RESUMEN
BACKGROUND: Time to computerized tomography (CT) is important to institute appropriate and timely hyperacute management in stroke. We aimed to evaluate mortality outcomes in relation to age and time to CT scan. METHODS: We used routinely collected data in 8 National Health Service trusts in East of England between September 2008 and April 2011. Stroke cases were prospectively identified and confirmed. Odds ratios (ORs) for unadjusted and adjusted models for age categories (<65, 65-74, 75-84, and ≥85 years) as well as time to CT categories (<90 minutes, ≥90 to <180 minutes, ≥180 minutes to 24 hours, and >24 hours) and in-hospital and early (<7 days) mortality outcomes were calculated. RESULTS: Of the 7693 patients (mean age 76.1 years, 50% male) included, 1151 (16%) died as inpatients and 336 (4%) died within 7 days. Older patients and those admitted from care home had a significantly longer time from admission until CT (P < .001). Patients who had earlier CT scans were admitted to stroke units more frequently (P < .001) but had higher in-patient (P < .001) and 7-day mortality (P < .001). Whereas older age was associated with increased odds of mortality outcomes, longer time to CT was associated with significantly reduced mortality within 7 days (corresponding ORs for the above time periods were 1.00, .61 [95% confidence interval {CI}: .39-.95], .39 [.24-.64], and .16 [.08-.33]) and in-hospital mortality (ORs 1.00, .86 [.64-1.15], .57 [.42-.78] and .71 [.52-.98]). CONCLUSIONS: Older age was associated with a significantly longer time to CT. However, using CT scan time as a benchmarking tool in stroke may have inherent limitations and does not appear to be a suitable quality marker.
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Angiografía Cerebral/métodos , Angiografía por Tomografía Computarizada , Diagnóstico Tardío , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/mortalidad , Factores de Edad , Anciano , Anciano de 80 o más Años , Inglaterra , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/terapia , Factores de Tiempo , Tiempo de TratamientoRESUMEN
OBJECTIVES: To examine the effect of dysphasia and dysphagia on stroke outcome. DESIGN: Retrospective database study. SETTING: Norfolk, United Kingdom. PARTICIPANTS: Two thousand nine hundred eighty-three men and women with stroke admitted to the hospital between 1997 and 2001. MEASUREMENTS: Inpatient mortality and likelihood of longer length of hospital stay, defined as longer than median length of stay (LOS). Dysphagia was defined as difficulty swallowing any liquid (including saliva) or solid material. Dysphasia was defined as speech disorders in which there was impairment of the power of expression by speech, writing, or signs or impairment of the power of comprehension of spoken or written language. An experienced team assessed dysphagia and dysphasia using explicit criteria. RESULTS: Two thousand nine hundred eighty-three patients (1,330 (44.6%) male), median age 78 (range 17-105), were included, of whom 77.7% had ischemic, 10.5% had hemorrhagic, and 11.8% had undetermined stroke types. Dysphasia was present in 41.2% (1,230) and dysphagia in 50.5% (1,506), and 27.7% (827) had both conditions. Having either or both conditions was associated with greater mortality and longer LOS (P<.001 for all). Using multiple logistic regression models controlling for age, sex, premorbid Rankin score, previous disabling stroke, and stroke type, corresponding odds ratios for death and longer LOS were 2.2 (95% confidence interval (CI)=1.8-2.7) and 1.4 (95% CI=1.2-1.6) for dysphasia; 12.5 (95% CI=8.9-17.3) and 3.9 (95% CI=3.3-4.6) for dysphagia, 5.5 (95% CI=3.7-8.2), 1.9 (95% CI=1.6-2.3) for either, and 13.8 (95% CI=9.4-20.4) and 3.7 (95% CI=3.1-4.6) if they had both, versus having no dysphasia, no dysphagia, or none of these conditions, respectively. CONCLUSION: Patients with dysphagia have worse outcome in terms of inpatient mortality and length of hospital stay than those with dysphasia. When both conditions are present, the presence of dysphagia appears to determine the likelihood of poor outcome. Whether this effect is related just to stroke severity or results from problems related directly to dysphagia is unclear.
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Afasia/mortalidad , Trastornos de Deglución/mortalidad , Mortalidad Hospitalaria , Tiempo de Internación/estadística & datos numéricos , Accidente Cerebrovascular/mortalidad , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Causas de Muerte , Hemorragia Cerebral/mortalidad , Infarto Cerebral/mortalidad , Evaluación de la Discapacidad , Inglaterra , Femenino , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Pronóstico , Sistema de Registros , Estudios Retrospectivos , Adulto JovenRESUMEN
BACKGROUND: Current demographic trends pose a major societal challenge due to the rising number of older people with chronic conditions such as stroke. The relative impact of various disabilities at the time of discharge from an acute unit on discharge outcome is poorly understood. OBJECTIVE: To examine the association between cognition, continence and transfer status at the time of discharge from the acute stroke unit and discharge destination. METHODS: A retrospective stroke register database study was conducted in an acute stroke unit in a UK hospital with a catchment population of 568,000. Consecutive acute stroke admissions between 1997 and 2003 who were discharged alive were identified and the likelihood of adverse discharge outcomes defined as institutionalization or a requirement for longer-term rehabilitation was estimated. RESULTS: A total of 2,521 discharges were analyzed (median length of hospital stay 8 days). The presence of confusion, urinary incontinence or the need for help with transfers at the time of discharge predicted a higher likelihood of an adverse outcome even after controlling for age, stroke subtype, premorbid Rankin score and length of hospital stay. The need for help with transfers appeared to be the most consistent and significant factor associated with an adverse outcome regardless of age, sex or stroke subtype across the sample distribution. CONCLUSION: The ability to transfer has a pivotal role in the clinical decision making of discharge destination after stroke. Understanding of the factors which may increase the potential for improving this ability after acute stroke could have an impact on clinical outcome.
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Cognición , Transferencia de Pacientes , Accidente Cerebrovascular/complicaciones , Incontinencia Urinaria/complicaciones , Anciano , Anciano de 80 o más Años , Confusión/etiología , Inglaterra , Femenino , Hospitales , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Alta del Paciente , Pronóstico , Sistema de Registros/estadística & datos numéricos , Estudios Retrospectivos , Factores de Riesgo , Accidente Cerebrovascular/psicología , Rehabilitación de Accidente Cerebrovascular , Resultado del Tratamiento , Incontinencia Urinaria/psicología , Incontinencia Urinaria/rehabilitaciónRESUMEN
BACKGROUND: Several studies have examined the incidence and mortality of stroke in relation to season. However, the evidence is conflicting partly due to variation in the populations (community vs. hospital-based), and in climatic conditions between studies. Moreover, they may not have been able to take into account the age, sex and stroke type of the study population. We hypothesized that the age, sex and type of stroke are major determinants of the presence or absence of winter excess in morbidity and mortality associated with stroke. METHODS: We analyzed a hospital-based stroke register from Norfolk, UK to examine our prior hypothesis. Using Curwen's method, we performed stratified sex-specific analyses by (1) seasonal year and (2) quartiles of patients' age and stroke subtype and calculated the winter excess for the number of admissions, in-patient deaths and length of acute hospital stay. RESULTS: There were 5,481 patients (men=45%). Their ages ranged from 17 to 105 years (median=78 years). There appeared to be winter excess in hospital admissions, deaths and length of acute hospital stay overall accounting for 3/100,000 extra admissions (winter excess index of 3.4% in men and 7.6% in women) and 1/100,000 deaths (winter excess index of 4.7 and 8.6% in women) due to stroke in winter compared to non-winter periods. Older patients with non-haemorrhagic stroke mainly contribute to this excess. If our findings are replicated throughout England and Wales, it is estimated that there are 1,700 excess admissions, 600 excess in-patient deaths and 24,500 extra acute hospital bed days each winter, related to stroke within the current population of approximately 60 million. CONCLUSIONS: Further research should be focused on the determinants of winter excess in morbidity and mortality associated with stroke. This may subsequently reduce the morbidity and mortality by providing effective preventive strategies in future.
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Estaciones del Año , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/mortalidad , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Mortalidad Hospitalaria , Hospitalización/estadística & datos numéricos , Humanos , Tiempo de Internación , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores Sexuales , Tomografía Computarizada por Rayos X , Reino Unido/epidemiologíaRESUMEN
INTRODUCTION: how the National Service Framework (NSF) for older people in England might be associated with changes in clinically relevant stroke outcome has not been investigated. We looked for changes in computerised tomography (CT) scan rate, inpatient case-fatality rate (CFR), length of acute hospital stay and discharge destination for older people with stroke, compared with their younger counterparts, for a period before, and after, the introduction of the NSF. METHODS: two periods, 4 years before and 2 years after the publication of the NSF, were selected to compare the above outcomes between three age categories: < 65, 65-84 and > or = 85 years of age. Annual summary data for these periods were compared for the magnitude of changes in all age categories for all outcomes measured between pre- and post-NSF periods. RESULTS: n = 5,219. Utilisation of CT imaging had increased in all age groups post-NSF, with the most significant improvement in the oldest group. This change was associated with a greater proportion of people who had CT in this age group being discharged home in the post-NSF period. There was no change in the mortality from stroke in any age group during the study. Although the length of acute hospital stay increased, this was associated with a higher percentage of home discharges particularly in > 65-year olds, suggesting better clinical outcome in those who survived. CONCLUSIONS: in this single-centre analysis, the post-NSF period appeared to be associated with improvement in outcome in older people with stroke. Continual monitoring using stroke registry data may help to assess whether these effects are sustained in the longer term.