Kori Sauser

Hospital Variation in Thrombolysis Times Among Patients With Acute Ischemic Stroke: The Contributions of Door-to-Imaging Time and Imaging-to-Needle Time

IMPORTANCE Given the limited time window available for treatment with tissue plasminogen activator (tPA) in patients with acute ischemic stroke, guidelines recommend door-to-imaging time (DIT) within 25 minutes of hospital arrival and door-to-needle (DTN) time within 60 minutes for patients with acute ischemic stroke. Despite improvements in DITs, DTN times for tPA treatment in patients with acute ischemic stroke remain suboptimal. OBJECTIVES To examine the contributions of DIT and imaging-to-needle (ITN) time to delays in timely delivery of tPA to patients with acute ischemic stroke and to assess between-hospital variation in DTN times. DESIGN, SETTING, AND PARTICIPANTS A cohort analysis of 1193 patients having acute ischemic stroke treated with intravenous tPA between January 2009 and December 2012. Multilevel linear regression models included random effects for 25 Michigan hospitals participating in the Paul Coverdell National Acute Stroke Registry. MAIN OUTCOMES AND MEASURES The primary outcome was a continuous measure of DTN time, in minutes, from emergency department arrival to thrombolytic delivery. RESULTS The mean age was 68.1 years, the median National Institutes of Health Stroke Scale score was 11.0 (interquartile range, 6-17), 51.4% were female, and 37.5% were of nonwhite race/ethnicity.The mean (SD) DTN time was 82.9 (35.4) minutes, the mean (SD) DIT was 22.8 (15.9) minutes, and the mean (SD) ITN time was 60.1 (32.3) minutes. Most patients (68.4%) had DIT within 25 minutes, while 28.7% had DTN time within 60 minutes. Hospital variation accounted for 12.7% of variability in DTN times. Neither annual stroke volume nor primary stroke center designation was a significant predictor of shorter DTN time. Patient factors (age, sex, race/ethnicity, arrival mode, onset-to-arrival time, and stroke severity) explained 15.4% of the between-hospital variation in DTN times. After adjustment for patient-level factors, DIT explained 10.8% of the variation in hospital risk-adjusted DTN times, while ITN time explained 64.6%. CONCLUSIONS AND RELEVANCE Compared with DIT, ITN time is a much greater source of variability in hospital DTN times and is a more common contributor to delays in timely tPA therapy for acute ischemic stroke. More attention is needed to determine systems changes that can decrease ITN time for patients with acute ischemic stroke.

Emergency Department Hospitalization Volume and Mortality in the United States

STUDY OBJECTIVE Although numerous studies have demonstrated a relationship between higher volume and improved outcomes in the delivery of health services, it has not been extensively explored in the emergency department (ED) setting. Therefore, we seek to examine the association between ED hospitalization volume and mortality for common high-risk conditions. METHODS Using data from the Nationwide Inpatient Sample, a national sample of hospital discharges, we evaluated mortality overall and for 8 different diagnoses between 2005 and 2009 (total admissions 17.55 million). These conditions were chosen because they are frequent (in the top 25 of all ED hospitalizations) and high risk (> 3% observed mortality). EDs were excluded from analysis if they did not have at least 1,000 total annual admissions and 30 disease-specific cases. EDs were then placed into quintiles based on hospitalized volume. Regression techniques were used to describe the relationship between volume (number of hospitalized ED patients per year) and both subsequent early inpatient mortality (within 2 days of admission) and overall mortality, adjusted for patient and hospital characteristics. RESULTS Mortality decreased as volume increased overall and for all diagnoses, but the relative importance of volume varied, depending on the condition. Absolute differences in adjusted mortality rates between very high-volume EDs and very low-volume EDs ranged from -5.6% for sepsis (95% confidence interval [CI] -6.5% to -4.7%) to -0.2% for pneumonia (95% CI -0.6% to 0.1%). Overall, this difference was -0.4% (95% CI -0.6% to -0.3%). A similar pattern was observed when early hospital deaths were evaluated. CONCLUSION Patients have a lower likelihood of inhospital death if admitted through high-volume EDs.

Quality of life assessment for acute heart failure patients from emergency department presentation through 30 days after discharge: a pilot study with the Kansas City Cardiomyopathy Questionnaire.

BACKGROUND There are no well validated patient-reported disease status instruments for acute heart failure (HF). We assessed the feasibility of using the Kansas City Cardiomyopathy Questionnaire (KCCQ) during acute heart failure hospitalization, and the association of acute changes with 30-day readmission. METHODS AND RESULTS A convenience sample of acute HF patients were administered the KCCQ on presentation, discharge, and 30 days after discharge. We examined mean differences in KCCQ scores over time, and we stratified by readmission status to examine differences in hospital-based changes with the use of t test and logistic regression. Among 52 patients (mean age 63 ± 35 years, 56.9% male, 46.2% white), discharge and 30-day assessments were each completed by 90%. Scores were lowest at presentation, improved during hospitalization, and were highest at 30 days. The mean change was +11.9 ± 97.0 (P = .007) between presentation and discharge and +19.8 ± 87.8 (P < .001) between discharge and 30 days. Within the 30-day follow-up, 10 patients were readmitted, and there were no significant differences in score changes during hospitalization between patients with and without readmission (readmitted patients: +4.8 ± 81.5 vs no readmission +16.2 ± 27.4; P = .32). CONCLUSIONS In this pilot study, the KCCQ is feasible to use during acute HF hospitalizations and demonstrates sensitivity to acute changes, but score changes during hospitalization did not predict 30-day readmission.

Time to Brain Imaging in Acute Stroke Is Improving Secondary Analysis of the INSTINCT Trial

Background and Purpose— Patients with acute ischemic stroke benefit from rapid evaluation and treatment, and timely brain imaging is a necessary component. We determined the effect of a targeted behavioral intervention on door-to-imaging time (DIT) among patients with ischemic stroke treated with tissue-type plasminogen activator. Second, we examined the variation in DIT accounted for by patient-level and hospital-level factors. Methods— The Increasing Stroke Treatment through Interventional behavioral Change Tactics (INSTINCT) trial was a cluster-randomized, controlled trial involving 24 Michigan hospitals. The intervention aimed to increase tissue-type plasminogen activator utilization. Detailed chart abstractions collected data for 557 patients with ischemic stroke. We used a series of hierarchical linear mixed-effects models to evaluate the effect of the intervention on DIT (difference-in-differences analysis) and used patient-level and hospital-level explanatory variables to decompose variation in DIT. Results— DIT improved over time, without a difference between intervention and control hospitals (intervention: 23.7–19.3 minutes, control: 28.9–19.2 minutes; P=0.56). Adjusted DIT was faster in patients who arrived by ambulance (7.2 minutes; 95% confidence interval, 4.1–10.2), had severe strokes (1.0 minute per +5-point National Institutes of Health Stroke Scale; 95% confidence interval, 0.1–2.0), and presented in the postintervention period (4.9 minutes; 95% confidence interval, 2.3–7.4). After accounting for these factors, 13.8% of variation in DIT was attributable to hospital. Neither hospital stroke volume nor stroke center status was associated with DIT. Conclusions— Performance on DIT improved similarly in intervention and control hospitals, suggesting that nonintervention factors explain the improvement. Hospital-level factors explain a modest proportion of variation in DIT, but further research is needed to identify the hospital-level factors responsible.

A review of the clinical evidence related to early treatment of elevated LDL for cardiovascular primary prevention

Background The American College of Cardiology/American Heart Association updated cholesterol treatment guidelines dropped treatment recommendations based on elevated low-density lipoprotein (LDL) levels. Yet some experts cite the benefit of early statins in patients with elevated LDL for preventing atherosclerosis. We sought clinical evidence for this early LDL treatment hypothesis. Methods and results A review of the clinical evidence examining the relationship between LDL reduction and outcomes (excluding LDL >190). We found three arguments proposed in the literature citing clinical evidence supporting the early LDL treatment hypothesis: (1), lower risk patients get relatively more primary prevention benefit from statins than higher risk patients, (2), statins demonstrate a legacy effect with prolonged risk reduction even after stopping treatment, and (3), genetic studies illustrate the benefit of lifelong LDL reduction for lowering CV risk. A review of the primary evidence found little clinical evidence supporting the first two arguments, but strong grade B+ evidence for the third. However, we found no evidence for or against whether intervening before 10-year risk exceeds 7.5-12.5% would result in substantial incremental net clinical benefit. If early intervention is practiced, evidence to date suggests that overall CV risk should be the primary indication. Conclusions We found consistent grade B+ evidence that the effectiveness of LDL reduction on risk reduction will increase over time, however, we found no clinical evidence for or against whether starting before 10-year CV risk is 7.5–12.5% provides substantive additional net patient benefit, and grade A- evidence that elevated age-adjusted CV risk should be the primary indication for early treatment, but found no evidence for or against whether degree of LDL elevation should be a secondary factor. Additional clinical research is needed, especially with regard the long-term safety of statins and how long it takes for LDL reduction to reach full effectiveness.

Policy Responses to Demand for Health Care Access: From the Individual to the Population

CURRENT DEBATE AND DISAGREEMENTS REGARDING health care obscure strong public sentiment calling for reform of the US health care system. Public support for the 2010 Patient Protection and Affordable Care Act (ACA) is split nearly perfectly along party lines, with recent polls indicating that 45% of Americans favor the law and 40% oppose it. A generation ago, Congress reacted to public demand for reform by passing the Emergency Medical Treatment and Active Labor Act (EMTALA), signed into law by President Ronald Reagan in 1986. EMTALA was timely legislation, intended by Congress to impart a social contract between the health care–seeking public and a US health care system that the public progressively distrusted. In reality, EMTALA served as a policy detour that may have misled the public into believing the problem of health care access had largely been solved. As President George W. Bush explained in 2007, “[P]eople have access to health care in America. After all, you just go to an emergency room.” Examining where and how EMTALA fell short highlights how the ACA can start to construct a system founded on shared societal obligations to health. The path forward in US health care reform lies in recognizing the shared ethical standard that supersedes political differences.

Bottleneck or Magnifying Glass? Monitoring the Health-Care System's Vital Signs through Emergency Departments.

aMassachusetts General Hospital, Department of Emergency Medicine, Boston, MA bHarvard Medical School, Department of Emergency Medicine, Boston, MA cHennepin County Medical Center/Hennepin Healthcare System, Departments of Medicine and Family Medicine, Minneapolis, MN dMinneapolis Medical Research Foundation, Minneapolis, MN eUniversity of Minnesota, Department of Medicine, Minneapolis, MN fUniversity of Michigan, Robert Wood Johnson Foundation, Clinical Scholars Program, Ann Arbor, MI gUniversity of Michigan, Departments of Pediatrics and Internal Medicine, Ann Arbor, MI hUniversity of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI iUniversity of Michigan, Gerald R. Ford School of Public Policy, Ann Arbor, MI