Improving COPD Care in a Medically Underserved Primary Care Clinic: A Qualitative Study of Patient Perspectives.

We conducted a focus group study in an urban hospital-based primary care teaching clinic serving an indigent and Hispanic (predominantly Puerto Rican) population in New England in order to learn how patients with Chronic Obstructive Lung Disease (COPD) perceive their disease, how they experience their medical care, and the barriers they face managing their disease and following medical recommendations. The research team included medical doctors, nurses, a medical anthropologist, a clinical pharmacist, a hospital interpreter, and a systems analyst. Four focus groups were conducted in Spanish and English in April and May 2014. The demographic characteristics of the 25 focus group participants closely reflected the demographics of the total COPD clinic patients. The participants were predominantly female (72%) and Hispanic (72%) and had a median age of 63. The major themes expressed in the focus groups included: problems living with COPD; coping with complexities of comorbid illnesses; challenges of quitting smoking and maintaining cessation; dealing with second-hand smoke; beliefs and myths about quitting smoking; difficulty paying for and obtaining medications; positive experiences obtaining and managing medications; difficulties in using sleep machines at home; expressions of disappointment with the departure of their doctors; and overall satisfaction with the clinic health care providers. The study led to the creation of an action plan that addresses the concerns expressed by the focus study participants. The action plan is spearheaded by a designated bilingual and bicultural nurse and is now in operation.

Effect of ß-Adrenergic Antagonists on In-Hospital Mortality after Ischemic Stroke.

BACKGROUND: Ischemic stroke accounts for 85%-90% of all strokes and currently has very limited therapeutic options. Recent studies of ß-adrenergic antagonists suggest they may have neuroprotective effects that lead to improved functional outcomes in rodent models of ischemic stroke; however, there are limited data in patients. We aimed to determine whether there was an improvement in mortality rates among patients who were taking ß-blockers during the acute phase of their ischemic stroke. METHODS: A retrospective analysis of a prospectively collected database of ischemic stroke patients was performed. Patients who were on ß-adrenergic antagonists both at home and during the first 3 days of hospitalization were compared with patients who were not on ß-adrenergic antagonists to determine the association with patient mortality rates. RESULTS: The study included a patient population of 2804 patients. In univariate analysis, use of ß-adrenergic antagonists was associated with older age, atrial fibrillation, hypertension, and more-severe initial stroke presentation. Despite this, multivariable analysis revealed a reduction in in-hospital mortality among patients who were treated with ß-adrenergic antagonists (odds ratio, .657; 95% confidence interval, .655-.658). CONCLUSIONS: The continuation of home ß-adrenergic antagonist medication during the first 3 days of hospitalization after an ischemic stroke is associated with a decrease in patient mortality. This supports the work done in rodent models suggesting neuroprotective effects of ß-blockers after ischemic stroke.

Clinical Characteristics and Outcomes of Patients with Intracerebral Hemorrhage after Interhospital Transfer to a Designated Stroke Center.

UNLABELLED: Patients with acute ischemic stroke have improved outcomes when cared for in designated stroke centers (SC), in part due to enhanced thrombolytic use. Whether patients with intracerebral hemorrhage (ICH) also benefit from SC care is unknown. In this study, we compared the clinical characteristics and outcomes of ICH patients who underwent interhospital transfer (IHT) to a Joint Commission (JC) designated SC, to ICH patients who presented directly to the SC's emergency department (ED). METHODS: Patients with ICH admitted between 2006 and 2013 were evaluated. The primary outcome measure was in-hospital death or hospice. RESULTS: Among 760 consecutive admissions for ICH, 321 (42.2%) were IHTs. There has been a 30% annual increase in IHT of ICH patients since 2006. The IHT group was younger (70.26 vs 72.28; P =.055), had lower ICH scores (P = .007), a higher Glasgow Coma Scale (GCS) (P = .037), and lower systolic blood pressure (SBP) (P = .003) than those arriving directly to the ED. Female sex was a predictor of in-hospital mortality (OR = 2.26). CONCLUSION: IHT is increasingly common for patients with ICH. The benefit of transfer remains unclear, as younger, healthier patients were the most likely to be transferred. Comprehensive stroke registries are needed to determine if outcomes differ for ICH patients based on transfer or SC care.

Community implementation of intravenous thrombolysis for acute ischemic stroke in the 3- to 4.5-hour window.

BACKGROUND: Intravenous (IV) tissue plasminogen activator (tPA) administration for ischemic stroke between 3 and 4.5 hours after onset was found to be safe and beneficial in the ECASS III trial. However, its use has remained controversial, and its benefit as applied in routine practice at community stroke centers is less well defined. METHODS: This retrospective database study compared safety and clinical outcomes in 500 patients given IV tPA either from 0 to 3 or 3 to 4.5 hours after onset at a high-volume community center from January 2008 to October 2012. Additional independent variables included for univariate and multivariate analysis were age, sex, hypertension, diabetes mellitus, National Institutes of Health stroke scale on arrival. RESULTS: There were no significant differences seen in rates of symptomatic intracranial hemorrhage (3.8% vs 5.8%, P > .05), in-hospital mortality, or Barthel index at 3 months between groups. In addition, tPA administration despite ECASS III contraindications did not appear to be an independent predictor of hemorrhage in the first 24 hours. DISCUSSION: Our results show that the conclusions of the ECASS III trial can be applied to routine stroke treatment at a community center and that IV thrombolysis in the 3- to 4.5-hour window results in similar safety and efficacy functional outcome at 3 months compared with administration before 3 hours after onset.

Intracerebral hemorrhage with hypothyroidism.

BACKGROUND: Hypothyroidism is associated with increased ischemic stroke risk but paradoxically results in more favorable outcomes once a stroke occurs. Whether a similar pattern emerges in patients with primary intracerebral hemorrhage (ICH) is unknown. METHODS: A retrospective analysis of a prospective stroke center database was performed to analyze the clinical presentation and outcomes of hypothyroid patients with spontaneous ICH. Patients were classified into groups with no history of thyroid disease (n=491) versus those with hypothyroidism (n=72). Hypothyroid patients were further classified into patients receiving thyroid replacement on admission or those without replacement. The Glasgow Coma Scale, ICH score, and the National Institutes of Health Stroke Scale (NIHSS) were used to assess the initial severity. Outcome was assessed by admission to discharge change in the NIHSS and modified Barthel Index (mBI), in-hospital mortality, discharge disposition and mortality, and the mBI at 3 and 12 months. RESULTS: There were 563 patients in the analysis. Seventy-two patients had a history of hypothyroidism, and of these, 63% received thyroid hormone replacement. Patients receiving replacement had significantly lower NIHSS at presentation (median 4 [IQR 1, 11]) compared with either the control group (median 8 [IQR 3, 16]) or hypothyroid patients without replacement (median 9 [IQR 3.8, 15.5]; P=.004). There was no difference in in-hospital and 3-month mortality or functional outcomes at 3 and 12 months among the groups. CONCLUSIONS: This study suggests that the history of hypothyroidism does not affect clinical severity or outcome after ICH.

Impact of emergency department transitions of care on thrombolytic use in acute ischemic stroke.

BACKGROUND AND PURPOSE: In-hospital mortality is higher for certain medical conditions based on the time of presentation to the emergency department. The primary goal of this study was to determine whether patients with acute ischemic stroke who arrived to the emergency department during a nursing shift change had similar rates of thrombolytic use and functional outcomes compared with patients presenting during nonshift change hours. METHODS: A retrospective review of patients with acute ischemic stroke presenting to the emergency department of a primary stroke center from 2005 through 2010. The time to notify the stroke team, perform a head CT scan, and to start intravenous or intra-arterial thrombolysis was assessed. Thrombolysis rates, mortality rate, discharge disposition, change in the National Institutes of Health Stroke Scale, and change in modified Barthel Index at 3 and 12 months were assessed. RESULTS: Of 3133 patients with acute ischemic stroke, 917 met criteria for inclusion. Arrival during nursing shift change, weekends, and July through September had no impact on process times, thrombolysis rates, and functional outcomes. Arrival at night did result in longer time to intra-arterial but not to intravenous thrombolysis, higher mortality rate, and smaller gain in functional status as measured by the modified Barthel Index at 3 months. The degree of emergency department "busyness" also did not influence tissue-type plasminogen activator treatment times. CONCLUSIONS: Presentation during a nursing shift change, a time of transition of care, did not delay thrombolytic use in eligible patients with acute ischemic stroke. Presentation with acute ischemic stroke at night did result in delays of care for patients undergoing interventional therapies.

Peripheral leukocyte counts and outcomes after intracerebral hemorrhage.

BACKGROUND: Intracerebral hemorrhage (ICH) is a devastating disease that carries a 30 day mortality of approximately 45%. Only 20% of survivors return to independent function at 6 months. The role of inflammation in the pathophysiology of ICH is increasingly recognized. Several clinical studies have demonstrated an association between inflammatory markers and outcomes after ICH; however the relationship between serum biomarkers and functional outcomes amongst survivors has not been previously evaluated. Activation of the inflammatory response as measured by change in peripheral leukocyte count was examined and assessment of mortality and functional outcomes after ICH was determined. FINDINGS: Patients with spontaneous ICH admitted to a tertiary care center between January 2005 and April 2010 were included. The change in leukocyte count was measured as the difference between the maximum leukocyte count in the first 72 hours and the leukocyte count on admission. Mortality was the primary outcome. Secondary outcomes were mortality at 1 year, discharge disposition and the modified Barthel index (MBI) at 3 months compared to pre-admission MBI. 423 cases were included. The in-hospital mortality was 30.4%. The change in leukocyte count predicted worse discharge disposition (OR = 1.258, p = 0.009). The change in leukocyte count was also significantly correlated with a decline in the MBI at 3 months. These relationships remained even after removal of all patients with evidence of infection. CONCLUSIONS: Greater changes in leukocyte count over the first 72 hours after admission predicted both worse short term and long term functional outcomes after ICH.

Stroke severity and outcomes for octogenarians receiving statins.

Pre-exposure to 3-hydroxy-3-methylgutaryl-coenzyne A reductase inhibitors (statins) appears to improve outcomes in patients with acute ischemic stroke (AIS). Whether this extends to patients over 80 is not known. Patients ≥80 years of age with AIS were retrospectively reviewed from the stroke registry of a tertiary stroke center. Pre-admission statin use, demographics, vascular risk factors, and comorbid conditions were assessed. Primary outcomes were admission National Institutes of Health Stroke Scale (NIHSS) scores and in-hospital mortality/discharge to hospice, and secondary outcomes included subsequent intracerebral hemorrhage (ICH) and modified Barthel index (mBI) at 3 months. Multivariable logistic regression was used to evaluate the association between pre-admission statin use and outcomes among elderly patients. Among 804 patients ≥80, those taking statins prior to AIS admission were overall younger, were more likely to have hypertension, coronary artery disease, diabetes, hyperlipidemia, and were more likely to be on an antiplatelet, but less likely to receive treatment with IV tissue plasminogen activator (tPA). Patients on statin had lower stroke severity (NIHSS>16: 21.9% vs. 27.6%) and in-hospital mortality/discharge to hospice (22.8% vs. 27.6%), but neither was significant. There was no difference in ICH (1.2% vs. 1.9%), and patients on statins had a non-significant trend toward less disability on mBI (27.5% vs. 35.7%). Pre-admission statin use did not show a statistical difference in either outcome, but it did show a trend toward lower stroke severity and improved short-term outcomes. In addition, our study suggests that statins may be safe in elderly stroke patients and may not increase the risk of ICH.