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Longer treatment delays, worse outcomes for in-hospital ischemic stroke

JAMA Neurology
Reuters Health - 22/09/2020 - Times to reperfusion are longer and functional outcomes worse for patients with in-hospital ischemic stroke, compared with those having out-of-hospital stroke, according to a registry study.

"Hospitals that have acknowledged the importance and morbidity of inpatient strokes have developed and practiced inpatient stroke protocols, minimizing the disparities in treatment," Dr. Feras Akbik of Emory University Hospital, in Atlanta, told Reuters Health by email. "Our data demonstrate that these protocols are clearly not developed and/or practiced in a significant percentage of hospitals nationally."

An estimated 2.2% to 10.8% of all acute ischemic strokes take place in hospitals. Limited national data suggest that inpatients are less likely than outpatients to be treated with intravenous thrombolysis (IVT), but there have been no national data on the use of endovascular therapy (EVT) in patients with in-hospital stroke, Dr. Akbik and colleagues note in JAMA Neurology.

They used data from the American Heart Association Get With the Guidelines-Stroke registry from 2008 to 2018 to examine temporal trends in the use of IVT and EVT for the treatment of in-hospital versus out-of-hospital stroke.

Among the 2.2 million patients from 1,355 sites discharged with acute ischemic stroke, 3.0% had in-hospital stroke onset.

Overall, 15.5% of patients with in-hospital stroke were treated with IVT and 3.7% underwent EVT, compared with 9.9% and 1.9%, respectively, among patients with out-of-hospital stroke.

During the period covered by this study, IVT utilization rates for in-hospital stroke increased significantly from 9.1% to 19.1%, whereas EVT utilization rates remained stable at 2.5% until the positive endovascular trials were published in 2015, after which there was a 0.23% increase per quarter to 6.9% at the end of this period.

Among patients treated with IVT, those with in-hospital stroke onset had 55% lower odds of being treated within 60 minutes of onset (P<0.001), 22% lower odds of independent ambulation at hospital discharge (P<0.001), 31% lower odds of being discharged to home (P<0.001) and 39% higher odds of in-hospital mortality or discharge to hospice (P<0.001), compared with out-of-hospital stroke patients.

Similarly, for patients treated with EVT, in-hospital stroke onset was associated with 35% lower odds of being treated within 120 minutes of symptom recognition or emergency department arrival (P<0.001), 23% lower odds of ambulating independently at hospital discharge (P<0.001), 32% lower odds of being discharged to home (P<0.001), and 58% greater odds of dying or being discharged to hospice (P<0.001).

"We hope that our colleagues in hospitals around the country take a look at their inpatient stroke protocols," Dr. Akbik said. "If they do not have one, this is a call to develop and implement one. If they do (have one), our data highlight the importance of reevaluating and practicing the protocol to optimize patient outcomes."

"Triage will always be faster in the emergency department; it's what they do all day, every day," he said. "But we can do better upstairs."

Dr. Akbik added, "Our data also highlight important successes. First, intravenous thrombolysis rates have steadily increased year over year, more than doubling from 2008 to 2018. Second, there has been a steady improvement in treatment times over the last 10 years, both for intravenous and endovascular therapy. These data suggest that we are nevertheless making progress, although we continue to have room for improvement."

Dr. Amy Yu of the University of Toronto, Sunnybrook Health Sciences Center, in Toronto, Canada, who co-authored a linked editorial, told Reuters Health by email, "Patients with in-hospital stroke make up a non-negligible minority of patients with stroke, and improving care in this population is important and feasible."

"Multilevel education, implementation of protocols for assessment and treatment of in-hospital stroke, and ensuring high-quality stroke care even after the hyperacute treatments to optimize secondary prevention and mitigate stroke complications (e.g., pneumonia) are a few examples of strategies to improve outcomes in this population," she said.

By Will Boggs MD

SOURCE: https://bit.ly/2Ep2LJA and https://bit.ly/3hQwKrt JAMA Neurology, online September 21, 2020.

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