Risk of Recurrent Stroke and Mortality Among Black and White Patients With Poststroke Depression.

BACKGROUND: Poststroke depression (PSD) is a treatable and common complication of stroke that is underdiagnosed and undertreated in minority populations. We compared outcomes of Black and White patients with PSD in the United States to assess whether race is independently associated with the risk of recurrent stroke and mortality. METHODS: We used deidentified Medicare data from inpatient, outpatient, and subacute nursing facilities for Black and White US patients from January 1, 2016, to December 31, 2019, to perform this retrospective cohort analysis. International Classification of Diseases, Tenth Revision codes were used to identify patients diagnosed with depression within 6 months of index stroke with no depression diagnosis 1-year preceding index stroke. We performed an unadjusted Kaplan-Meier analysis of the cumulative risk of recurrent stroke up to 3 years after index acute ischemic stroke admission and all-cause mortality following acute ischemic stroke stratified by Black and White race. We performed adjusted and reduced Cox regression to calculate hazard ratios for the main predictor of race (Black versus White), for recurrent stroke and all-cause mortality, adjusting for sociodemographic characteristics, comorbidities, characteristics of the hospitalization, and acute stroke interventions. RESULTS: Of 474 770 Medicare patients admitted with acute index stroke, 443 486 were categorized as either Black or White race and 35 604 fulfilled our criteria for PSD. Within the PSD cohort, 25 451 (71.5%) had no death or recurrent stroke within 6 months and 5592 (15.7%) had no death or readmission of any cause within 6 months. Black patients with PSD had a persistently elevated cumulative risk of recurrent stroke compared with White patients with PSD up to 3 years following acute ischemic stroke (log-rank P=0.0011). In our reduced multivariable model, Black patients had a 19.8% (hazard ratio, 1.198 [95% CI, 1.022-1.405]; P=0.0259) greater risk of recurrent stroke than White patients. The unadjusted cumulative risk of all-cause mortality was higher in this cohort of older White patients with PSD compared with Black patients; however, this difference disappeared with adjustment for age and other cofactors. CONCLUSIONS: Black patients with PSD face a persistently elevated risk of recurrent stroke compared with White patients but a similar risk of all-cause mortality. Our findings support that black race is an independent predictor of recurrent stroke in patients with PSD and highlight the need to address social determinants of health and systemic racism that impact poststroke outcomes among racial minorities.

National Institutes of Health Stroke Scale Reporting in Medicare Claims Data: Reporting in the First 3 Years.

BACKGROUND: Since 2016, hospitals have been able to document International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for the National Institutes of Health Stroke Scale (NIHSS). As of 2023, the Centers for Medicare & Medicaid Services uses NIHSS as a risk adjustment variable. We assessed associations between patient- and hospital-level variables and contemporary NIHSS reporting. METHODS: We performed a retrospective cross-sectional analysis of 2019 acute ischemic stroke admissions using deidentified, national 100% inpatient Medicare Fee-For-Service data sets. We identified index acute ischemic stroke admissions using the ICD-10-CM code I63.x and abstracted demographic information, medical comorbidities, hospital characteristics, and NIHSS. We linked Medicare and Mount Sinai Health System (New York, NY) registry data from 2016 to 2019. We calculated NIHSS documentation at the patient and hospital levels, predictors of documentation, change over time, and concordance with local data. RESULTS: There were 231 383 index acute ischemic stroke admissions in 2019. NIHSS was documented in 44.4% of admissions and by 66.5% of hospitals. Hospitals that documented ≥1 NIHSS were more commonly teaching hospitals (39.0% versus 5.5%; standardized mean difference score, 0.88), stroke certified (37.2% versus 8.0%; standardized mean difference score, 0.75), higher volume (mean, 80.8 [SD, 92.6] versus 6.33 [SD, 14.1]; standardized mean difference score, 1.12), and had intensive care unit availability (84.9% versus 23.2%; standardized mean difference score, 1.57). Adjusted odds of documentation were lower for patients with inpatient mortality (odds ratio, 0.64 [95% CI, 0.61-0.68]; P<0.0001), in nonmetropolitan areas (odds ratio, 0.49 [95% CI, 0.40-0.61]; P<0.0001), and male sex (odds ratio, 0.95 [95% CI, 0.93-0.97]; P<0.0001). NIHSS was documented for 52.9% of Medicare cases versus 93.1% of registry cases, and 74.7% of Medicare NIHSS scores equaled registry admission NIHSS. CONCLUSIONS: Missing ICD-10-CM NIHSS data remain widespread 3 years after the introduction of the ICD-10-CM NIHSS code, and there are systematic differences in reporting at the patient and hospital levels. These findings support continued assessment of NIHSS reporting and caution in its application to risk adjustment models.

Provider Care Segregation and Hospital-Region Racial Disparities in the United States for Acute Ischemic Stroke and Endovascular Therapy Outcomes.

BACKGROUND: Reasons for racial disparities in the use and outcomes of endovascular treatment (ET) are not known. We examined patterns in care segregation for acute ischemic stroke (AIS) in the United States, and outcomes of segregation of care after ET. METHODS AND RESULTS: We used deidentified Medicare data sets to identify AIS admissions between January 1, 2016 and December 31, 2019, using validated International Classification of Diseases, Tenth Revision (ICD-10) codes. For AIS, we calculated (1) the proportion of White patients at the hospital, (2) the proportional difference in the proportion of White patients between hospital patients and the county, and (3) provider care segregation by the dissimilarity index for ET cases. Using unadjusted and adjusted multilevel logistic models, we examined associations between measures of segregation and outcomes of discharge home, inpatient mortality, and 30-day mortality. The mean proportional difference in the proportion of White patients comparing hospitalized patients with AIS to the county race distribution was 0.015 (SD, 0.219) at the hospital level. For ET, the mean proportional difference in the proportion of White patients comparing patients receiving ET to the county race distribution was much higher, at 0.146 (SD, 0.374). The dissimilarity index for ET providers was high, with a mean of 0.48 (SD, 0.29) across all hospitals. Black patients with AIS (compared with White patients) had reduced odds of discharge home, inpatient mortality, and 30-day mortality. CONCLUSIONS: In this national study with contemporary data in the endovascular era of AIS treatment, we found substantial evidence for segregation of care in the United States, not for only AIS in general but also especially for ET.

Variation in US acute ischemic stroke treatment by hospital regions: limited endovascular access despite evidence.

BACKGROUND: Although national organizations recognize the importance of regionalized acute ischemic stroke (AIS) care, data informing expansion are sparse. We assessed real-world regional variation in emergent AIS treatment, including growth in revascularization therapies and stroke center certification. We hypothesized that we would observe overall growth in revascularization therapy utilization, but observed differences would vary greatly regionally. METHODS: A retrospective cross-sectional analysis was carried out of de-identified national inpatient Medicare Fee-for-Service datasets from 2016 to 2019. We identified AIS admissions and treatment with thrombolysis and endovascular thrombectomy (ET) with International Classification of Diseases, 10th Revision, Clinical Modification codes. We grouped hospitals in Dartmouth Atlas of Healthcare Hospital Referral Regions (HRR) and calculated hospital, demographic, and acute stroke treatment characteristics for each HRR. We calculated the percent of hospitals with stroke certification and AIS cases treated with thrombolysis or ET per HRR. RESULTS: There were 957 958 AIS admissions. Relative mean (SD) growth in percent of AIS admissions receiving revascularization therapy per HRR from 2016 to 2019 was 13.4 (31.7)% (IQR -6.1-31.7%) for thrombolysis and 28.0 (72.0)% (IQR 0-56.0%) for ET. The proportion of HRRs with decreased or no difference in ET utilization was 38.9% and the proportion of HRRs with decreased or no difference in thrombolysis utilization was 32.7%. Mean (SD) stroke center certification proportion across HRRs was 45.3 (31.5)% and this varied widely (IQR 18.3-73.4%). CONCLUSIONS: Overall growth in AIS treatment has been modest and, within HRRs, growth in AIS treatment and the proportion of centers with stroke certification varies dramatically.

Patterns and outcomes of weekend admission for acute ischemic stroke.

BACKGROUND AND OBJECTIVES: The "weekend effect" describes worse care delivery during off-hours or weekends and has been demonstrated in multiple sub-specialties. Off-hours care for acute ischemic stroke (AIS) has been associated with poorer outcomes. However, there is less data about the "weekend effect" on endovascular thrombectomy (ET) outcomes. METHODS: We used Medicare 100% sample datasets and included all AIS admissions from 2018-2019, using validated International Classification of Diseases, 10th Revision, Clinical Modification codes to identify AIS and comorbidities. Medicare provides the date of admission for all hospitalizations, and the day of the week was determined and assigned to weekend (Saturday or Sunday) or weekday (Monday through Friday). We defined 3 major outcomes: inpatient mortality, discharge home (vs. other destination), and 30-day mortality. RESULTS: Among 471427 AIS admissions,13.0% and 12.9% of all AIS admissions occurred on a Saturday and Sunday, respectively, less than the expected 14.3% occurring on any given day (p-value <0.0001). AIS admissions on a weekend were less likely to receive IV thrombolysis (13.6% on Saturday and 12.9% on Sunday) and ET (13.1% on Saturday and 13.2% on Sunday), p-value <0.0001. Among all AIS admissions, weekend admission was associated with worse outcomes, including higher odds of inpatient mortality (adjusted OR 1.04 [95% CI 1.01-1.08, p<0.0001]), lower odds of discharge home (0.94 [0.93-0.96, p<0.0001]), and higher odds of 30-day mortality (1.06 [1.04-1.08, p<0.0001]). However, among AIS patients treated with ET, there was no association of weekend admission with outcomes. CONCLUSIONS: In this national and contemporary dataset, we observed that the proportion of thrombolysis and ET cases was less over the weekend, and outcomes (inpatient mortality, 30-day mortality and odds of discharge home) were worse overall. We did not observe this association among AIS patients undergoing ET on a weekend vs. weekday.

Relationships among hospital acute ischemic stroke volumes, hospital characteristics, and outcomes in the US.

BACKGROUND AND OBJECTIVES: Prior research on volume-based patient outcomes related to acute ischemic stroke (AIS) have demonstrated contradictory results and fail to reflect recent advances in stroke care. We sought to examine contemporary relationships between hospital AIS volumes and outcomes. METHODS: We used complete Medicare datasets in a retrospective cohort study using validated International Classification of Diseases Tenth Revision codes to identify patients admitted with AIS from January 1, 2016 through December 31, 2019. AIS volume was calculated as the total number of AIS admissions per hospital during the study period. We examined several hospital characteristics by AIS volume quartile. We performed adjusted logistic regressions testing associations of AIS volume quartiles with: inpatient mortality, receipt of tissue plasminogen activator (tPA) and endovascular therapy (ET), discharge home, and 30-day outpatient visit. We adjusted for sex, age, Charlson comorbidity score, teaching hospital status, MDI, hospital urban-rural designation, stroke certification status and ICU and neurologist availability at the hospital. RESULTS: There were 952400 AIS admissions among 5084 US hospitals; AIS 4-year volume quartiles were: 1st: 1-8 AIS admissions; 2nd: 9-44; 3rd: 45-237; 4th: 238+. Highest quartile hospitals more often were stroke-certified (49.1% vs 8.7% in lowest quartile, p<0.0001), with ICU bed availability (19.8% vs 4.1%, p<0.0001) and with neurologist expertise (91.1% vs 3%, p<0.0001). In the highest AIS quartile (compared to the lowest quartile), there was lower inpatient mortality (odds ratio [OR] 0.71 [95%CI 0.57-0.87, p<0.0001]), lower 30-day mortality (0.55 [0.49-0.62], p<0.0001), greater receipt of tPA (6.60 [3.19-13.65], p<0.0001) and ET (16.43 [10.64-25.37], p<0.0001, and greater likelihood of discharge home (1.38 [1.22-1.56], p<0.0001). However, when the highest quartile hospitals were examined separately, higher volumes were associated with higher mortality despite higher rates of tPA and ET receipt. CONCLUSIONS: High AIS-volume hospitals have greater utilization of acute stroke interventions, stroke certification and availability of neurologist and ICU care. These features likely play a role in the better outcomes observed at such centers, including inpatient and 30-day mortality and discharge home. However, the highest volume centers had higher mortality despite greater receipt of interventions. Further research is needed to better understand volume-outcome relationships in AIS to improve care at lower volume centers.

Patterns and Outcomes of Intensive Care on Acute Ischemic Stroke Patients in the US.

BACKGROUND: Up to 20% of acute ischemic stroke (AIS) patients may benefit from intensive care unit (ICU)-level care; however, there are few studies evaluating ICU availability for AIS. We aim to summarize the proportion of elderly AIS patients in the United States who are admitted to an ICU and assess the national availability of ICU-level care in AIS. METHODS: We performed a retrospective cohort study using de-identified Medicare inpatient datasets from January 1, 2016 through December 31, 2019 for US individuals aged ≥65 years. We used validated International Classification of Diseases, Tenth Revision, Clinical Modification codes to identify AIS admission and interventions. ICU-level care was identified by revenue center code. AIS patient characteristics and interventions were stratified by receipt of ICU-level care, comparing differences through calculated standardized mean difference score due to large sample sizes. RESULTS: From 2016 through 2019, a total of 952 400 admissions by 850 055 individuals met criteria for hospital admission for AIS with 19.9% involving ICU-level care. Individuals were predominantly >75 years of age (58.5%) and identified as white (80.0%). Hospitals on average admitted 11.4% (SD 14.6) of AIS patients to the ICU, with the median hospital admitting 7.7% of AIS patients to the ICU. The ICU admissions were younger and more likely to receive reperfusion therapy but had more comorbid conditions and neurologic complications. Of the 5084 hospitals included, 1971 (38.8%) reported no ICU-level AIS care. Teaching hospitals (36.9% versus 1.6%, P<0.0001) with larger AIS volume (P<0.0001) or in larger metropolitan areas (P<0.0001) were more likely to have an ICU available. CONCLUSIONS: We found evidence of national variation in the availability of ICU-level care for AIS admissions. Since ICUs may provide comprehensive care for the most severe AIS patients, continued effort is needed to examine ICU accessibility and utility among AIS.

Patterns in the number of interventionalists for endovascular treatment of acute ischemic stroke in the US.

BACKGROUND: Endovascular thrombectomy (ET) has become the standard of stroke care for large vessel occlusion acute ischemic stroke (AIS) involving the anterior circulation. With continued eligibility expansion, the demand for neuro-intervention is growing. Current estimates indicate inadequate supply of interventionalists. However, there is limited data describing the number of interventionalists per hospital in the US, and correlations with outcomes. METHODS: We used Medicare 100% sample datasets and included all AIS admissions from 2018 to 2019, using validated International Classification of Diseases, 10th Revision, Clinical Modification codes to identify AIS and comorbidities. We utilized National Provider Identifier codes to identify distinct interventionalists at the hospital. We examined outcomes at the hospital level, including percent of AIS treated with thrombolysis, percent of AIS with inpatient mortality, percent of AIS with discharge home, and percent of AIS with death within 30 days. RESULTS: Among 471,427 AIS admissions, 16,253 received ET over the 2-year period of the study. Only 683 of 4576 AIS-treating institutions provided ET (14.9%). These ET centers most frequently only had one interventionalist performing ET and were clustered in large metropolitan areas with high AIS volumes. As AIS volumes, ET volumes, and mean NIHSS scores increased, so did the number of interventionalists. With each additional interventionalist, there was an increased likelihood of poor outcomes including inpatient mortality, discharge home, and 30-day mortality. CONCLUSIONS: We confirmed a relative lack of neuro-interventionalists among US hospitals, with a concentration of interventionalists in urban, high-volume centers. The greater likelihood of poor outcomes associated with increasing number of interventionalists is likely due to increasing complexity and severity of cases at high-volume ET centers, but further study is needed.

Risk, Determinants, and Pharmacologic Treatment of Depression Following Acute Ischemic Stroke.

Background and Purpose: We assessed risk and determinants of new-onset depression in acute ischemic stroke (AIS) patients of all ages and no known history of depression. Additionally, we assessed patterns of post-stroke depression (PSD) treatment with pharmacotherapy. Methods: Retrospective cohort study of de-identified Marketscan Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits Datasets for adults age ≥18 years admitted with AIS from July 1, 2016-July 1, 2017. We created Kaplan-Meier curves of cumulative risk of PSD up to 1.5 years following index AIS admission. We performed Cox regression to report hazard ratios for determinants of PSD up to 1.5 years following AIS. We summarized proportions treated with pharmacotherapy and identified the most commonly prescribed medications. Results: Of 8089 AIS patients, 1059 were diagnosed with PSD. At 1 year, cumulative risk of PSD was 13.4% (standard error .4) and 15.3% (standard error .5) at 1.5 years. History of anxiety was most strongly associated with PSD and discharge home least. Among those with PSD, 68.8% were prescribed an antidepressant and 8.4% an antipsychotic. The most commonly prescribed antidepressant was sertraline (28.5%). Conclusions: Among AIS patients of all ages, there is a persistently elevated cumulative risk of new diagnosis of PSD in the 1.5 years following AIS. Of the >2/3 treated with an antidepressant, sertraline was most commonly prescribed. Screening and treatment strategies for PSD require further study.

National Patterns and Outcomes of Neurologist Care in Acute Ischemic Stroke.

Background & Purpose: Specialist care of acute ischemic stroke patients has been associated with improved outcomes but is not well-characterized. We sought to elucidate the involvement and influence of neurologists on acute ischemic stroke care. Methods: Using 100% Medicare datasets, index acute ischemic stroke admissions from 2016-2018 were identified with International Classification of Diseases, 10th Revision codes. Neurologists were identified by NPI code. Neurologist involvement in care was defined as: "neurologist involved in care"; "hospital with a neurologist"; and "percent of acute ischemic stroke treated by neurologist." Adjusted logistic regression models summarized exposure to neurologists and their association with outcomes (inpatient mortality, good outcome, and 30-day readmission). Results: Among 647838 index AIS admissions from 2016-2018, 15.6% included a neurologist involved in care, associated with receiving intravenous thrombolysis (19.1% vs 6.5%), endovascular thrombectomy (13.2% vs 1.4%), treatment at a teaching hospital (87.7% vs 55.5%), and treatment at a hospital in the highest volume quartile (95.3% vs 75.6%). Of 4797 hospitals, 36.1% had a neurologist, among which the mean percent of admissions treated by a neurologist was 14.7% (SD 24.4). Neurologist involvement was associated with increased inpatient mortality (OR 1.81; 95% CI 1.75-1.86), decreased odds of a good outcome (OR .92; 95% CI .90-.93), and increased 30-day readmission (OR 1.04; 95% C: 1.01-1.06). Conclusions: The minority of acute ischemic stroke admissions among the elderly in the US are treated by neurologists. Neurologist involvement in care is associated with worse outcomes, possibly from the allocation of severe cases to neurologists.

Variability in Intensive Care Utilization for Intracerebral Hemorrhage in the United States: Retrospective Cohort Study.

OBJECTIVES: There are urban-rural geographic health disparities in intracerebral hemorrhage (ICH) outcomes. However, there is limited data regarding the relationship between intensive care (ICU) availability and ICH outcomes. We examined whether ICU availability was a significant contributor to ICH outcomes by US geographic region. MATERIALS AND METHODS: We used de-identified Medicare inpatient datasets from January 2016 to December 2019 and identified all index ICH admissions, stratifying by ICU care received during the hospitalization. Distributions of teaching hospital status, quartile of ICH volume, hospital urban-rural designation, and ICU availability were obtained using chi-square test. Propensity-score matching was utilized to compare outcomes of more favorable outcome, inpatient mortality, and 30-day all-cause readmissions by ICU availability at each hospital. RESULTS: Out of a total of 119,891 hospitalizations for ICH, 66,306 (55.3%) received ICU-level care. Of hospitals that treated at least one ICH, 42.6% did not provide ICU level care for any ICH admission during the study period. Teaching hospitals (48.0% vs 7.0%; p<0.0001), hospitals with higher ICH case volumes (p<0.0001) and in larger metropolitan areas (p<0.0001) were more likely to have an ICU available. Propensity score-matched models showed that hospital ICU availability was associated with a lower likelihood of inpatient mortality (29.4% vs 33.7%; p=0.0016) CONCLUSIONS: Rural-urban disparities in ICH outcomes are likely multifactorial, but ICU availability likely contributes to the disparity. Additional studies are necessary to elucidate other contributing mechanisms.

Triptan medication use among patients with migraine with contraindications in the US.

OBJECTIVE: We sought to investigate the prevalence of triptan use among patients with migraine who have contraindications to triptan usage, and to explore specifics of the medication prescribed, dosage, and route of administration. BACKGROUND: Triptan medications are a mainstay of acute migraine therapy, but little is known about prevalence and patterns of triptan prescribing among patients with contraindications in the United States. METHODS: In this retrospective cohort study, we used data from the IBM Marketscan database to identify patients aged ≥ 18 years with migraine from January 1, 2016, to December 31, 2017, using International Classification of Diseases, Clinical Modification 10 codes. Contraindications to triptan medications were identified by review of package labels as listed on the US Food and Drug Administration website. Triptan medications were identified from the IBM Micromedex Redbook linked to prescription claims along with route of administration and dosage. RESULTS: Of 1,038,472 individuals diagnosed with migraine, 400,112 (38.5%) were prescribed triptan medication, and of those who were prescribed a triptan, 55,707 (13.9%) had at least one contraindication, with the most common contraindication being cardiac arrhythmia (33,696/400,112 individuals, 8.4%) followed by cerebrovascular disease (14,787/400,112, 3.7%) and coronary artery disease (10,236/400,112, 2.6%). Sumatriptan was the most prescribed triptan (261,736/1,038,472, 25.2%), and the subcutaneous and intranasal routes were more commonly prescribed among those with contraindications compared with those without contraindications. DISCUSSION: A substantial proportion of patients with migraine with contraindications were prescribed triptan medications. These findings call for further research on the outcomes of patients with medical contraindications who are prescribed triptan medications, and for greater clarity in prescribing guidelines about the optimal approach for acute therapy among patients with migraine.

Electroencephalography at the height of a pandemic: EEG findings in patients with COVID-19.

OBJECTIVE: To characterize continuous video electroencephalogram (VEEG) findings of hospitalized COVID-19 patients. METHODS: We performed a retrospective chart review of patients admitted at three New York City hospitals who underwent VEEG at the peak of the COVID-19 pandemic. Demographics, comorbidities, neuroimaging, VEEG indications and findings, treatment, and outcomes were collected. RESULTS: Of 93 patients monitored, 77% had severe COVID-19 and 40% died. Acute ischemic or hemorrhagic stroke was present in 26% and 15%, respectively. Most common VEEG indications were encephalopathy/coma (60%) and seizure-like movements (38%). Most common VEEG findings were generalized slowing (97%), generalized attenuation (31%), generalized periodic discharges (17%) and generalized sharp waves (15%). Epileptiform abnormalities were present in 43% and seizures in 8% of patients, all of whom had seizure risk factors. Factors associated with an epileptiform VEEG included increasing age (OR 1.07, p = 0.001) and hepatic/renal failure (OR 2.99, p = 0.03). CONCLUSIONS: Most COVID-19 patients who underwent VEEG monitoring had severe COVID-19 and over one-third had acute cerebral injury (e.g., stroke, anoxia). Seizures were uncommon. VEEG findings were nonspecific. SIGNIFICANCE: VEEG findings in this cohort of hospitalized COVID-19 patients were those often seen in critical illness. Seizures were uncommon and occurred in the setting of common seizure risk factors.

SUBRETINAL DRUSENOID DEPOSITS AND SOFT DRUSEN: Are They Markers for Distinct Retinal Diseases?

PURPOSE: Soft drusen and subretinal drusenoid deposits (SDDs) characterize two pathways to advanced age-related macular degeneration (AMD), with distinct genetic risks, serum risks, and associated systemic diseases. METHODS: One hundred and twenty-six subjects with AMD were classified as SDD (with or without soft drusen) or non-SDD (drusen only) by retinal imaging, with serum risks, genetic testing, and histories of cardiovascular disease (CVD) and stroke. RESULTS: There were 62 subjects with SDD and 64 non-SDD subjects, of whom 51 had CVD or stroke. SDD correlated significantly with lower mean serum high-density lipoprotein (61 ± 18 vs. 69 ± 22 mg/dL, P = 0.038, t-test), CVD and stroke (34 of 51 SDD, P = 0.001, chi square), ARMS2 risk allele (P = 0.019, chi square), but not with CFH risk allele (P = 0.66). Non-SDD (drusen only) correlated/trended with APOE2 (P = 0.032) and CETP (P = 0.072) risk alleles (chi square). Multivariate independent risks for SDD were CVD and stroke (P = 0.008) and ARMS2 homozygous risk (P = 0.038). CONCLUSION: Subjects with subretinal drusenoid deposits and non-SDD subjects have distinct systemic associations and serum and genetic risks. Subretinal drusenoid deposits are associated with CVD and stroke, ARMS2 risk, and lower high-density lipoprotein; non-SDDs are associated with higher high-density lipoprotein, CFH risk, and two lipid risk genes. These and other distinct associations suggest that these lesions are markers for distinct diseases.

Racial differences in persistence to secondary prevention medication regimens after ischemic stroke.

BACKGROUND: Prior stroke is one of the biggest risk factors for future stroke events. Effective secondary prevention medication regimens can dramatically reduce recurrent stroke risk. Guidelines recommend the use of antithrombotic, antihypertensive and lipid-lowering medications after stroke. Medication adherence is known to be better in the presence of a caregiver but long-term adherence after stroke is unknown and disparities may persist. METHODS: We examined the effects of race and sex on baseline prescription and maintenance of secondary prevention regimens in the presence of a caregiver using the Caring for Adults Recovering from the Effects of Stroke (CARES) study, an ancillary study of the national REasons for Geographic and Racial Differences in Stroke (REGARDS). RESULTS: Incident ischemic stroke survivors (N = 172; 36% Black) with family caregivers had medications recorded at hospital discharge and on average 9.8 months later during a home visit. At discharge, antithrombotic prescription (95.9%), lipid-lowering medications (78.8%) and antihypertensives (89.9%) were common and there were no race or sex differences in discharge prescription rates. One year later, medication persistence had fallen to 86.6% for antithrombotics (p = 0.002) and 69.8% for lipid lowering (p = 0.008) but increased to 93.0% for antihypertensives (p = 0.30). Blacks were more likely to have discontinued antithrombotics than Whites (18.3% v 7.7%, p = 0.04). No significant differences in persistence were seen with age, sex, income, depression, or cognitive impairment. CONCLUSIONS: Medication persistence was high in this sample, likely due to the presence of a caregiver. In our cohort, despite similar prescription rates at the time of hospital discharge, Black stroke survivors were more than twice as likely to stop antithrombotics than Whites. The effect of changes in patterns of medication usage on health outcomes in Black stroke survivors warrants continued investigation.

Depression readmission risk is elevated in multiple sclerosis compared to other chronic illnesses.

OBJECTIVE: Assess readmissions for depression or suicide attempt (SA) after MS admission versus other chronic inflammatory illnesses. METHODS: This retrospective cohort study identified MS, asthma, rheumatoid arthritis (RA), depression, and SA in the 2013 National Readmissions Database by International Classification of Diseases codes. Index admissions (MS, n = 7698; asthma, n = 93,590; RA, n = 3685) and depression or SA readmission rates were analyzed. Hazard ratios (HRs) estimated 1-year depression/SA readmission hazard, comparing MS to asthma or RA, adjusting for age, sex, psychiatric comorbidity, substance abuse, tobacco use, income, and index hospitalization characteristics. RESULTS: MS had more baseline depression (24.7%) versus asthma (15.6%) and RA (14.6%). Ninety-day depression readmission rate was higher in MS (0.5%) than asthma (0.3%) and RA (0.03%). Depression readmission HR was higher after MS admission versus asthma (HR = 1.37, 95% confidence interval (CI) = 1.00-1.86, p = 0.0485) and RA (HR = 4.68, 95% CI = 1.60-13.62, p = 0.0047). HR was not different for SA readmission across groups. Depression readmission HR was more than double in MS patients with psychiatric disease or substance abuse versus RA or asthma patients with either comorbidity. CONCLUSION: Depression readmission risk after MS hospitalization was elevated versus asthma/RA. Substance use and baseline psychiatric comorbidity were more strongly associated with depression readmission in MS patients.

Readmission for cardiac and non-cardiac causes among adults with epilepsy or multiple sclerosis - A nationwide analysis.

PURPOSE: The aim of this study was to determine proportions of 30-day cardiac readmissions in adults with epilepsy compared to multiple sclerosis (MS) or those with neither condition. Predictors and causes of readmissions were also examined. METHODS: We used the 2014 Nationwide Readmissions Database and ICD-9-CM codes to identify people with epilepsy, MS, and without epilepsy or MS. Multinomial logistic regressions were fitted to: (1) examine association between 30-day readmissions and epilepsy, MS or neither, and (2) to describe causes and predictors of 30-day readmission for cardiac readmissions in epilepsy. RESULTS: Out of 6,870,508 adults admitted in 2014, 202,938 (2.98%) had epilepsy and 29,556 (0.45%) had MS. The proportion of 30-day readmission for epilepsy and MS were, respectively: (1) due to cardiac causes (0.17% vs. 0.13%); (2) due to other causes (13.89% vs. 10.61%). The odds of 30-day cardiac readmission in those with epilepsy and MS were lower compared to those without either condition (OR = 0.64, 95% CI 0.57-0.73, p < 0.0001; OR = 0.60, 95% CI 0.43-0.84, p = 0.003). Among those with epilepsy, increasing age (OR = 1.03, 95% CI 1.02-1.04, p < 0.0001) and a Charlson comorbidity index ≥1 (OR = 1.79, 95% CI 1.24-2.60, p = 0.002) were associated with higher odds of 30-day cardiac readmission. A higher proportion of those with epilepsy readmitted within 30-days due to cardiac causes died in hospital (10.09%) compared to those with MS (not reportable due to cell frequency <10) or without epilepsy or MS (5.61%). CONCLUSION: Those admitted to a hospital and living with epilepsy had a higher proportion of cardiac readmissions and death in hospital when compared to those living with MS, and the determinants are likely multifactorial. These findings are important and need to be further explored to identify strategies to prevent readmissions due to any cause and treatments that could reduce mortality.

Healthcare Utilization for Stroke Patients at the End of Life: Nationally Representative Data.

Objectives Stroke and post-stroke complications are associated with high morbidity, mortality, and cost. Our objective was to examine healthcare utilization and hospice enrollment for stroke patients at the end of life. Materials and methods The 2014 Nationwide Readmissions Database is a national database of > 14 million admissions. We used validated ICD-9 codes to identify fatal ischemic stroke, summarized demographics and hospitalization characteristics, and examined healthcare use within 30 days before fatal stroke admission. We used de-identified 2014 Medicare hospice data to identify stroke and non-stroke patients admitted to hospice. Results Among IS admissions in 2014 (n = 472,969), 22652 (4.8%) had in-hospital death. 28.2% with fatal IS had two or more hospitalizations in 2014. Among those with fatal IS admission, 13.0% were admitted with cerebrovascular disease within 30 days of fatal IS admission. Half of stroke patients discharged to hospice from the Medicare dataset were hospitalized with cerebrovascular disease within the thirty days prior to hospice enrollment. Within the study year, 6.9% of hospice enrollees had one or more emergency room visits, 31.7% had one or more inpatient encounters, and 5.2% had one or more nursing facility encounters (compared to 21.4%, 70.6%, and 27.2% respectively in the 30-day period prior to enrollment). Conclusions High rates of readmission prior to fatal stroke may indicate opportunity for improvement in acute stroke management, secondary prevention, and palliative care involvement as encouraged by AHA/ASA guidelines. For patients who are expected to survive 6 months or less, hospice may offer goal-concordant services for patients and caregivers who desire comfort-focused care.

Sex Differences in Post-Stroke Depression in the Elderly.

OBJECTIVE: Post-stroke depression (PSD) occurs in approximately one-third of ischemic stroke patients. However, there is conflicting evidence on sex differences in PSD. We sought to assess sex differences in risk and time course of PSD in US ischemic stroke (IS) patients. We hypothesized that women are at greater risk of PSD than men, and that a greater proportion of women experience PSD in the acute post-stroke phase. MATERIALS AND METHODS: We conducted a retrospective cohort study of 100% de-identified data for US Medicare beneficiaries admitted for ischemic stroke from July 1, 2016 to December 31, 2017. We calculated Kaplan-Meier unadjusted cumulative risk of depression, stratified by sex, up to 1.5 years following index admission. We performed Cox regression to report the hazard ratio (HR) for diagnosis of depression up to 1.5 years post-stroke in females vs. males, adjusting for patient demographics, comorbidities, length of stay, and acute stroke interventions. RESULTS: In elderly stroke patients, females (n=90,474) were 20% more likely to develop PSD than males (n=84,427) in adjusted models. Cumulative risk of depression was consistently elevated for females throughout 1.5 years of follow-up (0.2055 [95% CI 0.2013-0.2097] vs. 0.1690 [95% CI 0.1639-0.1741] (log-rank p < 0.0001). HR for PSD in females vs. males remained significant in fully adjusted analysis at 1.20 (95% CI 1.17-1.23, p < 0.0001). CONCLUSIONS: Over 1.5 years of follow-up, female stroke patients had significantly greater hazard of developing PSD, highlighting the need for long-term depression screening in this population and further investigation of underlying reasons for sex differences.