19 research outputs found
Recommended from our members
Pearls & Oy-sters: May-Thurner syndrome as a cause of embolic stroke of undetermined source in a young patient
Recommended from our members
Abstract TP163: The Relationship Between PAP Adherence and Optimal Cardiovascular Disease Protective Regimen Prescription Depends on Race Among Veterans With Obstructive Sleep Apnea
Introduction:
Obstructive sleep apnea (OSA) severity is an independent predictor of cardiovascular disease (CVD) including stroke. Black race has been associated with higher likelihood of CVD morbidity and lower PAP adherence, an unhealthy patient behavior. Data are equivocal for “healthy user” effect: whether a patient’s regular PAP use is associated with physician behavior of optimal CVD prescription regimen. It is unknown if this relationship varies by patient race. We aim to describe whether the association of PAP use with optimal CVD treatment regimen prescription depended on race in veterans with OSA.
Methods:
We conducted a cross-sectional study of existing PAP users at a VA Medical Center. Data on demographics, medications, comorbidities, and OSA were collected. Optimal CVD medication regimen required prescription of antiplatelet, antihypertensive, and statin.
Objective:
PAP use was measured by % of days with use ≥ 4 hours. Using logistic regression, we examined whether the association of patient PAP use with physician optimal medication prescription varied by race. The model included race, PAP use, PAP use by race interaction term, and pertinent covariates.
Results:
A total of 499 veterans (95% male, 38% Black) were included. Two hundred seventy-three veterans (55%) were prescribed an optimal CVD prevention regimen, while 226 (45%) were prescribed a suboptimal regimen. In logistic regression analyses, older age (OR 1.06, 95% CI 1.0-1.1), Black race (OR 1.8, 95% CI 1.1-2.9), higher BMI (OR 1.1, CI 1.1-1.2), and higher Charlson Index (OR 1.3, 95% CI 1.2-1.5), and PAP use by race interaction term were significantly associated with optimal medication regimen prescription. Among white veterans, level of PAP use was not associated to likelihood of optimal CVD prescriptions regimen; However, among Black veterans, those with high levels of PAP use were significantly more likely to be prescribed optimal medication regimen than individuals with low levels of PAP use.
Conclusions:
A “healthy user” effect was detected for the relationship between patient PAP adherence and physician optimal CVD regimen prescription in Black, but not white, veterans. Longitudinal studies are needed to determine the temporal order of these health behavior associations
Recommended from our members
Reducing neurodisparity Recommendations of the 2017 AAN Diversity Leadership Program
Many advances in prevention, diagnosis, and treatment of neurologic disease have emerged in the last few decades, resulting in reduced mortality and decreased disability. However, these advances have not benefitted all populations equally. A growing body of evidence indicates that barriers to care fall along racial and ethnic lines, with persons from minority groups frequently having lower rates of evaluation, diagnosis, and intervention, and consequently experiencing worse neurologic outcomes than their white counterparts. The American Academy of Neurology (AAN) challenged its 2017 Diversity Leadership Program cohort to determine what the AAN can do to improve quality of care for racially and ethnically diverse patients with neurologic disorders. Developing a fuller understanding of the effect of disparities in neurologic care (neurodisparity) on patients is an important prerequisite for creating meaningful change. Clear insight into how bias and trust affect the doctor-patient relationship is also crucial to grasp the complexity of this issue. We propose that the AAN take a vital step toward achieving equity in neurologic care by enhancing health literacy, patient education, and shared decision-making with a focus on internet and social media. Moreover, by further strengthening its focus on health disparities research and training, the AAN can continue to inform the field and aid in the development of current and future leaders who will address neurodisparity. Ultimately, the goal of tackling neurodisparity is perfectly aligned with the mission of the AAN: to promote the highest-quality patient-centered neurologic care and enhance member career satisfaction
Recommended from our members
Target Stroke: Best Practice Strategies Cut Door to Thrombolysis Time to <30 Minutes in a Large Urban Academic Comprehensive Stroke Center
The therapeutic window for acute ischemic stroke with intravenous recombinant tissue plasminogen activator (IV rt-PA) is brief and crucial. The American Heart Association/American Stroke Association Target: Stroke Best Practice Strategies (TSBPS) aim to improve intravenous thrombolysis door-to-needle (DTN) time. We assessed the efficacy of implementation of selected TSBPS to reduce DTN time in a large tertiary care hospital. A multidisciplinary DTN committee assessed causes of delayed DTN time and implemented focused TSBPS in our urban academic medical center. We analyzed door-to-CT time, DTN time, and CT to IV rt-PA time in consecutive patients treated with IV rt-PA over 27 months preimplementation and 13 months postimplementation. One hundred forty-eight patients were included in the preimplementation and 126 in the postimplementation group. We found no significant difference between the groups in demographics, comorbidities, anticoagulation status, prethrombolysis hypertension treatment, arrival by EMS, after-hours arrival, or in stroke etiology. After implementation, median DTN time improved from 59 (interquartile range [IQR]: 52-80) to 29 (IQR: 20-41) minutes (
< .001). Door-to-CT time decreased from 17 (14-21) to 16 (12-19) minutes (
= .016), and CT-to-IV rt-PA time improved from 43 (IQR: 31-59) to 13 (IQR: 6-23) minutes (
< .001). Rates of symptomatic intracranial hemorrhage (2.7% vs 3.2%,
= .82) and treatment of stroke mimics (9% vs 13%,
= .31) were similar in both the groups. Individualized hospital gap analysis identifies targeted interventions that lead to rapid and sustained improvement in treatment times
Recommended from our members
Abstract WMP85: Target Stroke Implementation: Best Practice Strategies Cut Thrombolysis Time to <30 minutes in a 1,550 Bed Academic Urban County Hospital
Introduction:
Thrombolytic window for acute ischemic stroke is brief and crucial. The AHA/ASA Target: Stroke Best Practice Strategies (TSBPS) aim to help hospitals improve thrombolysis door-to-needle (DTN) time. We assessed long-term efficacy of TSBPS to reduce DTN in a tertiary care hospital.
Methods:
We initiated a quality improvement program across one regional academic medical center (1,550 beds, 900 annual stroke admissions) that serves a multi-ethnic population by establishing a multidisciplinary DTN committee to assess causes of delayed DTN and implement focused TSBPS. Strategies included stroke team pre-admission notification, direct transfer to CT scanner, storing and administering IV rt-PA at CT scanner, and immediate stakeholder feedback. Door-to-CT, DTN, CT to IV rt-PA and door-to-groin (DTG) times were analyzed prospectively in consecutive IV rt-PA treated patients over 27 months pre-implementation and 13 months post-implementation.
Results:
A total of 148 patients were included in the pre-implementation and 126 patients in the post-implementation group. The two groups had similar demographics, comorbidities, anticoagulation status, pre-thrombolysis hypertension treatment, stroke severity (median NIHSS 11 (6-18) vs. 11 (5-17), p= 0.483), arrival by EMS (96% vs. 97%, p=0.708), and arrival after hours. Post implementation, reductions in treatment times were observed for median DTN (IQR) 59 (52-80) to 28.5 (20-41) min (p<0.001), door-to-CT time 17 (14-21) to 16 (12-19) min (p=0.016), CT-to-IV rt-PA time 43 (31-59) to 13 (6-23) min (p<0.001), and DTG time 164 (136-188) min (n=37) to 86 (63-103) min (n=51) (p<0.001). Overall monthly IV r-tPA administration increased post-implementation (5.5 vs. 9.8, p<0.001). Rate of symptomatic intracranial hemorrhage (2.7% vs. 3.2%, p=0.817) and treatment of stroke mimics (9% vs. 13%, p=0.311) were similar pre- and post-implementation.
Conclusions:
In this study, delay in IV rt-PA administration was predominantly related to prolonged CT to IVrt-PA time. DTN committee implementation is a simple, low-cost intervention, that significantly reduced DTN and DTG with persistent effect and no increase in symptomatic intracranial hemorrhage or stroke mimic treatment rate
Recommended from our members
Abstract P870: Disparities in Timelines of Hospital Presentation in Patients With Ischemic Stroke: Florida Stroke Registry
Introduction: Characterizing the population of ischemic stroke (IS) patients presenting in the delayed reperfusion window is important to ensure equitable implementation of recently updated acute IS treatment guidelines. Methods: Florida Stroke Registry (FSR) data from Jan 2010 - Jan 2020, provided a complete dataset of 98,372 IS cases presenting within 24 hrs of symptom onset. Generalized linear regression analysis was used to identify differences between delayed IS cases (>4.5 hours) versus those presenting within the early time window (≤ 4.5 hr). Results: A total of 60,311 presented with 4.5 hr (median age 74 (interquartile range (IQR) 62-83), 49% women, 67% white, 15% Black, 18% Hispanic), and 38,061 presented in the delayed window (median age 72 (IQR 61- 82), 49% women, 63% white, 18% Black, 19% Hispanic). As compared to early presenters, delayed window patients were younger (OR 1.23, 95% confidence interval (CI) 1.17-1.29); more Black vs. White (OR 1.12, 95% CI 1.06-1.18), have higher NIHSS (OR 1.05, 95% 1.01-1.10), insured (OR 1.18, 95% 1.11-1.25), presenting to an academic hospital (OR 1.24, 95% CI 1.09-1.40) in South Florida (OR 1.23, 95% CI (1.08, 1.41)); less likely to arrive by EMS (OR 0.59, 95% CI 0.56-0.62) and less likely to receive reperfusion therapies (OR 0.86, 95% CI 0.79-0.94). In multivariable analysis adjusting for age, race, NIHSS, EMS, reperfusion therapies, hospital academic status and region, delayed window presentation was negatively associated with discharge home (OR 0.82, 95% CI 0.76-0.89), and ambulatory status at discharge (OR 0.89, 95% CI 0.84-0.93). Conclusion: We found significant race, ethnic, socioeconomic and geographical disparities amongst those presenting in the delayed vs early reperfusion time windows with consequential effects on patient outcomes. Stroke education to younger minorities and adaptation of regional stroke systems of care are urgently needed
Recommended from our members
Abstract P882: A Multi-Level Exploration of the Social Determinants of Health in Florida: Initial Findings From the Transitions of Care Stroke Disparities Study
Introduction: Social determinants of health (SDH) are major contributors to stroke incidence and disparities, yet their relationship with severity and disability is relatively unexplored. The purpose of this study is to provide preliminary findings on SDH measures at the individual- and ZIP code-level across outcomes of stroke severity and disability. Methods: We used data from 344 stroke patients from the ongoing Transitions of Care Stroke Disparities Study (TCSDS) enrolled 2018-2020 from sites throughout Florida. TCSDS aims to identify disparities in hospital-to-home transition of stroke care. Individual-level SDH were collected by a trained interviewer at discharge; ZIP-level SDH data were obtained from a contracted data company. Outcomes included stroke severity at admission measured by the NIH Stroke Scale (NIHSS; Mild: 0-4; Moderate: 5-14; Severe: ≥15) and obtained from the AHA Get with the Guidelines-Stroke program; and disability at discharge measured by the modified Rankin Scale (mRS; 0-1; 2-5). Non-parametric statistical tests were used to compare individual- and ZIP-level SDH by NIHSS and mRS scores. Results: Most patients were older (median age 62 years, IQR: 19), male (58%), non-Hispanic White (39%) or Hispanic (35%) and suffered mild strokes (median NIHSS, IQR: 2, 4) with mild disability (median mRS: 1, 4). Those living with children (LWC) had more moderate strokes, while those living with a spouse/partner (LWP) had more severe strokes (p=0.004). Less than high school (HS)-, HS-, and college-educated patients had more moderate, mild, and severe strokes, respectively (p=0.02). ZIP-level unemployment rate was positively associated with NIHSS (p=0.031). Higher mRS was seen among Spanish and Haitian Creole speakers (p=0.005); HS- and less than HS-educated patients (p=0.005); and those with lower levels of social support (p=0.019). LWC had higher mRS scores, while the opposite was true for LWP (p=0.001). Conclusions: Despite the intersectional nature of SDH, these findings highlight possible mechanisms by which education, economic conditions and psychosocial factors may influence stroke severity and disability after stroke. More data are necessary to determine whether these SDH influence long term stroke outcomes post-discharge
Recommended from our members
Abstract P877: Race-Ethnic Disparities in Intracerebral Hemorrhage Outcomes
Introduction: Prior literature has reported differences in outcomes following stroke by race/ethnicity. While more attention has been focused on ischemic stroke, we sought to identify race/ethnic disparities in hospital outcomes at discharge following intracerebral hemorrhage (ICH). Methods: Data were obtained from the Florida Stroke Registry (FSR) consisting of stroke centers utilizing the Get With the Guidelines-Stroke (GWTG-S) tool. Pearson Chi-square and Kruskall-Wallis tests were used to compare descriptive statistics by race/ethnicity on 26,113 Florida cases with ICH discharged 2010-2018. Outcomes at discharge included in-hospital mortality, disposition, ambulation, modified Rankin Scale score & timing of initiation of comfort measures only (CMO). Generalized estimating equations logistic models accounted for age, sex, insurance, smoking, hypertension, diabetes, dyslipidemia, prior anti-coagulant/platelet use, history of stroke/TIA, admission NIHSS, ICH score, arrival mode, hospital size, teaching status & years in GWTG-S. Results: 65% were non-Hispanic White (NHW), 20% non-Hispanic Black (NHB) and 15% Hispanic. NHB were younger at ICH onset (median 60, IQR 52-71; NHW: 71, 58-81; Hispanic: 69, 52-80; p < 0.0001), had higher risk of hypertension (HTN; 74%; NHW: 66%; Hispanic: 64%; p < 0.0001), diabetes (29%; NHW: 20%; Hispanic: 27%; p < 0.0001), smoking (14%; NHW: 12%; Hispanic: 9%; p < 0.0001) and chronic renal insufficiency (8%; NHW: 4%; Hispanic: 4% ; p < 0.0001). NHW had higher risk of dyslipidemia (35%; NHB: 21%; Hispanic: 27%; p < 0.0001), atrial fibrillation/flutter (20%; NHB: 6%; Hispanic: 10%; p < 0.0001) and a higher use of prior anticoagulants (13%; NHB: 6%, Hispanic: 8%, p < 0.0001). NHB had lower odds of in-hospital mortality (adjusted OR=0.77, 95% CI=[0.61-0.96]) and CMO on days 0/1 (0.63, 0.45-0.87) compared to NHW. Conclusions: Differences in risk factor profiles, such as higher rates of HTN in NHB and greater use of anticoagulants among NHW, raises the possibility of tailoring preventive and acute care responses to ICH by race/ethnicity. Moreover, despite observing persistently lower odds of mortality and CMO among NHB after adjustment, more data are needed to identify the unobserved effects leading to these disparities
Recommended from our members
Abstract P436: Outcomes in Intracerebral Hemorrhage Patients Presenting With Impaired Level of Consciousness
Background: Impaired level of consciousness (LOC) on presentation after intracerebral hemorrhage (ICH) may affect outcomes and the decision to withdraw life-sustaining treatment (WLST). We aim to investigate the outcomes and trends after ICH by the LOC status on presentation. Methods: We studied 37,613 cases with ICH in the Florida Stroke Registry from 2010-2019. Pearson chi-squared and Kruskall-Wallis tests were used to compare descriptive statistics. A multivariable-logistic regression with GEE accounted for basic demographics, comorbidities, ICH severity, hospital size and teaching status. Results: At stroke presentation, 12,272 (33%) cases had impaired LOC (mean age 72, 49% women, 61 white%, 20% Black, 14% Hispanic). Compared to cases with preserved LOC, LOC case were older (72 vs. 70 years old), more women (49% vs. 45%), more likely to have aphasia (38% vs. 16%), had lower GCS score (9 vs. 15), had greater ICH score (3 vs. 1), greater WLST rates (41% vs. 18%), and had greater in-hospital mortality rates (32% vs. 12%). In our adjusted model, no association was found between impaired LOC and in-hospital mortality, or length of stay. Those with preserved LOC were more likely discharged home/rehab (OR 0.4, 95%CI 0.2-0.9, p=0.03) and more likely to ambulate independently (OR 1.6, 95%CI 1.1-2.4, p=0.02). Trend analysis (2010-2019) showed decreased mortality, increased length of stay, and increased rates of discharge to home/rehab in all, regardless of the LOC status. Conclusion: In this large multi-center registry, a third of ICH cases presents with impaired LOC. Although LOC was not associated with significantly more in-hospital morality, LOC was associated with had higher rates of WLST and more disability at discharge. Future efforts should focus on biomarkers of LOC that detect early recovery and reduced disability in ICH patients with impaired LOC
Recommended from our members
Abstract P397: Outcomes in Acute Ischemic Stroke Patients Presenting With Impaired Level of Consciousness
Background: Impaired level of consciousness (LOC) on presentation after acute ischemic stroke (AIS) may affect outcomes and the decision to withdraw life-sustaining treatment (WLST). We aim to investigate the outcomes and their trends after AISby the LOC on stroke presentation. Methods: We studied 238,989 cases with AIS in the Florida Stroke Registry from 2010-2019. Pearson chi-squared and Kruskall-Wallis tests were used to compare descriptive statistics. A multivariable-logistic regression with GEE accounted for basic demographics, comorbidities, stroke severity, location, hospital size and teaching status. Results: At stroke presentation, 32,861 (14%) cases had impaired LOC (mean age 77, 54% women, 60 white%, 19% Black, 16% Hispanic). Compared to cases with preserved LOC, impaired cases were older (77 vs. 72 years old), more women (54% vs. 48%), had more comorbidities, greater stroke severity on NIHSS ≥ 5 (49% vs. 27%), higher WLST rates (3% vs. 0.6%), and greater in-hospital mortality rates (9% vs. 3%). In our adjusted model however, no significant association was found between impaired LOC and in-hospital mortality, or length of stay. Those with preserved LOC were more likely discharged home/rehab (OR 0.7, 95%CI 0.6-0.8, p<0.0001) and more likely to ambulate independently (OR 0.7, 95%CI 0.6-0.9, p=0.001). Trend analysis (2010-2019) showed decreased mortality, increased length of stay, and increased rates of discharge to home/rehab in all irrespective of LOC status. Conclusion: In this large multicenter registry, AIS cases presenting with impaired LOC had more severe strokes at presentation. Although LOC was not associated with significantly worse in-hospital morality, it was associated with higher rates of WLST and more disability among survivors. Future efforts should focus on biomarkers of LOC that discriminates the potential for early recovery and reduced disability in acute stroke patients with impaired LOC