BMJ Open

OBJECTIVE: This study aims to evaluate whether the first wave of the COVID-19 pandemic resulted in a deterioration in the quality of care for socially and/or clinically vulnerable stroke and ST-segment elevation myocardial infarction (STEMI) patients. DESIGN: Two cohorts of STEMI and stroke patients in the Aquitaine neurocardiovascular registry. SETTING: Six emergency medical services, 30 emergency units, 14 hospitalisation units and 11 catheterisation laboratories in the Aquitaine region in France. PARTICIPANTS: This study involved 9218 patients (6436 stroke and 2782 STEMI patients) in the neurocardiovascular registry from January 2019 to August 2020. PRIMARY OUTCOME MEASURES: Care management times in both cohorts: first medical contact-to-procedure time for the STEMI cohort and emergency unit admission-to-imaging time for the stroke cohort. Associations between social (deprivation index) and clinical (age >65 years, neurocardiovascular history) vulnerabilities and care management times were analysed using multivariate linear mixed models, with an interaction on the time period (pre-wave, per-wave and post-first COVID-19 wave). RESULTS: The first medical contact procedure time was longer for elderly (p<0.001) and 'very socially disadvantaged' (p=0.003) STEMI patients, with no interaction regarding the COVID-19 period (age, p=0.54; neurocardiovascular history, p=0.70; deprivation, p=0.64). We found no significant association between vulnerabilities and the admission imaging time for stroke patients, and no interaction with respect to the COVID-19 period (age, p=0.81; neurocardiovascular history, p=0.34; deprivation, p=0.95). CONCLUSIONS: This study revealed pre-existing inequalities in care management times for vulnerable STEMI and stroke patients; however, these inequalities were neither accentuated nor reduced during the first COVID-19 wave. Measures implemented during the crisis did not alter the structured emergency pathway for these patients. TRIAL REGISTRATION NUMBER: NCT04979208

Evaluation de la qualité de la prise en charge de l'accès palustre à Plasmodium Falciparum dans un service d'urgence de janvier 2004 à octobre 2006

BORDEAUX2-BU Santé (330632101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Rev Epidemiol Sante Publique

Contexte et objectif : Lors d'un accident vasculaire cérébral ischémique dû à une occlusion d'un gros vaisseau, plus la thrombectomie mécanique (TM) est réalisée rapidement, meilleur est le pronostic fonctionnel. Cependant, l'organisation des soins ne permet pas systématiquement un accès rapide à la TM. L'objectif de notre étude était de déterminer les facteurs cliniques et organisationnels associés au délai d'accès à la TM. Méthodes : Nous avons réalisé une étude de cohorte dans le département de la Gironde, en France. Les patients nécessitant une TM et régulés par les Services d'Aide Médicale Urgente (SAMU) de Gironde entre le 01/01/2017 et le 31/12/2018 ont été inclus. Le délai d'accès à la TM correspondait à la différence entre le premier appel au SAMU et la ponction de l'aine pour TM. Les principales variables explicatives étaient : le type de parcours de soins (mothership (MS), drip and ship (DS) avec imagerie cérébrale réalisée au centre hospitalier de proximité (CHP) et DS sans imagerie au CHP) ; le score NIHSS ; la distance kilométrique pour accéder à la TM ; le moment de survenue de l'AVC (week-end ou jour férié, vacances scolaires, autre) ; l'âge et le sexe. Des modèles de régression linéaire ont été utilisés pour expliquer le délai d'accès à la TM. Les données manquantes ont été gérées à l'aide d'une procédure d'imputation multiple (spécification conditionnelle complète, Mice R-Package) exécutée dans notre modèle de régression linéaire multivariable. Une analyse quantitative du biais a été réalisée en pondérant le délai imputé d'accès à la TM et en identifiant le poids qui modifie les conclusions de notre analyse. Résultats : Parmi les 314 patients inclus, 152 étaient des femmes (48,4 %), et le score NIHSS moyen à l'admission était de 16,4. Deux cent deux (64,3 %) patients ont été pris en charge dans parcours MS. Le délai moyen entre le premier appel au SAMU et la ponction fémorale pour TM était de 251 minutes. Dans l'analyse multivariable, le délai d'accès à la TM était plus long lorsque les patients étaient pris en charge dans le parcours DS avec imagerie dans le CHP (+106 min, p=0,03), et encore plus long dans le parcourd DS sans imagerie dans le CHP (+197 min, p=0,002), par rapport au parcours MS. Le délai d'accès à la TM diminuait avec l'augmentation du score NIHSS (-6 min par point NIHSS, p<.0001). Dans notre analyse quantitative des biais, nous avons multiplié le délai imputé d'accès à la TM dans les parcours DS uniquement (avec ou sans imagerie dans le CHP) par des poids variant de 0,9 à 0,2 (délais imputés réduits de 10 % à 80 %). Avec une réduction de 40 % ou plus, il n'y avait plus de différence de délai d'accès à la TM entre les trois parcours de soins étudiés. Conclusions : Le parcours DS peut encore être raccourci en généralisant l'accès à l'imagerie cérébrale au sein des CHP. L'optimisation de l'orientation pré-admission vers la TM est un point majeur dans la prise en charge des accidents vasculaires cérébraux ischémiques dûs à une occlusion d'un gros vaisseau.BACKGROUND AND PURPOSE: When an ischaemic stroke due to a large vessel occlusion occurs, the sooner Mechanical Thrombectomy (MT) is performed, the better the functional prognosis. However, the organisation of care does not systematically allow rapid access to MT. The aim of our study was to determine the clinical and organisational factors associated with the time to access to MT. METHODS: We conducted a cohort study in Gironde County, France. Patients admitted for MT and regulated by the Gironde Emergency Medical Services (EMS) between 01/01/2017 and 31/12/2018 were included. The time to access to MT was the difference between the first call to EMS and groin puncture for MT. The main explanatory variables were: type of pathway (mothership (MS), drip and ship (DS) with cerebral imaging performed in the local hospital centre (LHC), and DS without imaging in the LHC); NIHSS score; driving distance to MT; time of stroke onset (weekend or holiday, school holidays, other); age and sex. Linear regression models were used to explain time to access to MT. Missing data were handled using a multiple imputation procedure (Full conditional specification, Mice R-Package) carried out in our multivariable linear regression model. A quantitative bias analysis was performed by weighing the imputed time to access to MT and identifying the weight changing the conclusions of our analysis. RESULTS: Among the 314 included patients, 152 were women (48.4%), and the mean NIHSS score was 16.4. Two hundred and two (64.3%) patients were managed through the MS pathway. The average time from onset to femoral puncture was 251 minutes. In the multivariate analysis, the time to MT was longer when patients were managed DS with imaging in the LHC pathway (+106 min, p = 0.03), and even longer in the DS without imaging in the LHC pathway (+197 min, p = 0.002), compared with MS. Time from onset to MT decreased with increasing NIHSS score (-6 min per NIHSS point, p <.0001). In our quantitative bias analysis, we multiplied the imputed time in access to MT in the DS pathways only (with or without imaging in the LHC) by weights varying from 0.9 to 0.2 (imputed delays reduced from 10% to 80%). With reduction of 40% or more, there was no longer any difference in time to access to MT between the three studied pathways. CONCLUSIONS: The DS pathway can be shortened by generalizing access to cerebral imaging in LHCs. Optimizing pre-admission orientation toward MT is a major issue in LVOS management

Sequelae and Quality of Life in Patients Living at Home 1 Year After a Stroke Managed in Stroke Units

International audienceIntroduction: Knowledge about residual deficiencies and their consequences on daily life activities among stroke patients living at home 1-year after the initial event managed in stroke units is poor. This multi-dimensional study assessed the types of deficiencies, their frequency and the consequences that the specific stroke had upon the daily life of patients.Methods: A cross-sectional survey, assessing, using standardized scales, 1 year post-stroke disabilities, limitations of activities, participation and quality of life, was carried out by telephone interview and by mail in a sample of stroke patients who returned home after having been initially managed in a stroke unit.Results: A total of 161 patients were included (142 able to answer the interview on their own; 19 needing a care-giver). Amongst a sub-group of the patients interviewed, 55.4% (95% Confidence Interval [47.1-63.7]) complained about pain and 60.0% (95% CI [51.4-68.6]) complained of fatigue; about 25% presented neuropsychological or neuropsychiatric disability. Whilst 87.3% (95% CI [81.7-92.9]) were independent for daily life activities, participation in every domains and quality of life scores, mainly in daily activity, pain, and anxiety subscales, were low.Conclusion: Despite a good 1-year post-stroke functional outcome, non-motor disabling symptoms are frequent amongst patients returned home and able to be interviewed, contributing to a low level of participation and a poor quality of life. Rehabilitation strategies focused on participation should be developed to break the vicious circle of social isolation and improve quality of life

Rev Neurol

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

Appariement entre un registre régional de pratiques en cardiologie interventionnelle et la base médico-administrative d’hospitalisation française : développement et validation d’un algorithme d’appariement déterministe

PROBLÉMATIQUE: Afin de reconstruire le parcours de soins hospitalier des patients ayant bénéficié d’un acte de coronarographie ou d’angioplastie coronaire, un appariement entre le registre de pratiques aquitain de cardiologie interventionnelle ACIRA et la base pseudonymisée du Programme de médicalisation du système d’information (PMSI) de la région ex-Aquitaine a été réalisé. L’objectif de cette étude était de développer et valider un algorithme d’appariement déterministe entre ces bases de données exhaustives et complémentaires. MÉTHODES: Après une phase de prétraitement des bases pour standardiser les 11 variables d’appariement identifiées, un algorithme d’appariement déterministe a été développé sur les séjours ACIRA des patients hospitalisés entre décembre 2011 et décembre 2014 dans neuf centres de cardiologie interventionnelle et les données des bases PMSI consolidées de la région ex-Aquitaine des années 2011 à 2014. L’appariement a été effectué en 12 étapes successives, la première consistant en un appariement strict sur les 11 variables. Les performances de l’algorithme ont été analysées en termes de sensibilité, spécificité, valeur prédictive positive (VPP) et valeur prédictive négative (VPN) et testées en faisant varier l’algorithme initial selon des stratégies complémentaires (modification de l’ordre des variables et du prétraitement des bases). L’analyse comparative des patients appariés/non appariés a permis d’explorer les potentielles causes de non-appariement. RÉSULTATS: L’algorithme a permis de retrouver au final 97,2 % des 31 621 séjours ACIRA avec une sensibilité de 99,9 % (IC 95 % [99,9 ; 99,9]), une spécificité de 97,9 % (IC 95 % [97,7 ; 98,1]), une VPP de 99,9 % (IC 95 % [99,9 ; 99,9]) et une VPN de 96,9 % (IC 95 % [96,7 ; 97,1]). Les stratégies complémentaires n’ont pas permis d’obtenir de meilleurs résultats. Les patients non appariés étaient plus âgés, avaient majoritairement été hospitalisés en 2012 et dans deux centres de cardiologie interventionnelle. CONCLUSION: Cette étude a montré la faisabilité et la validité d’un appariement indirect déterministe pour faire le lien en routine entre un registre de pratiques utilisant des données hospitalières et les bases médico-administratives pseudonymisées. Cette méthode, extrapolable à d’autres événements de santé donnant lieu à une hospitalisation, permet de façon efficace de reconstruire le parcours de soins hospitalier des patients.BACKGROUND: To recreate the in-hospital healthcare pathway for patients treated with coronary angiography or percutaneous coronary intervention, we linked the interventional cardiology registry (ACIRA) and the pseudonymized French hospital medical information system database (PMSI) in the Aquitaine region. The objective of this study was to develop and validate a deterministic merging algorithm between these exhaustive and complementary databases. METHODS: After a pre-treatment phase of the databases to standardize the 11 identified linking variables, a deterministic linking algorithm was developed on ACIRA hospital stays between December 2011 and December 2014 in nine interventional cardiology centers as well as the data from the consolidated PMSI databases of the Aquitaine region from 2011 to 2014. Merging was carried out through 12 successive steps, the first consisting in strict linking of the 11 variables. The performance of the algorithm was analyzed in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Strategies complementary to the initial algorithm (change in the order of variables and base preprocessing) were tested. Comparative analysis of merged/unmerged patients explored potential causes of mismatch. RESULTS: The algorithm found 97.2% of the 31,621 ACIRA stays to have sensitivity of 99.9% (95% CI [99.9; 99.9]), specificity of 97.9% (95% CI [97.7; 98.1]), PPV of 99.9% (95% CI [99.9; 99.9]) and NPV of 96.9% (95% CI [96.7; 97.1]). Complementary strategies did not yield better results. The unmerged patients were older, and hospitalized mostly in 2012 in two interventional cardiology centers. CONCLUSION: This study underscored the feasibility and validity of an indirect deterministic pairing to routinely link a registry of practices using hospital data to pseudonymized medico-administrative databases. This method, which can be extrapolated to other health events leading to hospitalization, renders it possible to effectively reconstruct patients' hospital healthcare pathway

Crit Pathw Cardiol

Background: In France, there is a lack of information about practices and pathways of coronary angiographies and percutaneous coronary interventions (PCI). We present the design and the first results of the ACIRA registry, the goal of which is to answer questions about quality, security, appropriateness, efficiency of, and access to interventional cardiology (IC) healthcare pathway in the French Aquitaine region. Methods: The ACIRA registry is an on-going, multicenter, prospective, exhaustive, scalable, and nominative cohort study of patients who undergo coronary angiographies or percutaneous coronary intervention in any of the catheterization laboratories. The data related to hospitalizations and procedures are directly extracted from hospital information systems. In-hospital mortality, readmissions, and cardiovascular morbidity are collected from the French hospital medical information system database. An identity management system has been implemented to create the patient health care pathway. Results: From January 1, 2012, to June 30, 2018, 147,136 procedures performed on 106,005 patients have been included in the ACIRA registry. Conclusions: ACIRA has shown its ability to study the patient IC healthcare pathway, up to 1 year after the procedure. Nominative data enable the linkage between clinical and medico-administrative databases and possible supplementary data collection. The use of existing databases allowed us to limit patients lost to follow-up, prevent the double entry of data, improve data quality, and reduce the operating costs. The prospect of linkage with the French National Health Data System may offer promising opportunities for future medical research projects and for developing collaboration and benchmarking with other IC registries abroad

BMC Health Serv Res

BACKGROUND: Stroke is a health problem with serious consequences, both in terms of mortality, and after-effects affecting patient quality of life. Stroke requires both urgent and chronic management involving the entire health care system. Although large variability in the management of stroke patients have been noticed, knowledge of the diversity and the scalability of post-stroke pathways, whether it is the care pathway or the life pathway, is currently not sufficient. Moreover the link between post-stroke pathways and patients sequelae have not been yet clearly defined. All this information would be useful to better target the needs to improve stroke patient management. The purposes are to identify the post-stroke life pathways components associated with sequelae (activity limitations - main purpose, cognitive disorders, anxio-depressive disorders, fatigue, participation restrictions) at 3 months and 1 year post-stroke, to define a typology of life pathways of patients during the post-stroke year and to analyze the social and geographical inequalities in the management of stroke. METHODS: Design: a prospective multicenter comparative cohort study with a follow up to 1 year after the acute episode. Participant centers: 13 hospitals in the Aquitaine region (France). STUDY POPULATION: patients diagnosed with a confirmed ischemic or hemorrhagic stroke included in the Aquitaine Observatory of Stroke (ObA2) cohort and voluntary to participate. Data sources are existing databases (ObA2 database and the French National Health Data System - SNDS) to collect information about care pathways, patient characteristics and stroke characteristics and Ad hoc surveys to collect information about life pathways and post-stroke sequelae. The endpoints of the study are post-stroke activity limitations evaluated by the modified Rankin score, other post-stroke sequelae (Cognitive disorders, anxio-depressive disorders, fatigue, restriction of participation) assessed by standardized and validated scales and Clusters of patients responding to pathways with common or similar characteristics.; DISCUSSION: By integrating a longitudinal dimension and relying on a large cohort, the project will make it possible to identify the sources of disturbances and the factors favorable to the outcome of the life pathways, important for the planning of the offer and the management of the public policies concerning stroke pathways. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT03865173 , March 6th, 2019

Development and evaluation of the accuracy of an indicator of the appropriateness of interventional cardiology generated from a French registry

BACKGROUND: Development of appropriateness indicators of medical interventions has become a major quality-of-care issue, especially in the domain of interventional cardiology (IC). The objective of this study was to develop and evaluate the accuracy of an indicator of the appropriateness of interventional cardiology acts (invasive coronary angiographies (ICA) and percutaneous coronary interventions (PCI)) in patients with coronary stable disease and silent ischemia, automated from a French registry. METHODS: All ICA and PCI recorded in a Regional IC Registry (ACIRA) and operated for a stable coronary artery disease or silent ischemia from January 1st to December 31th 2013 in eight IC hospitals of Aquitaine, southwestern France, were included. The indicator was developed to reflect European guidelines. Classification of appropriateness by the indicator, measured on the registry database, was compared to the classification of a reference standard (expert judgment applied through complete record review) on a random sample of 300 interventions. Accuracy parameters were estimated. A second version of the indicator was defined, based on the analysis of false negative and positive results, and its accuracy estimated. RESULTS: The second indicator accuracy was: sensitivity 63.5% (95% confidence interval CI [51.7-75.3]), specificity 76.0% (95%CI [70.4-81.6]), PPV 43.0% (95% CI [33.0-53.0]) and NPV 88.0% (95% CI [83.4-92.6]). When stratified on the type of act, parameters were better for ICA alone than for PCI. CONCLUSIONS: Accuracy of the indicator should raise with improvement of database quality. Despite its average accuracy, it is already used as a benchmark indicator for cardiologists. It is sent annually to each IC center with value of the indicator at the region level to allow a comparison

Effects of healthcare system transformations spurred by the COVID-19 pandemic on management of stroke and STEMI: a registry-based cohort study in France

International audienceOBJECTIVE: To assess the impact of changes in use of care and implementation of hospital reorganisations spurred by the COVID-19 pandemic (first wave) on the acute management times of patients who had a stroke and ST-segment elevation myocardial infarction (STEMI). DESIGN: Two cohorts of patients who had an STEMI and stroke in the Aquitaine Cardio-Neuro-Vascular (CNV) registry. SETTING: 6 emergency medical services, 30 emergency units (EUs), 14 hospitalisation units and 11 cathlabs in the Aquitaine region.PARTICIPANTS: This study involved 9218 patients (6436 patients who had a stroke and 2782 patients who had an STEMI) in the CNV Registry from January 2019 to August 2020.METHOD: Hospital reorganisations, retrieved in a scoping review, were collected from heads of hospital departments. Other data were from the CNV Registry. Associations between reorganisations, use of care and care management times were analysed using multivariate linear regression mixed models. Interaction terms between use-of-care variables and period (pre-wave, per-wave and post-wave) were introduced.MAIN OUTCOME MEASURES: STEMI cohort, first medical contact-to-procedure time; stroke cohort, EU admission-to-imaging time. RESULTS: Per-wave period management times deteriorated for stroke but were maintained for STEMI. Per-wave changes in use of care did not affect STEMI management. No association was found between reorganisations and stroke management times. In the STEMI cohort, the implementation of systematic testing at admission was associated with a 41% increase in care management time (exp=1.409, 95% CI 1.075 to 1.848, p=0.013). Implementation of plan blanc, which concentrated resources in emergency activities, was associated with a 19% decrease in management time (exp=0.801, 95% CI 0.639 to 1.023, p=0.077).CONCLUSIONS: The pandemic did not markedly alter the functioning of the emergency network. Although stroke patient management deteriorated, the resilience of the STEMI pathway was linked to its stronger structuring. Transversal reorganisations, aiming at concentrating resources on emergency care, contributed to maintenance of the quality of care.TRIAL REGISTRATION NUMBER: NCT04979208