<0.001), starting in mid-2015 after the positive thrombectomy trials had been released.

Among stroke patients who received IV thrombolysis without endovascular therapy, the in-hospital onset group waited longer from stroke recognition to cranial imaging (33 vs 16 minutes, P<0.001) and to thrombolysis bolus (81 vs 60 minutes, P<0.001) compared with the out-of-hospital onset group.

Delays in care aside, in-hospital onset patients also had worse outcomes, being less likely to ambulate independently at discharge (adjusted OR 0.78, 95% CI 0.74-0.82) and more likely to die or to be discharged to hospice (adjusted OR 1.39, 95% CI 1.29-1.50).

Findings were similar when comparing in-hospital versus out-of-hospital stroke patients who received endovascular therapy.

“Dedicated inpatient stroke protocols are advised to bridge this disparity in stroke care,” the researchers wrote.

Source References: JAMA Neurology 2020; DOI: 10.1001/jamaneurol.2020.3362

Editorial: JAMA Neurology 2020; DOI: 10.1001/jamaneurol.2020.3368

Study Highlights and Explanation of Findings:

Based on a representative nationwide registry of patients with acute ischemic stroke, Akbik and colleagues found that in-hospital strokes were increasingly recognized and treated with reperfusion therapy in recent years. Nevertheless, these findings were accompanied by longer delays in imaging and treatment initiation and worse functional outcomes compared with patients with out-of-hospital strokes.

In keeping with the researchers’ hypothesis, endovascular therapy utilization rates for in-hospital strokes significantly increased following the publication of pivotal 2015 trials. However, IV thrombolysis rates also significantly increased throughout the study period, doubling during the 10-year span. The researchers attributed part of this trend to increased ascertainment and reporting of in-hospital strokes, with greater tendencies to include cases if they received endovascular therapy or IV thrombolysis.

“Our data notably conflict with recent reports of comparable or even faster treatment times and equivalent outcomes for patients with in-hospital stroke onset who received EVT [endovascular therapy], although these reports were indexed to symptom onset and not to our use of stroke presentation,” they wrote.

“Those studies were limited by being reported from single, high-volume centers, uncertainty about any bias regarding when in-hospital EVT was offered, and the low frequency of EVT for in-hospital stroke at any given institution,” they added.

However, the current analysis leveraged a national database to analyze time intervals in 2,494 patients who experienced strokes at a hospital and were treated with endovascular therapy to show that, similar to patients treated with IV thrombolysis, those who received endovascular therapy had longer delays to treatment and worse functional outcomes, despite already being in hospital at stroke onset.

“Activating acute stroke responders, identifying the appropriate radiology suite, and mobilizing an interdisciplinary team to transport the patient are likely slower in the inpatient setting as opposed to the emergency department, where higher volumes and numbers of dedicated personnel can facilitate the acute stroke treatment pathway,” the researchers noted.

“Even after the initial CT scan, the present study found that there were still longer delays to both IVT [IV thrombolysis] bolus and arterial access for EVT. These delays likely reflect the lack of rigorous protocol use and adherence, similar to the early experience reported in the interventional cardiology literature, or the inability to rapidly access a legally authorized representative to provide consent,” they added.

This study “strongly supports the notion that treatment can be better,” commented Amy Yu, MD, MSc, of the University of Toronto and Sunnybrook Health Sciences Centre in Ontario, and Michael Hill, MD, MSc, of the University of Calgary in Alberta.

“Contemporary hyperacute stroke care has shifted from a time-based focus to an emphasis on tissue-based assessment using neurovascular imaging to identify patients who may benefit from revascularization with thrombolysis or endovascular thrombectomy. It is therefore highly relevant to reexamine the quality of care and outcomes after short-term reperfusion treatment in patients with in-hospital stroke,” they wrote in an accompanying editorial.

Reliance on the voluntary registry meant that the study’s findings may not be generalizable to non-participating hospitals. There was also the possibility of reporting bias in the study, as well as unmeasured confounding given that the original indication for hospital admission was not recorded for in-hospital stroke patients.

“Nevertheless, the concurrent increase of in-hospital stroke events and the proportion of these patients who receive reperfusion therapies suggest that increased recognition of in-hospital stroke is occurring,” Yu and Hill wrote.

“Identifying metrics for quality of stroke care, establishing achievable targets, implementing iterative quality improvement protocols, and monitoring the care and clinical outcomes are necessary for ensuring excellence of care and improving patient outcomes,” they concluded.

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Source: MedicalNewsToday.com