Emi Watanabe

Outcomes after ischemic stroke for hospitals with and without Joint Commission–certified primary stroke centers

Background: The Joint Commission (JC) began certifying primary stroke centers (PSCs) in the United States in 2003. We assessed whether 30-day risk-standardized mortality (RSMR) and readmission (RSRR) rates differed between hospitals with and without JC-certified PSCs in 2006. Methods: The study cohort included all fee-for-service Medicare beneficiaries ≥65 years old discharged with a primary diagnosis of ischemic stroke (International Classification of Diseases, ninth revision, Clinical Modification 433, 434, 436) in 2006. Hierarchical linear regression models calculated hospital-level RSMRs and RSRRs, adjusting for patient demographics, comorbid conditions, and hospital referral region. Hospitals were categorized as being higher than, no different from, or lower than the national average. Results: There were 310,381 ischemic stroke discharges from 315 JC-certified PSC and 4,231 noncertified hospitals. Mean overall 30-day RSMR and RSRR were 10.9% ± 1.7% and 12.5% ± 1.4%, respectively. The RSMRs of hospitals with JC-certified PSCs were lower than in noncertified hospitals (10.7% ± 1.7% vs 11.0% ± 1.7%), but the RSRRs were comparable (12.5% ± 1.3% vs 12.4% ± 1.7%). Almost half of JC-certified PSC hospitals had RSMRs lower than the national average compared with 19% of noncertified hospitals, but 13% of JC-certified PSC hospitals had lower RSRRs vs 15% of noncertified hospitals. Conclusions: Hospitals with JC-certified PSCs had lower RSMRs compared with noncertified hospitals in 2006; however, differences were small. Readmission rates were similar between the 2 groups. PSC certification generally identified better-performing hospitals for mortality outcomes, but some hospitals with certified PSCs may have high RSMRs and RSRRs whereas some hospitals without PSCs have low rates. Unmeasured factors may contribute to this heterogeneity.

Predictors of Hospital Readmission After Stroke: A Systematic Review

Background and Purpose— Risk-standardized hospital readmission rates are used as publicly reported measures reflecting quality of care. Valid risk-standardized models adjust for differences in patient-level factors across hospitals. We conducted a systematic review of peer-reviewed literature to identify models that compare hospital-level poststroke readmission rates, evaluate patient-level risk scores predicting readmission, or describe patient and process-of-care predictors of readmission after stroke. Methods— Relevant studies in English published from January 1989 to July 2010 were identified using MEDLINE, PubMed, Scopus, PsycINFO, and all Ovid Evidence-Based Medicine Reviews. Authors of eligible publications reported readmission within 1 year after stroke hospitalization and identified ≥1 predictors of readmission in risk-adjusted statistical models. Publications were excluded if they lacked primary data or quantitative outcomes, reported only composite outcomes, or had <100 patients. Results— Of 374 identified publications, 16 met the inclusion criteria for this review. No model was specifically designed to compare risk-adjusted readmission rates at the hospital level or calculate scores predicting a patients risk of readmission. The studies providing multivariable models of patient-level and/or process-of-care factors associated with readmission varied in stroke definitions, data sources, outcomes (all-cause and/or stroke-related readmission), durations of follow-up, and model covariates. Few characteristics were consistently associated with readmission. Conclusions— This review identified no risk-standardized models for comparing hospital readmission performance or predicting readmission risk after stroke. Patient-level and system-level factors associated with readmission were inconsistent across studies. The current literature provides little guidance for the development of risk-standardized models suitable for the public reporting of hospital-level stroke readmission performance.

Stroke Patient Outcomes in US Hospitals Before the Start of the Joint Commission Primary Stroke Center Certification Program

Background and Purpose— The Joint Commission (JC) began certifying Primary Stroke Centers in November 2003. Cross-sectional studies assessing the impact of certification could be biased if these centers had better outcomes before the start of the program. We determined whether hospitals certified within the first years of the JC program had better outcomes than noncertified hospitals before the start of the certification program. Methods— The study sample included Medicare fee-for-service beneficiaries ≥65 years of age discharged with ischemic stroke in 2002 from 5070 hospitals, 317 of which were JC-certified by June 2007. Hierarchical logistic regression and Cox proportional hazards models were used to compare in-hospital mortality, 30-day mortality, and 30-day readmission for patients treated at future JC-certified versus noncertified hospitals. Results— Among 366 551 patients, 18% (66 300) were treated at hospitals with centers that were JC-certified within the first few years of the program. These patients were younger, more likely to be white and male, and had fewer comorbidities and hospitalizations within the prior year. Unadjusted in-hospital mortality (4.7% versus 5.5%), 30-day mortality (9.8% versus 11.3%), and readmissions (13.8% versus 14.6%) were lower in the future JC-certified hospitals (all P<0.001). These differences remained after risk adjustment (in-hospital mortality: OR, 0.93; 95% CI, 0.90 to 0.96; 30-day mortality: OR, 0.92; 95% CI, 0.87 to 0.96; 30-day readmission: hazard ratio, 0.97; 95% CI, 0.95 to 0.99). Conclusions— JC Primary Stroke Center-certified hospitals had better outcomes than noncertified hospitals even before the program began. Cross-sectional studies assessing the effects of stroke center certification need to account for these pre-existing differences.

Hospital Arrival Time and Intravenous t-PA Use in US Academic Medical Centers, 2001–2004

Background and Purpose— Prompt care-seeking behavior is a focus of US national public stroke educational campaigns. We determined whether the time between symptom onset and hospital arrival and the receipt of intravenous tissue-type plasminogen activator (IV t-PA) changed for ischemic stroke patients evaluated at US academic centers between 2001 and 2004. Methods— Medical records were abstracted for consecutive ischemic stroke patients admitted from the Emergency Department within 48 hours of symptom onset at 35 academic medical centers participating in the University HealthSystem Consortium Ischemic Stroke Benchmarking Project between January 1, 2001 and March 31, 2001, and 32 centers between January 1, 2004 and June 30, 2004. Demographic and clinical characteristics of patients who presented within and after 2 hours of symptom onset were compared. Multivariate logistic regression was used to compare time to arrival by year and to identify patient characteristics associated with earlier hospital arrival. Results— The study included 428 patients from 2001 and 481 from 2004. Although there was no difference in the percentage of patients who arrived within 2 hours between the 2 periods (37% in 2001 vs 38% in 2004, P=0.63), the percentage of these patients treated with IV t-PA increased (14.0% to 37.5%, P<0.0001). In risk-adjusted analysis, black patients had a lower odds of arriving within 2 hours (odds ratio=0.55; 95% CI, 0.39 to 0.78), whereas those with severe strokes were more likely to arrive promptly (odds ratio=2.17; 95% CI, 1.49 to 3.15). Conclusions— There was no change in the proportion of stroke patients arriving at hospitals within 2 hours of symptom onset between 2001 and 2004; however, the rate of IV t-PA use increased, indicating system-level improvements of in-hospital care.

Symptom Recognition and Healthcare Experiences of Young Women With Acute Myocardial Infarction

Background—Prompt recognition of acute myocardial infarction symptoms and timely care-seeking behavior are critical to optimize acute medical therapies. Relatively little is known about the symptom presentation and care-seeking experiences of women aged ⩽55 years with acute myocardial infarction, a group shown to have increased mortality risk as compared with similarly aged men. Understanding symptom recognition and experiences engaging the healthcare system may provide opportunities to reduce delays and improve acute care for this population. Methods and Results—We conducted a qualitative study using in-depth interviews with 30 women (aged 30–55 years) hospitalized with acute myocardial infarction to explore their experiences with prodromal symptoms and their decision-making process to seek medical care. Five themes characterized their experiences: (1) prodromal symptoms varied substantially in both nature and duration; (2) they inaccurately assessed personal risk of heart disease and commonly attributed symptoms to noncardiac causes; (3) competing and conflicting priorities influenced decisions about seeking acute care; (4) the healthcare system was not consistently responsive to them, resulting in delays in workup and diagnosis; and (5) they did not routinely access primary care, including preventive care for heart disease. Conclusions—Participants did not accurately assess their cardiovascular risk, reported poor preventive health behaviors, and delayed seeking care for symptoms, suggesting that differences in both prevention and acute care may be contributing to young women’s elevated acute myocardial infarction mortality relative to men. Identifying factors that promote better cardiovascular knowledge, improved preventive health care, and prompt care-seeking behaviors represent important target for this population.

Utilization of Intravenous Tissue Plasminogen Activator for Ischemic Stroke: Are There Sex Differences?

Background: We evaluated whether there were sex-related differences in the administration of intravenous tissue plasminogen activator (IV-tPA) to patients with acute ischemic stroke admitted to US academic medical centers. Methods: Medical records were abstracted for consecutive ischemic stroke patients admitted to 32 academic medical centers from January through June, 2004, as part of the University HealthSystem Consortium Ischemic Stroke Benchmarking Project. Multivariate logistic models were used to test for sex-related differences in the receipt of IV-tPA with adjustment for demographic and clinical factors. Results: The study included 1,234 patients (49% women; mean age 66.6 years; 56% white). IV-tPA was given to 7% (6.5% of women versus 7.5% of men, p = 0.49). Women and men were equally likely to receive IV-tPA in risk-adjusted analyses (OR 1.02, 95% CI 0.64–1.64). Approximately 77% of women and men who did not receive IV-tPA did not meet the 3-hour treatment window or their time of onset was unknown. Conclusions: Women admitted to academic hospitals receive IV-tPA as often as men; however, a substantial percentage of both women and men are not arriving within the 3-hour time window required for diagnostic assessment and administration of intravenous thrombolytic therapy. Additional efforts are needed to improve the rapid identification, evaluation and treatment of stroke patients.

Use of Antithrombotic Medications Among Elderly Ischemic Stroke Patients

Background— The use of antithrombotic medications after ischemic stroke is recommended for deep vein thrombosis prophylaxis and secondary stroke prevention. We assessed the rate of receipt of these therapies among eligible ischemic stroke patients age ≥65 years and determined the effects of age and other patient characteristics on treatment. Methods and Results— The analysis included Medicare fee-for-service beneficiaries discharged with ischemic stroke (ICD 433.x1, 434.x1, 436) randomly selected for inclusion in the Medicare Health Care Quality Improvement Programs National Stroke Project 1998 to 1999, 2000 to 2001. Patients discharged from nonacute facilities, transferred, or terminally ill were excluded. Receipt of in-hospital pharmacological deep vein thrombosis prophylaxis, antiplatelet medication, anticoagulants for atrial fibrillation, and antithrombotic medications at discharge were assessed in eligible patients, stratified by age (65 to 74, 75 to 84, and 85+ years). Descriptive models identified characteristics associated with treatment. Among 31 554 patients, 14.9% of those eligible received pharmacological deep vein thrombosis prophylaxis, 83.9% antiplatelet drugs, 82.8% anticoagulants for atrial fibrillation, and 74.2% were discharged on an antithrombotic medication. Rates of treatment decreased with age and were lowest for patients ages 85 years or older. Admission from a skilled nursing facility and functional dependence were associated with lower treatment rates. Conclusions— There was substantial underutilization of antithrombotic therapies among elderly ischemic stroke patients, particularly among the very elderly, those admitted from skilled nursing facilities, and patients with functional dependence. The reasons for low use of antithrombotic therapies, including the apparent underutilization of deep vein thrombosis prophylaxis in otherwise eligible patients, require further investigation.

Postendarterectomy mortality in octogenarians and nonagenarians in the USA from 1993 to 1999.

Background: Relatively little is known about trends in the utilization or outcomes of carotid endarterectomy (CEA) in the very elderly. We determined trends in the rates of CEA and perioperative (in-hospital and 30-day) and long-term (1-, 2-, 3-, 4- and 5-year) mortality in a US national sample of patients ≧80 years of age. Methods: All fee-for-service Medicare patients (80–89 and ≧90 years of age) who had a CEA [ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification): 38.12] from 1993 to 1999 were identified using the Centers for Medicare and Medicaid Services Inpatient Standard Analytic Files. Demographic characteristics and comorbid conditions were determined using ICD-9-CM diagnostic codes within the year prior to the index hospitalization for CEA. Results: A total of 140,376 CEA were performed in patients aged 80–89 years and 6,446 in those aged ≧90 years during this 7-year period. The annual number of operations increased from 13,115 in 1993 to 21,582 in 1999 for octogenarians, and from 481 in 1993 to 1,257 in 1999 for nonagenarians. Perioperative mortality was 2.2% in octogenarians and 3.3% in nonagenarians. Long-term mortality increased by approximately 10% per year after the operation, and was 43% in octogenarians and 56% in nonagenarians at 5 years. Perioperative mortality rates remained relatively stable over the 7-year period for both age groups although comorbidities increased. Conclusions: The number of CEA performed in the very elderly in the USA increased from 1993 to 1999. Perioperative mortality rates were high compared with trial results, while long-term survivorship was comparable to that of similarly-aged peers in the USA.

Elderly Women Have Lower Rates of Stroke, Cardiovascular Events, and Mortality After Hospitalization for Transient Ischemic Attack

Background and Purpose— Patients with transient ischemic attack (TIA) are at increased risk for stroke, cardiovascular events, and death, yet little is known about whether these risks differ for men and women. We determined whether there are sex-based differences in these outcomes 30 days and 1 year after TIA using a national sample of elderly patients. Methods— Rates of 30-day and 1-year hospitalization for TIA (International Classification of Diseases, 9th Revision Code 435), stroke (International Classification of Diseases, 9th Revision Codes 433, 434, and 436), coronary artery disease (International Classification of Diseases, 9th Revision Codes 410 to 414), all-cause readmission, and mortality were determined for fee-for-service Medicare patients ≥65 years of age discharged with a TIA in 2002. Cox proportional hazards models and random-effects logistic models compared outcomes with risk adjustment for demographics, medical history, comorbidities, and prior hospitalizations. Results— The study included 122 063 TIA hospitalizations (mean age, 79.0±7.6 years; 62% women; 86% white). Men were younger but had higher rates of cardiac comorbidities than women. Women had lower unadjusted rates of stroke, coronary artery disease, and mortality at 30 days and 1 year after TIA admission. These relationships persisted in risk-adjusted analyses at 30 days for stroke (hazard ratio, 0.70; 95% CI, 0.64 to 0.77), coronary artery disease (hazard ratio, 0.86; 0.74 to 1.00), and mortality (odds ratio, 0.74; 0.68 to 0.82) as well as at 1 year for stroke (hazard ratio, 0.85; 0.81 to 0.89), coronary artery disease (hazard ratio, 0.81; 0.77 to 0.86), and mortality (odds ratio, 0.78; 0.75 to 0.81). Conclusion— These data suggest that women have a better prognosis than men within the first year after hospital discharge for a TIA. Additional research is needed to identify factors that may explain these sex-related differences in outcomes.

Diagnostic Evaluation for Patients with Ischemic Stroke: Are There Sex Differences?

Background and Purpose: Differences in the management of women and men with acute coronary symptoms are well documented, but relatively little is known about practices for patients with ischemic stroke. We sought to determine whether there are sex-associated differences in the utilization of diagnostic tests for ischemic stroke patients treated at academic hospitals in the United States. Methods: Medical records were abstracted for consecutive ischemic stroke patients admitted to 32 US academic medical centers from January through June, 2004, as part of the University HealthSystem Consortium Ischemic Stroke Benchmarking Project. We compared the utilization rates of diagnostic tests including neuroimaging (CT or MRI), electrocardiogram (ECG), ultrasound of the carotid arteries, and echocardiography (transthoracic or transesophageal) for women and men. Multivariate logistic regression was used to test for sex differences with adjustment for potential confounders. Results: The study included 1,256 ischemic stroke patients (611 women; 645 men; mean age 66.6 ± 14.6 years; 56% white). There were no differences between women and men in the use of neuroimaging (odds ratio, OR = 1.37; 95% confidence interval, CI = 0.58–3.24), ECG (OR = 1.00, 95% CI = 0.70–1.44), carotid artery ultrasound (OR = 0.93, 95% CI = 0.72–1.21) or echocardiography (OR = 0.70, 95% CI = 0.70–1.22). The results were similar after covariate adjustment. Conclusions: Women and men admitted to US academic hospitals receive comparable diagnostic evaluations, even after adjusting for sociodemographic and clinical factors.