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BACKGROUND: Patients with ischemic stroke and concomitant COVID-19 infection have worse outcomes than those without this infection, but the impact of COVID-19 on hemorrhagic stroke remains unclear. We aimed to assess if COVID-19 worsens outcomes in intracerebral hemorrhage (ICH). METHODS AND RESULTS: We conducted an observational study of ICH outcomes using Get With The Guidelines Stroke data. We compared patients with ICH who were COVID-19 positive and negative during the pandemic (March 2020-February 2021) and prepandemic (March 2019-February 2020). Main outcomes were poor functional outcome (defined as a modified Rankin scale score of 4 to 6 at discharge), mortality, and discharge to a skilled nursing facility or hospice. The first stage included 60 091 patients with ICH who were COVID-19 negative and 1326 COVID-19 positive. In multivariable analyses, patients with ICH with versus without COVID-19 infection had 68% higher odds of poor outcome (odds ratio [OR], 1.68 [95% CI, 1.41-2.01]), 51% higher odds of mortality (OR, 1.51 [95% CI, 1.33-1.71]), and 66% higher odds of being discharged to a skilled nursing facility/hospice (OR, 1.66 [95% CI, 1.43-1.93]). The second stage included 62 743 prepandemic and 64 681 intrapandemic cases with ICH. In multivariable analyses, patients with ICH admitted during versus before the COVID-19 pandemic had 10% higher odds of poor outcomes (OR, 1.10 [95% CI, 1.07-1.14]), 5% higher mortality (OR, 1.05 [95% CI, 1.02-1.08]), and no significant difference in the risk of being discharged to a skilled nursing facility/hospice (OR, 0.93 [95% CI, 0.90-0.95]). CONCLUSIONS: The pathophysiology of the COVID-19 infection and changes in health care delivery during the pandemic played a role in worsening outcomes in the patient population with ICH.
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COVID-19 , Accidente Cerebrovascular , Humanos , Pandemias , COVID-19/epidemiología , Hemorragia Cerebral , PacientesRESUMEN
OBJECTIVES: This study examined the prognostic value of the get-with-the-guidelines heart-failure risk score (GWTG-HF) on mortality in patients with low-flow-low-gradient aortic valve stenosis (LFLG-AS) after transcatheter aortic valve implantation (TAVI). BACKGROUND: Data on feasibility of TAVI and mortality prediction in the LFLG-AS population are scarce. Clinical risk assessment in this particular population is difficult, and a score has not yet been established for this purpose. METHODS: A total of 212 heart failure (HF) patients with real LFLG-AS were enrolled. Patients were classified into low-risk (n = 108), intermediate-risk (n = 90) and high-risk (n = 14) groups calculated by the GWTG-HF score. Clinical outcomes of cardiovascular events according to Valve Academic Research Consortium (VARC-2) recommendations and composite endpoint of death and hospitalization for heart failure (HHF) were assessed at discharge and 1 year of follow-up. RESULTS: Baseline parameters of the groups showed a median age of 81.0 years [77.0; 84.0] (79.0 vs. 82.0 vs. 86.0, respectively p < 0.001), median EuroSCORE II of 6.6 [4.3; 10.7] (5.5 vs. 7.2 vs. 9.1, p = 0.004) and median indexed stroke volume of 26.7 mL/m2 [22.0; 31.0] (28.2 vs. 25.8 vs. 25.0, p = 0.004). The groups significantly differed at follow-up in terms of all-cause mortality (10.2 vs. 21.1 vs. 28.6%; p < 0.035). There was no difference in intrahospital event rate (VARC). Postprocedural mean gradients were lower in high-risk group (7.0 vs. 7.0 vs. 5.0 mmHg, p = 0.011). No differences in postprocedural aortic valve area (1.9 vs. 1.7 vs. 1.9 cm2, p = 0.518) or rate of device failure (5.6 vs. 6.8 vs. 7.7%, p = 0.731) could be observed. After adjustment for known predictors, the GWTG score (HR 1.07 [1.01-1.14], p = 0.030) as well as pacemaker implantation (HR 3.97 [1.34-11.75], p = 0.013) turned out to be possible predictors for mortality. An increase in stroke volume index (SVI) was, in contrast, protective (HR 0.90 [0.83-0.97]; p = 0.006). CONCLUSIONS: The GWTG score may predict mortality after TAVI in LFLG-AS HF patients. Interestingly, all groups showed similar intrahospital event and mortality rates, independent of calculated mortality risk. Low SVI and new conduction disturbances associated with PPI after THV implantation had negative impact on mid-term outcome in post-TAVI HF-patients.
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Background The GWTG (Get With The Guidelines)-Stroke registry supports clinical research and quality improvement projects that often rely on past medical history elements, the reliability of which remains largely unknown. Here, we evaluated the reliability of specific past medical history elements in a local GWTG-Stroke data set, with particular attention to calculating the CHA2DS2-VASc score. Methods and Results A single-center cohort was identified by querying the Hospital of the University of Pennsylvania's GWTG IQVIA Registry Platform for patients admitted with acute ischemic stroke between January 2017 and December 2020, with a previously known history of atrial fibrillation. Demographics and previously known medical history elements were retrieved from the registry to calculate the CHA2DS2-VASc score. Five neurologists abstracted the same medical history elements from the health records. The κ statistics quantified the reliability of medical history elements and CHA2DS2-VASc score. Four hundred fifty-three patients with acute ischemic stroke and previously known atrial fibrillation were included in the cohort. In comparison with manual reabstraction, registry-based medical history elements were only moderately reliable: congestive heart failure (κ=0.53), hypertension (κ=0.42), diabetes (κ=0.80), prior stroke (κ=0.45), and vascular disease (κ=0.48). However, leveraging these variables to calculate the CHA2DS2-VASc score was more reliable (κ=0.73). Conclusions Previously known medical history elements in the GWTG-Stroke registry were only modestly reliable in this single-center study, suggesting caution should be exercised when relying on any individual history elements in registry-based research. Combining these variables to calculate the CHA2DS2-VASc score was somewhat more reliable. Multicenter data are needed before assuming generalizability.
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Fibrilación Atrial , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/epidemiología , Hospitales , Humanos , Sistema de Registros , Reproducibilidad de los Resultados , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/epidemiologíaRESUMEN
OBJECTIVE: To assess whether survival rates for in-hospital cardiac arrest (IHCA) vary across hospitals depending on whether resuscitations are typically led by an attending physician, a physician trainee, or a nonphysician. PATIENTS AND METHODS: In 2018, we conducted a survey of hospitals participating in the national Get with the Guidelines - Resuscitation registry for IHCA. Using responses from the question "Who typically leads codes at your institution?" we categorized hospitals on the basis of who typically leads their resuscitations: attending physician, physician trainee, or nonphysician. We then compared risk-adjusted hospital rates of return of spontaneous circulation, survival to discharge, and favorable neurological survival from 2015 to 2017 between these 3 hospital groups by using multivariable hierarchical regression. RESULTS: Overall, 193 hospitals completed the study survey, representing a total of 44,477 IHCAs (mean age, 65.0±15.5 years; 40.8% were women). Most hospitals had resuscitations led by physicians, with 121 (62.7%) led by an attending physician, 58 (30.0%) by a physician trainee, and 14 (7.3%) by a nonphysician. The risk-standardized rates of survival to discharge were similar across hospitals, regardless of whether resuscitations were typically led by an attending physician, a physician trainee, or a nonphysician (25.6%±4.8%, 25.9%±4.7%, and 25.7%±3.6%, respectively; P=.88). Similarly, there were no differences between the 3 groups in risk-adjusted rates of return of spontaneous circulation (71.7%±6.3%, 73%±6.3%, and 73.4%±6.4%; P=.30) and favorable neurological survival (21.6%±7.1%, 22.7%±6.1%, and 20.9%±6.5%; P=.50). CONCLUSION: In hospitals in a national IHCA registry, IHCA resuscitations were usually led by physicians. However, there was no association between a hospital's typical resuscitation team leader credentials and IHCA survival outcomes.
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INTRODUCTION: Cardiopulmonary arrests (CPAs) are common in the intensive care unit (ICU). However, effects of protocol deviations on CPA outcomes in the ICU are relatively unknown. OBJECTIVES: To establish the frequency of errors of commission (EOCs) during CPAs in the ICU and their relationship with CPA outcomes. METHODS: Retrospective analysis of data entered into institutional registry with inclusion criteria of age >18 years and non-traumatic cardiac arrest in the ICU. EOCs consist of administration of drugs or procedures performed during a CPA that are not recommended by ACLS guidelines.Primary outcome: relationship of EOCs with likelihood of return of spontaneous circulation (ROSC). Secondary outcomes: relationship of specific EOCs to ROSC and relationship of EOCs and CPA length on ROSC. RESULTS: Among 120 CPAs studied, there was a cumulative ROSC rate of 66%. Cumulatively, EOCs were associated with a decreased likelihood of ROSC (OR: 0.534, 95% CI: 0.387-0.644). Specifically, administration of sodium bicarbonate (OR: 0.233, 95% CI: 0.084-0.644) and calcium chloride (OR: 0.278, 95% CI: 0.098-0.790) were the EOCs that significantly reduced likelihood of attaining ROSC. Each 5-minute increment in CPA duration and/or increase in number of EOCs corresponded to fewer patients sustaining ROSC. CONCLUSIONS: EOCs during CPAs in the ICU were common. Among all EOCs studied, sodium bicarbonate and calcium chloride seemed to have the greatest association with decreased likelihood of attaining ROSC. Number of EOCs and CPA duration both seemed to have an inversely proportional relationship with the likelihood of attaining and sustaining ROSC. EOCs represent potentially modifiable human factors during a CPA through resources such as life safety nurses.
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Reanimación Cardiopulmonar , Paro Cardíaco , Paro Cardíaco Extrahospitalario , Adolescente , Paro Cardíaco/terapia , Humanos , Unidades de Cuidados Intensivos , Estudios RetrospectivosRESUMEN
BACKGROUND: Reliable risk scores in patients undergoing transcatheter edge-to-edge mitral valve repair (TMVR) are lacking. Heart failure is common in these patients, and risk scores derived from heart failure populations might help stratify TMVR patients. METHODS: Consecutive patients from three Heart Centers undergoing TMVR were enrolled to investigate the association of the "Get with the Guidelines Heart Failure Risk Score" (comprising the variables systolic blood pressure, urea nitrogen, blood sodium, age, heart rate, race, history of chronic obstructive lung disease) with all-cause mortality. RESULTS: Among 815 patients with available data 177 patients died during a median follow-up time of 365 days. Estimated 1-year mortality by quartiles of the score (0-37; 38-42, 43-46 and more than 46 points) was 6%, 10%, 23% and 30%, respectively (p < 0.001), with good concordance between observed and predicted mortality rates (goodness of fit test p = 0.46). Every increase of one score point was associated with a 9% increase in the hazard of mortality (95% CI 1.06-1.11%, p < 0.001). The score was associated with long-term mortality independently of left ventricular ejection fraction, NYHA class and NTproBNP, and was equally predictive in primary and secondary mitral regurgitation. CONCLUSION: The "Get with the Guidelines Heart Failure Risk Score" showed a strong association with mortality in patients undergoing TMVR with additive information beyond traditional risk factors. Given the routinely available variables included in this score, application is easy and broadly possible.
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Cateterismo Cardíaco/métodos , Procedimientos Quirúrgicos Cardíacos/métodos , Adhesión a Directriz , Insuficiencia de la Válvula Mitral/mortalidad , Volumen Sistólico/fisiología , Función Ventricular Izquierda/fisiología , Anciano , Anciano de 80 o más Años , Femenino , Alemania/epidemiología , Humanos , Masculino , Insuficiencia de la Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/cirugía , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendenciasRESUMEN
BACKGROUND: This study sought to examine the association between the albumin-bilirubin (ALBI) score and short-term and 4-year all-cause mortality in critically ill patients with heart failure (HF), and to build a simple and effective new predictive model. METHODS: The Monitoring in Intensive Care Database III was used to identify patients with HF who had been admitted to the intensive care unit (ICU) from 2001 to 2012. Correlations between ALBI scores and other commonly used risk-scoring methods and short-term and 4-year all-cause mortality were examined using the Kaplan-Meier method and Cox proportional hazards-regression models. RESULTS: The data of 3,381 ICU patients were included in the study, of whom 53.7% were male. The patients had a mean age of 70.02±12.55 years, and a short-term mortality rate of 27.7%. The ALBI score of survivors [-1.80 (-2.09 to -1.44)] was significantly lower than that of non-survivors [-1.43 (-1.80 to -0.99)] (P<0.001), and independently predicted short-term all-cause mortality and higher 4-year mortality. The area under the receiver operating characteristic curve (AUC) of the ALBI score for short-term mortality was 0.676, and that of the Get With the Guidelines-Heart Failure (GWTG-HF) score was 0.643. The new model, which combined the ALBI and GWTG-HF (the GWTG-HF-ALBI), had an AUC of 0.713. The AUC of the ALBI score for predicting 4-year all-cause mortality was 0.596, that of the GWTG-HF score was 0.638, and that of the GWTG-HF-ALBI risk score was 0.650. CONCLUSIONS: The ALBI score is useful at predicting the mortality of patients with HF requiring ICU admission. The GWTG-HF-ALBI model is simpler to use than other models that contain subjective items, such as the Glasgow Coma Score, and can be used to predict the short-term and 4-year all-cause mortality of these patients.
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Albúminas , Bilirrubina , Insuficiencia Cardíaca , Anciano , Anciano de 80 o más Años , Enfermedad Crítica , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios RetrospectivosRESUMEN
Patient-reported quality of life (PRQL) is a primary therapeutic target for patients with chronic heart failure (HF) and is associated with long-term prognosis. However, its utility in hospitalized HF (HHF) patients in the acute setting remains unclear. We aimed to assess the utility of PRQL (the Kansas City Cardiomyopathy Questionnaire [KCCQ]) in HHF patients and its association with long-term prognosis as well as with the clinical risk score (Get With The Guidelines-Heart Failure [GWTG-HF] risk score). PRQL was evaluated using the KCCQ in consecutive 114 HHF patients. Its association with the composite outcome of all-cause mortality or HF readmission within the first year after discharge was analyzed. Furthermore, its distribution by the clinical risk score (GWTG-HF) was evaluated using Pearson's correlation coefficient. The median KCCQ was 34.9, but was widely distributed (interquartile range 23.7-56.8). After adjustment for known prognostic indicators, the KCCQ was not an independent predictor of the composite outcome within the first year (group with high vs. low KCCQ scores: hazard ratio, 0.67; 95% confidence interval 0.26-1.71). There was no significant correlation between the KCCQ and the GWTG-HF risk score. In conclusion, PRQL during the acute phase of HF was significantly impaired and also varied widely, irrespective of patient characteristics or severity. PRQL assessment and risk prediction for HHF patients in the acute setting seemed to provide two distinct types of information for health care providers.
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Insuficiencia Cardíaca/terapia , Medición de Resultados Informados por el Paciente , Calidad de Vida , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Causas de Muerte , Femenino , Insuficiencia Cardíaca/mortalidad , Humanos , Japón , Estado de Ejecución de Karnofsky , Masculino , Persona de Mediana Edad , Alta del Paciente/estadística & datos numéricos , Pronóstico , Medición de RiesgoRESUMEN
BACKGROUND:: A significant percentage of terminally ill patients are discharged to hospice care following a devastating stroke. OBJECTIVE:: We sought to determine the factors associated with hospital discharge to hospice care in a large cohort of patients with stroke. METHODS:: Using the institutional Get With The Guidelines-Stroke database, all consecutive patients with acute ischemic stroke (AIS) who were alive at discharge, from January 2009 until July 2015, were analyzed. Univariate and multivariable statistical analyses were performed to determine the factors associated with discharge to hospice care. RESULTS:: Of 2446 patients with AIS, 3.4% died and were excluded of remaining 2363 patients, and 4.2% were discharged to hospice care. Univariate analysis identified patients who were discharged to hospice care to be older, caucasian, Medicare or private insurance, have atrial fibrillation, heart failure and less often had diabetes mellitus or smoked. Altered mentation at presentation and urinary tract infection were more common in patients discharged to hospice. On multivariable analysis, patients transferred to hospice care were older (odds ratio [OR]: 1.04, 95% confidence interval [CI]: 1.01-1.07; P < .001), had a high National Institute of Health Stroke Scale (NIHSS; OR: 1.15, 95% CI: 1.10-1.20; P < .001), and altered mental status at presentation (OR: 2.42, 95% CI: 1.29-4.55; P < .001). CONCLUSION:: In our study, elderly patients with high NIHSS and altered mental status were identified as factors associated with transition to hospice care following AIS. Prospective studies on the optimal timing of initiation of these consults are needed.
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Isquemia Encefálica/epidemiología , Cuidados Paliativos al Final de la Vida/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Accidente Cerebrovascular/epidemiología , Factores de Edad , Enfermedades Cardiovasculares/epidemiología , Diabetes Mellitus/epidemiología , Femenino , Humanos , Masculino , Salud Mental , Estudios Retrospectivos , Fumar/epidemiología , Factores SocioeconómicosRESUMEN
IntroductionIschemic stroke treatment is time-sensitive, and barriers to providing prehospital care encountered by Emergency Medical Services (EMS) providers have been under-studied.Hypothesis/ProblemThis study described barriers to providing prehospital care, identified predictors of these barriers, and assessed the impact of these barriers on EMS on-scene time and administration of tissue plasminogen activator (tPA) in the emergency department (ED). METHODS: A retrospective cohort study was performed using the Get With The Guidelines-Stroke (GWTG-S; American Heart Association [AHA]; Dallas, Texas USA) registry at two hospitals to identify ischemic stroke patients arriving by EMS. Variables were abstracted from prehospital and hospital medical records and merged with registry data. Barriers to care were grouped into themes. Logistic regression was used to identify predictors of barriers to care, and bi-variate tests were used to assess differences in EMS on-scene time and the proportion of patients receiving tPA between patients with and without barriers. RESULTS: Barriers to providing prehospital care were documented for 15.5% of patients: 29.6% related to access, 26.7% communication, 23.0% extrication and transportation, 20.0% refusal, and 14.1% assessment/management. Non-white and non-black race (OR: 3.69; 95% CI, 1.63-8.36) and living alone (OR: 1.53; 95% CI, 1.05-2.23) were associated with greater odds of barriers to providing care. The EMS on-scene time was ≥15 minutes for 70.4% of patients who had a barrier to care, compared with 49.0% of patients who did not (P<.001). There was no significant difference in the proportion of patients who were administered tPA between those with and without barriers to care (14.1% vs 19.2%; P=.159). CONCLUSIONS: Barriers to providing prehospital care were documented for a sizable proportion of ischemic stroke patients, with the majority related to patient access and communication, and occurred more frequently among non-white and non-black patients and those living alone. Although EMS on-scene time was longer for patients with barriers to care, the proportion of patients receiving tPA in the ED did not differ. LiT, CushmanJT, ShahMN, KellyAG, RichDQ, JonesCMC. Barriers to providing prehospital care to ischemic stroke patients: predictors and impact on care. Prehosp Disaster Med. 2018;33(5):501-507.
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Isquemia Encefálica/terapia , Servicios Médicos de Urgencia , Adhesión a Directriz , Accesibilidad a los Servicios de Salud , Accidente Cerebrovascular/terapia , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/epidemiología , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , New York/epidemiología , Guías de Práctica Clínica como Asunto , Estudios Retrospectivos , Accidente Cerebrovascular/epidemiologíaRESUMEN
BACKGROUND: Acute heart failure (AHF) is a life-threatening disease requiring urgent treatment, including a recommendation for immediate initiation of loop diuretics. OBJECTIVES: The authors prospectively evaluated the association between time-to-diuretic treatment and clinical outcome. METHODS: REALITY-AHF (Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure) was a prospective, multicenter, observational cohort study that primarily aimed to assess the association between time to loop diuretic treatment and clinical outcome in patients with AHF admitted through the emergency department (ED). Door-to-furosemide (D2F) time was defined as the time from patient arrival at the ED to the first intravenous furosemide injection. Patients with a D2F time <60 min were pre-defined as the early treatment group. Primary outcome was all-cause in-hospital mortality. RESULTS: Among 1,291 AHF patients treated with intravenous furosemide within 24 h of ED arrival, the median D2F time was 90 min (IQR: 36 to 186 min), and 481 patients (37.3%) were categorized as the early treatment group. These patients were more likely to arrive by ambulance and had more signs of congestion compared with the nonearly treatment group. In-hospital mortality was significantly lower in the early treatment group (2.3% vs. 6.0% in the nonearly treatment group; p = 0.002). In multivariate analysis, earlier treatment remained significantly associated with lower in-hospital mortality (odds ratio: 0.39; 95% confidence interval: 0.20 to 0.76; p = 0.006). CONCLUSIONS: In this prospective multicenter, observational cohort study of patients presenting at the ED for AHF, early treatment with intravenous loop diuretics was associated with lower in-hospital mortality. (Registry focused on very early presentation and treatment in emergency department of acute heart failure syndrome; UMIN000014105).
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Furosemida/administración & dosificación , Insuficiencia Cardíaca/tratamiento farmacológico , Pacientes Internos , Sistema de Registros , Tiempo de Tratamiento , Enfermedad Aguda , Anciano , Diuréticos/administración & dosificación , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/mortalidad , Mortalidad Hospitalaria/tendencias , Humanos , Inyecciones Intravenosas , Masculino , Oportunidad Relativa , Estudios Prospectivos , Tasa de Supervivencia/tendencias , Factores de TiempoRESUMEN
BACKGROUND AND PURPOSE: Hospitalist directed care is associated with improved outcomes in several medical conditions. The hospitalist effect has not been studied in acute ischemic stroke (AIS) patients. We compare length of stay (LOS), outcome, and adherence to "Get with the Guidelines" (GWTG) stroke quality measures among AIS patients admitted under a hospitalist with three other specialties (internist, family practice, or specialist). METHODS: We collected demographics, risk factors and discharge outcomes (modified Rankin Scale (mRS)) for consecutive AIS patients over 4-year period (2010-2014). We categorized all stroke admissions according to admitting physicians. We compared rates of adherence with all of the GWTG Stroke inpatient quality measures between the four groups. RESULTS: A total of 1584 patients [mean age ( ± SD) 68.6 ± 13.7 years; 55.6% men] were admitted with AIS. There was no statistically significant difference in LOS between the four groups (p=0.4). There was significant difference in the GWTG inpatient quality measures with the hospitalist group having lowest rates of any nonadherence observed in 5% of admissions (p=0.03), and the internists had the highest rate of nonadherence observed in 16% of admissions (p=0.01). The most common deficiency was not prescribing statin at discharge (56% of total fallouts). There was no difference in rates of poor outcomes on discharge (mRS 3-6) (p=0.2). CONCLUSIONS: There was a significantly higher rate of adherence to GWTG inpatient stroke measures when AIS patients were admitted under the care of a hospitalist. Prospective studies are required to evaluate if higher rates of adherence lead to better long term outcomes.
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BACKGROUND AND PURPOSE: Sex-specific disparities in stroke care including thrombolytic therapy and early hospital admission are reported. In a large registry of Florida and Puerto Rico hospitals participating in the Get With The Guidelines-Stroke program, we sought to determine sex-specific differences in ischemic stroke performance metrics and overall thrombolytic treatment. METHODS: Around 51 317 (49% women) patients were included from 73 sites from 2010 to 2014. Multivariable logistic regression with generalized estimating equations evaluated sex-specific differences in the prespecified Get With The Guidelines-Stroke metrics for defect-free care in ischemic stroke, adjusting for age, race-ethnicity, insurance status, hospital characteristics, individual risk factors, and the presenting stroke severity. RESULTS: As compared with men, women were older (73±15 versus 69±14 years; P<0.0001), more hypertensive (67% versus 63%, P<0.0001), and had more atrial fibrillation (19% versus 16%; P<0.0001). Defect-free care was slightly lower in women than in men (odds ratio, 0.96; 95% confidence interval, 0.93-1.00). Temporal trends in defect-free care improved substantially and similarly for men and women, with a 29% absolute improvement in women (P<0.0001) and 28% in men (P<0.0001), with P value of 0.13 for time-by-sex interaction. Women were less likely to receive thrombolysis (odds ratio, 0.92; 95% confidence interval, 0.86-0.99; P=0.02) and less likely to have a door-to-needle time <1 hour (odds ratio, 0.83; 95% confidence interval, 0.71-0.97; P=0.02) as compared with men. CONCLUSIONS: Women received comparable stroke care to men in this registry as measured by prespecified Get With The Guidelines metrics. However, women less likely received thrombolysis and had door-to-needle time <1 hour, an observation that calls for the implementation of interventions to reduce sex disparity in these measures.
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Isquemia Encefálica/tratamiento farmacológico , Disparidades en Atención de Salud , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica , Factores de Edad , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico , Femenino , Fibrinolíticos/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Sistema de Registros , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores Sexuales , Accidente Cerebrovascular/diagnóstico , Factores de Tiempo , Activador de Tejido Plasminógeno/uso terapéuticoRESUMEN
OBJECTIVES: The purpose of this study is to develop a method for risk-standardizing hospital survival after cardiac arrest. BACKGROUND: A foundation with which hospitals can improve quality is to be able to benchmark their risk-adjusted performance against other hospitals, something that cannot currently be done for survival after in-hospital cardiac arrest. METHODS: Within the Get With The Guidelines (GWTG)-Resuscitation registry, we identified 48,841 patients admitted between 2007 and 2010 with an in-hospital cardiac arrest. Using hierarchical logistic regression, we derived and validated a model for survival to hospital discharge and calculated risk-standardized survival rates (RSSRs) for 272 hospitals with at least 10 cardiac arrest cases. RESULTS: The survival rate was 21.0% and 21.2% for the derivation and validation cohorts, respectively. The model had good discrimination (C-statistic 0.74) and excellent calibration. Eighteen variables were associated with survival to discharge, and a parsimonious model contained 9 variables with minimal change in model discrimination. Before risk adjustment, the median hospital survival rate was 20% (interquartile range: 14% to 26%), with a wide range (0% to 85%). After adjustment, the distribution of RSSRs was substantially narrower: median of 21% (interquartile range: 19% to 23%; range 11% to 35%). More than half (143 [52.6%]) of hospitals had at least a 10% positive or negative absolute change in percentile rank after risk standardization, and 50 (23.2%) had a ≥20% absolute change in percentile rank. CONCLUSIONS: We have derived and validated a model to risk-standardize hospital rates of survival for in-hospital cardiac arrest. Use of this model can support efforts to compare hospitals in resuscitation outcomes as a foundation for quality assessment and improvement.
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Reanimación Cardiopulmonar/mortalidad , Paro Cardíaco/mortalidad , Paro Cardíaco/terapia , Mortalidad Hospitalaria/tendencias , Gestión de Riesgos/normas , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Reanimación Cardiopulmonar/métodos , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Pronóstico , Calidad de la Atención de Salud , Sistema de Registros , Reproducibilidad de los Resultados , Estudios Retrospectivos , Medición de Riesgo , Factores Sexuales , Análisis de Supervivencia , Estados UnidosRESUMEN
BACKGROUND: Prior studies found that only about half of stroke patients arrived at hospitals via emergency medical services (EMSs), yet since then, there have been efforts to increase public awareness that time is brain. Using contemporary Get With the Guidelines-Stroke data, we assessed nationwide EMS use by stroke patients. METHODS AND RESULTS: We analyzed data from 204 591 patients with ischemic and hemorrhagic stroke admitted to 1563 Get With the Guidelines-Stroke participating hospitals with data on National Institute of Health Stroke Score and insurance status. Hospital arrival by EMSs was observed in 63.7% of patients. Older patients, those with Medicaid and Medicare insurance, and those with severe stroke were more likely to activate EMSs. In contrast, minority race and ethnicity and living in rural communities were associated with decreased odds of EMS use. EMS transport was independently associated with earlier arrival (onset-to-door time, ≤3 hours; adjusted odds ratio, 2.00; 95% confidence interval, 1.93-2.08), prompter evaluation (more patients with door-to-imaging time, ≤25 minutes; odds ratio, 1.89; 95% confidence interval, 1.78-2.00), more rapid treatment (more patients with door-to-needle time, ≤60 minutes; odds ratio, 1.44; 95% confidence interval, 1.28-1.63), and more eligible patients to be treated with tissue-type plasminogen activator if onset is ≤2 hours (67% versus 44%; odds ratio, 1.47; 95% confidence interval, 1.33-1.64). CONCLUSIONS: Although EMS use is independently associated with more rapid evaluation and treatment of stroke, more than one third of stroke patients fail to use EMSs. Interventions aimed at increasing EMS activation should target populations at risk, particularly younger patients and those of minority race and ethnicity.
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Servicios Médicos de Urgencia/tendencias , Evaluación de Procesos y Resultados en Atención de Salud/tendencias , Aceptación de la Atención de Salud , Accidente Cerebrovascular/terapia , Tiempo de Tratamiento/tendencias , Factores de Edad , Anciano , Anciano de 80 o más Años , Distribución de Chi-Cuadrado , Servicios Médicos de Urgencia/estadística & datos numéricos , Servicio de Urgencia en Hospital/tendencias , Etnicidad , Femenino , Adhesión a Directriz/tendencias , Conocimientos, Actitudes y Práctica en Salud , Humanos , Masculino , Persona de Mediana Edad , Grupos Minoritarios , Oportunidad Relativa , Educación del Paciente como Asunto/tendencias , Guías de Práctica Clínica como Asunto , Sistema de Registros , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/etnología , Factores de Tiempo , Transporte de Pacientes/tendencias , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Stroke is the fourth leading killer in the US, the first in Brazil and a leading cause of adult long-term disability in both countries. In spite of widespread recommendation, clinical practice guidelines have had limited effect on changing physician behavior. Recognizing that both knowledge and acceptance of guidelines do not necessarily imply guideline adherence, the American Heart Association/American Stroke Association (AHA/ASA) developed a national stroke quality improvement program, the 'Get With The Guidelines (GWTG) stroke'. Even though GWTG has produced remarkable results in the US, other countries have not adopted the program. METHODS: We compared the stroke treatment quality indicators from a private Brazilian tertiary hospital to those published by the GWTG stroke program. Seven predefined performance measures selected by the GWTG stroke program as targets for stroke quality improvement were evaluated: (1) tissue plasminogen activator use in patients who arrived <2 h from symptom onset; (2) antithrombotic medication use within 48 h of admission; (3) deep vein thrombosis prophylaxis within 48 h of admission for nonambulatory patients; (4) discharge use of antithrombotics; (5) discharge use of anticoagulation for atrial fibrillation; (6) dosing of LDL and treatment for LDL >100 mg/dl in patients meeting the National Cholesterol Education Program Adult Treatment Panel (NCEP) III guidelines, and (7) counseling for smoking cessation. RESULTS: A total of 343 consecutive patients with acute ischemic stroke (70.8%) or transient ischemic attack (29.2%) were evaluated from August 2008 to December 2010. Antithrombotic medication within 48 h was used in 98.5% of the eligible patients and deep vein thrombosis prophylaxis in 100%. A total of 123 patients arrived within 2 h from symptoms onset, 23 were eligible for intravenous thrombolysis and 16 were treated (69.5%). All eligible patients were discharged using antithrombotic medication, and 86.9% of the eligible patients who had atrial fibrillation received anticoagulation. Only 56.1% of the eligible patients were treated according to the NCEP III guidelines. Counseling for smoking cessation was done in 63.6% of the eligible patients. CONCLUSIONS: Our study is the first in Brazil and the second outside the US to analyze compliance with the GWTG recommendations. Close attention to a better implementation of these measures may produce an improvement in such results similar to what happened after the full implementation of the program in the US. Whether or not a US disease-based registry such as GWTG can be adopted with success beyond the US is still a matter of debate.