A clinically actionable and explainable real-time risk assessment framework for stroke-associated pneumonia.

The current medical practice is more responsive rather than proactive, despite the widely recognized value of early disease detection, including improving the quality of care and reducing medical costs. One of the cornerstones of early disease detection is clinically actionable predictions, where predictions are expected to be accurate, stable, real-time and interpretable. As an example, we used stroke-associated pneumonia (SAP), setting up a transformer-encoder-based model that analyzes highly heterogeneous electronic health records in real-time. The model was proven accurate and stable on an independent test set. In addition, it issued at least one warning for 98.6 % of SAP patients, and on average, its alerts were ahead of physician diagnoses by 2.71 days. We applied Integrated Gradient to glean the model's reasoning process. Supplementing the risk scores, the model highlighted critical historical events on patients' trajectories, which were shown to have high clinical relevance.

Assessment of rehabilitation following intracerebral hemorrhage in China: findings from the Chinese stroke center alliance.

OBJECTIVES: Evidence shows that rehabilitation is the most effective strategy to reduce the disability rate of patients with stroke. However, there is limited understanding about the factors associated with rehabilitation assessment among patients with intracerebral hemorrhage (ICH) in China. We aimed to investigate the factors associated with rehabilitation assessment in patients with ICH and the relationship between rehabilitation assessment and hospitalization outcomes. METHODS: Data from 85,664 patients with ICH admitted to 1,312 hospitals between 1 August 2015 and 31 July 2019 were analyzed. A multivariable logistic regression model accounting for in-hospital clustering was used to identify patient and hospital factors associated with rehabilitation assessment during acute hospitalization. RESULTS: A total of 62,228 (72.6%) patients with ICH underwent rehabilitation assessments. In multivariable analyses, factors associated with an increased likelihood of undergoing a rehabilitation assessment (P < .05) included a higher Glasgow Coma Scale score on admission, a history of hypertension, a history of peripheral vascular disease, dysphagia screening, carotid vessel imaging, and a longer length of hospital stay. Conversely, patients admitted to the intensive care unit and tertiary-grade hospitals were less likely to undergo rehabilitation assessments during hospitalization for ICH. DISCUSSION: This study showed that the rate of rehabilitation assessment was 74.2%, which is low. Rehabilitation assessment was associated with longer hospital stays and lower mortality. Therefore, patients with acute cerebral haemorrhage should undergo comprehensive and professional rehabilitation assessment.

Risk factors for decline in Montreal Cognitive Assessment (MoCA) scores in patients with acute transient ischemic attack and minor stroke.

Cognitive impairment after stroke/transient ischemic attack (TIA) has a high prevalence. The authors aimed to explore the risk factors for declined cognitive function with Montreal Cognitive Assessment (MoCA)-Beijing in patients with stroke/TIA at acute phase. Total 2283 patients with acute stroke/TIA without a history of dementia were assessed at 2 weeks of onset. Patients were assessed by MoCA-Beijing on day 14 and at 3 months follow-ups. Cognitive impairment was defined as MoCA-Beijing ≤22. Patients' cognitive status was considered as declined if there were a reduction of ≥2 points in MoCA-Beijing score and patients were considered to have improved if there were an increase of ≥2 points. The score of MoCA-Beijing was considered to be stable if there were an increase or decrease of 1 point. Most patients were in 60 s (60.96 ± 10.75 years old) with a median (interquartile range) National Institute of Health Stroke Scale score of 3.00 (4.00) and greater than primary school level of education, and 1657 participants (72.58%) were male. Cognitive evaluation was conducted in 2283 of 2625 patients (82.70%) with MoCA-Beijing at baseline. Total 292 (12.79%) patients have a cognitive decline at 3 months, 786 (34.42%) patients were stable and 1205 (52.78%) patients were improved. In the logistic regression, a history of hypertension was associated with cognitive deterioration from baseline to 3-month. Patients with a history of hypertension have a higher risk for cognitive deterioration from baseline to 3-month after stroke/TIA.

Assessment of Trends in Guideline-Based Oral Anticoagulant Prescription for Patients With Ischemic Stroke and Atrial Fibrillation in China.

Importance: Adherence to oral anticoagulants (OACs) per guideline recommendations is crucial in reducing ischemic stroke and systemic thromboembolism in high-risk patients with ischemic stroke and atrial fibrillation. However, data on OAC use are underreported in China. Objective: To assess adherence to the Chinese Stroke Association or the American Heart Association/American Stroke Association's clinical management guideline-recommended prescription of OACs, the temporal improvement in adherence, and the risk factors associated with OAC prescriptions. Design, Setting, and Participants: This quality improvement study was conducted at 1430 participating hospitals in the Chinese Stroke Center Alliance (CSCA) among patients with ischemic stroke and atrial fibrillation enrolled in the CSCA between August 1, 2015, and July 31, 2019. Exposure: Calendar year. Main Outcomes and Measures: Adherence to the Chinese Stroke Association or the American Heart Association/American Stroke Association's clinical management guideline-recommended prescribing of OACs (warfarin and non-vitamin K OACs, including dabigatran, rivaroxaban, apixaban, and edoxaban) at discharge. Results: Among 35 767 patients (18 785 women [52.5%]; mean [SD] age, 75.5 [9.2] years) with previous atrial fibrillation at admission, the median CHA2DS2-VASc (cardiac failure or dysfunction, hypertension, age 65-74 [1 point] or ≥75 years [2 points], diabetes, and stroke, transient ischemic attack or thromboembolism [2 points]-vascular disease, and sex category [female]) score was 4.0 (interquartile range, 3.0-5.0); 6303 (17.6%) were taking OACs prior to hospitalization for stroke, a rate that increased from 14.3% (20 of 140) in the third quarter of 2015 to 21.1% (118 of 560) in the third quarter of 2019 (P < .001 for trend). Of 49 531 eligible patients (26 028 men [52.5%]; mean [SD] age, 73.4 [10.4] years), 20 390 (41.2%) had an OAC prescription at discharge, an increase from 23.2% (36 of 155) in the third quarter of 2015 to 47.1% (403 of 856) in the third quarter of 2019 (P < .001 for trend). Warfarin was the most commonly prescribed OAC (11 956 [24.2%]) and had the largest temporal increase (from 5.8% [9 of 155] to 20.7% [177 of 856]). Older age (adjusted odds ratio [aOR] per 5 year increase, 0.89;95% CI, 0.89-0.90), lower levels of education (aOR for below elementary school, 0.84; 95% CI, 0.74-0.95 ), lower income (aOR for ≤¥1000 [$154], 0.66; 95% CI, 0.59-0.73), having new rural cooperative medical scheme insurance (aOR, 0.92; 95% CI, 0.87-0.96), prior antiplatelet use (aOR, 0.70; 95% CI, 0.66-0.74), having several cardiovascular comorbid conditions (including stroke or transient ischemic attack [aOR, 0.78; 95% CI, 0.75-0.82], hypertension [aOR, 0.84; 95% CI, 0.80-0.89], diabetes [aOR, 0.91; 95% CI, 0.83-0.99], dyslipidemia [aOR, 0.87; 95% CI, 0.80-0.94], carotid stenosis [aOR, 0.83; 95% CI, 0.69-0.98], and peripheral vascular disease [aOR, 0.80; 95% CI, 0.71-0.90]), and admission to secondary hospitals (aOR, 0.71; 95% CI, 0.68-0.74) or hospitals located in the central region of China (aOR, 0.80; 95% CI, 0.75-0.84) were associated with not being prescribed an OAC at discharge. Conclusions and Relevance: This quality improvement study suggests that, despite significant improvement over time, OAC prescriptions remained low. Efforts to increase OAC prescriptions, especially non-vitamin K OACs, are needed for vulnerable subgroups by age, socioeconomic status, and presence of comorbid conditions.

Tranexamic acid for acute intracerebral haemorrhage growth based on imaging assessment (TRAIGE): a multicentre, randomised, placebo-controlled trial.

BACKGROUND: Studies show tranexamic acid can reduce the risk of death and early neurological deterioration after intracranial haemorrhage. We aimed to assess whether tranexamic acid reduces haematoma expansion and improves outcome in intracerebral haemorrhage patients susceptible to haemorrhage expansion. METHODS: We did a prospective, double-blind, randomised, placebo-controlled trial at 10 stroke centres in China. Acute supratentorial intracerebral haemorrhage patients were eligible if they had indication of haemorrhage expansion on admission imaging (eg, spot sign, black hole sign or blend sign), and were treatable within 8 hours of symptom onset. Patients were randomly assigned (1:1) to receive either tranexamic acid or a matching placebo. The primary outcome was intracerebral haematoma growth (>33% relative or >6 mL absolute) at 24 hours. Clinical outcomes were assessed at 90 days. RESULTS: Of the 171 included patients, 124 (72.5%) were male, and the mean age was 55.9±11.6 years. 89 patients received tranexamic acid and 82 received placebo. The primary outcome did not differ significantly between the groups: 36 (40.4%) patients in the tranexamic acid group and 34 (41.5%) patients in the placebo group had intracranial haemorrhage growth (OR 0.96, 95% CI 0.52 to 1.77, p=0.89). The proportion of death was lower in the tranexamic acid treatment group than placebo group (8.1% vs 10.0%), but there were no significant differences in secondary outcomes including absolute intracranial haemorrhage growth, death and dependency. CONCLUSIONS: Among patients susceptible to haemorrhage expansion treated within 8 hours of stroke onset, tranexamic acid did not significantly prevent intracerebral haemorrhage growth. Larger studies are needed to assess safety and efficacy of tranexamic acid in intracerebral haemorrhage patients.

Screening for cognitive impairment with the montreal cognitive assessment at six months after stroke and transient ischemic attack.

OBJECTIVE: Cognitive impairment usually occurs in the acute phase after stroke, but most stroke survivors experience some form of long-term cognitive deficit. The aim of this study was to establish the cutoff point of the Montreal Cognitive Assessment (MoCA-Beijing) in screening for cognitive impairment (CI) at 6 months of ischemic stroke or transient ischemic attack (TIA). METHODS: A total of 301 stroke patients and 15 TIA patients were recruited. Patients were assessed at six months by the MoCA-Beijing and a formal neuropsychological battery. The 1.5 SD below the level of the norm on several tests indicated cognitive impairment (CI). RESULTS: Most stroke and TIA patients were in their 60s (61.23 ± 10.60 years old). The optimal cutoff point for MoCA-Beijing in discriminating patients with CI from those with no cognitive impairment (NCI) was 24/25 (sensitivity 63.28%, specificity 71.22%, PPV = 73.68%, NPV = 60.37%, classification accuracy = 66.72%). The predominant cognitive deficits were visuospatial ability (84.85%), and then attention/executive function (79.27%). CONCLUSION: The MoCA-Beijing cutoff score for differentiating CI from NCI after stroke and TIA at six months was at 24/25, and it is important for routine clinical practice.

China Stroke Statistics 2019: A Report From the National Center for Healthcare Quality Management in Neurological Diseases, China National Clinical Research Center for Neurological Diseases, the Chinese Stroke Association, National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention and Institute for Global Neuroscience and Stroke Collaborations.

China faces the greatest challenge from stroke in the world. The death rate for cerebrovascular diseases in China was 149.49 per 100 000, accounting for 1.57 million deaths in 2018. It ranked third among the leading causes of death behind malignant tumours and heart disease. The age-standardised prevalence and incidence of stroke in 2013 were 1114.8 per 100 000 population and 246.8 per 100 000 person-years, respectively. According to the Global Burden of Disease Study 2017, the years of life lost (YLLs) per 100 000 population for stroke increased by 14.6%; YLLs due to stroke rose from third highest among all causes in 1990 to the highest in 2017. The absolute numbers and rates per 100 000 population for all-age disability-adjusted life years (DALYs) for stroke increased substantially between 1990 and 2017, and stroke was the leading cause of all-age DALYs in 2017. The main contributors to cerebrovascular diseases include behavioural risk factors (smoking and alcohol use) and pre-existing conditions (hypertension, diabetes mellitus, dyslipidaemia and atrial fibrillation (AF)). The most prevalent risk factors among stroke survivors were hypertension (63.0%-84.2%) and smoking (31.7%-47.6%). The least prevalent was AF (2.7%-7.4%). The prevalences for major risk factors for stroke are high and most have increased over time. Based on the latest national epidemiological data, 26.6% of adults aged ≥15 years (307.6 million adults) smoked tobacco products. For those aged ≥18 years, age-adjusted prevalence of hypertension was 25.2%; adjusted prevalence of hypercholesterolaemia was 5.8%; and the standardised prevalence of diabetes was 10.9%. For those aged ≥40 years, the standardised prevalence of AF was 2.31%. Data from the Hospital Quality Monitoring System showed that 3 010 204 inpatients with stroke were admitted to 1853 tertiary care hospitals during 2018. Of those, 2 466 785 (81.9%) were ischaemic strokes (ISs); 447 609 (14.9%) were intracerebral haemorrhages (ICHs); and 95 810 (3.2%) were subarachnoid haemorrhages (SAHs). The average age of patients admitted was 66 years old, and nearly 60% were male. A total of 1555 (0.1%), 2774 (0.6%) and 1347 (1.4%) paediatric strokes (age <18 years) were identified among IS, ICH and SAH, respectively. Over one-third (1 063 892 (35.3%)) of the patients were covered by urban resident basic medical insurance, followed by urban employee basic medical insurance (699 513 (23.2%)) and new rural cooperative medical schema (489 361 (16.3%)). The leading risk factor was hypertension (67.4% for IS, 77.2% for ICH and 49.1% for SAH), and the leading comorbidity was pneumonia or pulmonary infection (10.1% for IS, 31.4% for ICH and 25.2% for SAH). In-hospital death/discharge against medical advice rate was 8.3% for stroke inpatients, ranging from 5.8% for IS to 19.5% for ICH. The median and IQR of length of stay was 10.0 (7.0-14.0) days, ranging from 10.0 (7.0-13.0) in IS to 14.0 (8.0-22.0) in SAH. Data from the Chinese Stroke Center Alliance demonstrated that the composite scores of guideline-recommended key performance indicators for patients with IS, ICH and SAH were 0.77±0.21, 0.72±0.28 and 0.59±0.32, respectively.

Disparities in outcomes associated with rural-urban insurance status in China among inpatient women with stroke: a registry-based cohort study.

BACKGROUND: Despite a few studies have demonstrated sex differences in stroke care and outcomes, limited research has explored insurance-related disparities in outcomes, particularly among women stroke patients. The aim was to determine whether rural-urban health insurance status affect the stroke treatment, process of care, and 1-year clinical outcomes for inpatient ischemic stroke in women. METHODS: Women patients with acute ischemic stroke (AIS) covered by New Rural Cooperative Medical Scheme (NRCMS) and urban resident/employee-based basic medical insurance scheme (URBMI/UEBMI) were abstracted from the China National Stroke Registry II (CNSR II). Shared frailty model in the Cox model or generalized estimating equation with consideration of the hospital's cluster effect were used to assess the associations between rural-urban insurance status and quality of care during hospitalization and 1-year stroke outcomes including all-cause death, 1-year recurrence, and 1-year disability. RESULTS: A total of 5,707 women patients enrolled from 219 hospitals in CNSR II were analyzed. Compared with 2,880 women patients covered by URBMI/UEBMI, 2,827 women patients covered by NRCMS were younger (65.7 versus 68.9 years), less likely to have vascular risk factors, awareness and treatment of hypertension and dyslipidemia prior to stroke. Women covered by NRCMS were more likely to receive early antithrombotics, discharge antithrombotics, lipid-lowering drugs, but less likely to receive antihypertensive medication than those covered by URBMI/UEBMI. One-year all-cause mortality and stroke recurrence were both significantly higher in women patients with NRCMS than those with URBMI/UEBMI [adjusted hazard ratio (95% confidence interval): 1.40 (1.06-1.84) and 1.38 (1.04-1.83), separately]. CONCLUSIONS: AIS women patients with rural-urban insurance status demonstrated remarkable differences in age, stroke risk factors, awareness and treatment, the process of care, and 1-year stroke recurrence and mortality. Healthcare policymakers need to focus their attention on these disparities and take proper steps to improve primary healthcare service in rural areas.

Assessment of Hemodynamic Alterations in Cerebral Veins in Patients With Intracerebral Hemorrhage Using Duplex Color-Coded Sonography.

OBJECTIVES: To investigate the contributions of hemodynamic alterations in cerebral veins to the prognosis of patients with primary intracerebral hemorrhage (ICH). METHODS: Duplex color-coded sonography was performed on 87 ICH patients between July 2016 and October 2017. The time-averaged peak velocity, the time-averaged mean velocity (TAMV), the blood flow volume (BFV) of bilateral internal jugular veins (IJVs) and vertebral veins (VVs), and the mean velocities of bilateral basal veins of Rosenthal, straight sinus, and bilateral transverse sinuses were calculated to understand the relationship of hemodynamic data with prognosis in patients with ICH. RESULTS: The study revealed that the time-averaged peak velocities, TAMVs and BFVs of both right IJV and VV in ICH patients with good clinical outcomes were higher than those of the left IJV and VV, whereas statistically significant differences were not found in the mean velocity of bilateral veins of Rosenthal. The perihematomal edema volume, time-averaged peak velocities, TAMVs, and BFVs of the bilateral IJVs and right VV and the TAMV of the left VV were associated with the prognosis of ICH patients in the univariate analysis. However, the TAMV of the right IJV and BFV of the left IJV were the independent factors that predicted prognosis in multivariate analysis. Partial correlation showed that there was a linear dependence between the differences in TAMV and BFV between bilateral IJVs. CONCLUSIONS: The presence of hemodynamic changes in cerebral veins in patients with ICH has an impact on prognosis.

Relationship of ideal cardiovascular health metrics with retinal vessel calibers and retinal nerve fiber layer thickness: a cross-sectional study.

BACKGROUND: Ideal cardiovascular health (CVH) metrics have been found to be associated with subclinical vascular abnormalities. However, the relationship between ideal CVH metrics and retinal vessel calibers and retinal nerve fiber layer (RNFL) thickness in a Chinese population is unknown. METHODS: We collected information on the seven ideal CVH metrics among 3376 participants aged 40 years or older from the Asymptomatic Polyvascular Abnormalities Community Study in 2012. Retinal vessel calibers and RNFL thickness were assessed by retinal photography and spectral-domain optical coherence tomography. Multivariable linear models were used to analyze the relationship between ideal CVH metrics and retinal parameters. RESULTS: With the decreased number of ideal CVH metrics, central retinal arteriolar equivalents (CRAE) was significantly narrowed and arterio- venous ratio (AVR) significantly decreased (p < 0.0001). While the RNFL thickness and central retinal venous equivalents (CRVE) showed no significant changes with the decreased ideal CVH metrics. Linear regression showed that both CRAE and AVR was positively related with the number of ideal CVH metrics (regression coefficient beta: 0.806, 95% confidence interval (CI): 0.266-1.346 for CRAE (micron); and regression coefficient beta: 0.005, 95% CI: 0.002-0.009 for AVR) after adjusting for age (year), sex = male (n), education (n), average monthly income (¥) and other related risk factors. CONCLUSIONS: These findings suggested a clear positive relationship between the number of ideal CVH metrics and CRAE and AVR in Chinese population, supporting the importance of ideal health behaviors and factors in subclinical vascular abnormalities prevention.

Insurance status and 1-year outcomes of stroke and transient ischaemic attack: a registry-based cohort study in China.

OBJECTIVE: Although more than 95% of the population is insured by urban or rural insurance programmes in China, little research has been done on insurance-related outcome disparities for patients with acute stroke and transient ischaemic attack (TIA). This study aimed to examine the relationship between insurance status and 1-year outcomes for patients with stroke and TIA. METHODS: We abstracted 24 941 patients with acute stroke and TIA from the China National Stroke Registry II. Insurance status was categorised as Urban Basic Medical Insurance Scheme (UBMIS), New Rural Cooperative Medical Scheme (NRCMS) and self-payment. The relationship between insurance status and 1-year outcomes, including all-cause death, stroke recurrence and disability, was analysed using the shared frailty model in the Cox model or generalised estimating equation with consideration of the hospital's cluster effect. RESULTS: About 50% of patients were covered by UBMIS, 41.2% by NRCMS and 8.9% by self-payment. Compared with patients covered by UBMIS, patients covered by NRCMS had a significantly higher risk of all-cause death (9.7% vs 8.6%, adjusted HR: 1.32 (95% CI 1.17 to 1.48), p<0.001), stroke recurrence (7.2% vs 6.5%, adjusted HR: 1.12 (95% CI 1.11 to 1.37), p<0.001) and disability (32.0% vs 26.3%, adjusted OR: 1.29 (95% CI 1.21 to 1.39), p<0.001). Compared with patients covered by UBMIS, self-payment patients had a similar risk of death and stroke recurrence but a higher risk of disability. CONCLUSIONS: Patients with stroke and TIA demonstrated differences in 1-year mortality, stroke recurrence and disability between urban and rural insurance groups in China.

Cost-effectiveness of mechanical thrombectomy within 6 hours of acute ischaemic stroke in China.

OBJECTIVES: Endovascular mechanical thrombectomy is an effective but expensive therapy for acute ischaemic stroke with proximal anterior circulation occlusion. This study aimed to determine the cost-effectiveness of mechanical thrombectomy in China, which is the largest developing country. DESIGN: A combination of decision tree and Markov model was developed. Outcome and cost data were derived from the published literature and claims database. The efficacy data were derived from the meta-analyses of nine trials. One-way and probabilistic sensitivity analyses were performed in order to assess the uncertainty of the results. SETTING: Hospitals in China. PARTICIPANTS: The patients with acute ischaemic stroke caused by proximal anterior circulation occlusion within 6 hours. INTERVENTIONS: Mechanical thrombectomy within 6 hours with intravenous tissue plasminogen activator (tPA) treatment within 4.5 hours versus intravenous tPA treatment alone. OUTCOME MEASURES: The benefit conferred by the treatment was assessed by estimating the cost per quality-adjusted life-year (QALY) gained in the long term (30 years). RESULTS: The addition of mechanical thrombectomy to intravenous tPA treatment compared with standard treatment alone yielded a lifetime gain of 0.794 QALYs at an additional cost of CNY 50 000 (US$7700), resulting in a cost of CNY 63 010 (US$9690) per QALY gained. The probabilistic sensitivity analysis indicated that mechanical thrombectomy was cost-effective in 99.9% of the simulation runs at a willingness-to-pay threshold of CNY 125 700 (US$19 300) per QALY. CONCLUSIONS: Mechanical thrombectomy for acute ischaemic stroke caused by proximal anterior circulation occlusion within 6 hours was cost-effective in China. The data may be used as a reference with regard to medical resources allocation for stroke treatment in low-income and middle-income countries as well as in the remote areas in the developed countries.

Is there a correlation between socioeconomic disparity and functional outcome after acute ischemic stroke?

BACKGROUND: To investigate the impact of low socioeconomic status (SES), indicated by low level of education, occupation and income, on 3 months functional outcome after ischemic stroke. METHODS: We analyzed data from the China National Stroke Registry (CNSR), a multicenter and prospective registry of consecutive patients with acute cerebrovascular events occurred between September 2007 and August 2008. 11226 patients with ischemic stroke had SES and clinical characteristics data collected at baseline and mRS measured as indicator of functional outcome in 3 months follow up. Multinomial and ordinal logistic regression models were performed to examine associations between SES and the functional outcome. RESULTS: At 3 months after stroke, 5.3% of total patients had mRS scored at 5, 11.3% at score 4, 11.1% at score 3, 14.4% at score 2, 34.2% at score 1 and 23.7% at score 0. Compared to patients with educational level of ≥ 6 years and non-manual laboring, those < 6 years and manual laboring tended to have higher mRS score (P<0.001). Multinomial adjusted odds ratios (ORs) of outcome in manual workers were significantly increased (ORs from1.38 to 1.87), but OR in patients with less income was not significant. There were similar patterns of association The impact may be stronger in patients aged <65 years (P = 0.003, P<0.001 respectively) and being male (P = 0.001, P<0.001 respectively). CONCLUSIONS: Our study provides evidence that people who are relatively more deprived in socioeconomic status suffer poorer outcome after ischemic stroke. The influence of low educational level and manual laboring can be more intensive than low income level on 3-month outcome. Health policy and service should target the deprived populations to reduce the public health burden in the society.

Assessment and provision of rehabilitation among patients hospitalized with acute ischemic stroke in China: Findings from the China National Stroke Registry II.

Background Stroke rehabilitation improves functional recovery among stroke patients. However, little is known about clinical practice in China regarding the assessment and provision of rehabilitation among patients with acute ischemic stroke. Aims We examined the frequency and determinants of an assessment for rehabilitation among acute ischemic stroke patients from the China National Stroke Registry II. Methods Data for 19,294 acute ischemic stroke patients admitted to 219 hospitals from June 2012 to January 2013 were analyzed. The multivariable logistic regression model with the generalized estimating equation method accounting for in-hospital clustering was used to identify patient and hospital factors associated with having a rehabilitation assessment during the acute hospitalization. Results Among 19,294 acute ischemic stroke patients, 11,451 (59.4%) were assessed for rehabilitation. Rates of rehabilitation assessment varied among 219 hospitals (IQR 41.4% vs 81.5%). In the multivariable analysis, factors associated with increased likelihood of a rehabilitation assessment ( p < 0.05) included disability prior to stroke, higher NIHSS on admission, receipt of a dysphagia screen, deep venous thrombosis prophylaxis, carotid vessel imaging, longer length of stay, and treatment at a hospital with a higher number of hospital beds (per 100 units). In contrast, patients with a history of atrial fibrillation and hospitals with higher number of annual stroke discharges (per 100 patients) were less likely to receive rehabilitation assessment during the acute stroke hospitalization. Conclusions Rehabilitation assessment among acute ischemic stroke patients was suboptimal in China. Rates varied considerably among hospitals and support the need to improve adherence to recommended care for stroke survivors.

Socioeconomic Status and the Quality of Acute Stroke Care: The China National Stroke Registry.

BACKGROUND AND PURPOSE: The association of socioeconomic status (SES) with quality of stroke care is not well understood, and few studies have examined the association with different indicators of SES simultaneously. We assessed the impacts of low levels of education, occupation, and income on the quality of stroke care. METHODS: We examined data from the China National Stroke Registry recording consecutive stroke patients between September 2007 and August 2008. Baseline low SES was measured using educational level <6 years, occupation as manual workers or no job, and average family income per capita at ≤¥1000 per month. Compliance with 11 performances was summarized in a composite score defined as the proportion of all needed care given. Poor quality of care was defined as having a composite score of 0.71 or less. RESULTS: Among 12 270 patients with ischemic stroke, 38.6% had <6 educational years, 37.6% had manual workers/no job, and 34.7% had income ≤¥1000 per month. There was an increased chance of receiving poor quality of care in patients with low education (adjusted odds ratio 1.15, 95% confidence interval 1.03-1.28), low occupation (adjusted odds ratio 1.16, 95% confidence interval 1.01-1.32), and low income (adjusted odds ratio 1.18, 95% confidence interval 1.06-1.30), respectively. People with low SES had poor performances on some aspects of care quality. Combined effects existed among these SES indicators; those with low SES from all 3 indicators had the poorest quality of care. CONCLUSIONS: There was a social gradient in the quality of stroke care. Continuous efforts of socioeconomic improvement will increase the quality of acute stroke care.

Screening for cognitive impairment with the Montreal Cognitive Assessment in Chinese patients with acute mild stroke and transient ischaemic attack: a validation study.

OBJECTIVE: We aimed to establish the cut-off point of the Montreal Cognitive Assessment (MoCA-Beijing) in screening for cognitive impairment (CI) within 2 weeks of mild stroke or transient ischaemic attack (TIA). METHODS: A total of 80 acute mild ischaemic stroke patients and 22 TIA patients were recruited. They received the MoCA-Beijing and a formal neuropsychological test battery. CI was defined by 1.5 SD below the established norms on a formal neuropsychological test battery. RESULTS: Most stroke and TIA patients were in their 50s (53.95±11.43 years old), with greater than primary school level of education. The optimal cut-off point for MoCA-Beijing in discriminating patients with CI from those with no cognitive impairment (NCI) was 22/23 (sensitivity 85%, specificity 88%, positive predictive value=91%, negative predictive value=80%, classification accuracy=86%). The predominant cognitive deficits were characteristic of frontal-subcortical impairment, such as visuomotor speed (46.08%), attention/executive function (42.16%) and visuospatial ability (40.20%). CONCLUSIONS: A MoCA-Beijing cut-off score of 22/23 is optimally sensitive and specific for detecting CI after mild stroke, and TIA in the acute stroke phase, and is recommended for routine clinical practice.

Cost-effectiveness of thrombolysis within 4.5 hours of acute ischemic stroke in China.

BACKGROUND: Previous economic studies conducted in developed countries showed intravenous tissue-type plasminogen activator (tPA) is cost-effective for acute ischemic stroke. The present study aimed to determine the cost-effectiveness of tPA treatment in China, the largest developing country. METHODS: A combination of decision tree and Markov model was developed to determine the cost-effectiveness of tPA treatment versus non-tPA treatment within 4.5 hours after stroke onset. Outcomes and costs data were derived from the database of Thrombolysis Implementation and Monitor of acute ischemic Stroke in China (TIMS-China) study. Efficacy data were derived from a pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Costs and quality-adjusted life-years (QALYs) were compared in both short term (2 years) and long term (30 years). One-way and probabilistic sensitivity analyses were performed to test the robustness of the results. RESULTS: Comparing to non-tPA treatment, tPA treatment within 4.5 hours led to a short-term gain of 0.101 QALYs at an additional cost of CNY 9,520 (US$ 1,460), yielding an incremental cost-effectiveness ratio (ICER) of CNY 94,300 (US$ 14,500) per QALY gained in 2 years; and to a long-term gain of 0.422 QALYs at an additional cost of CNY 6,530 (US$ 1,000), yielding an ICER of CNY 15,500 (US$ 2,380) per QALY gained in 30 years. Probabilistic sensitivity analysis showed that tPA treatment is cost-effective in 98.7% of the simulations at a willingness-to-pay threshold of CNY 105,000 (US$ 16,200) per QALY. CONCLUSIONS: Intravenous tPA treatment within 4.5 hours is highly cost-effective for acute ischemic strokes in China.

Cost-effectiveness of clopidogrel-aspirin versus aspirin alone for acute transient ischemic attack and minor stroke.

BACKGROUND: Treatment with the combination of clopidogrel and aspirin taken soon after a transient ischemic attack (TIA) or minor stroke was shown to reduce the 90-day risk of stroke in a large trial in China, but the cost-effectiveness is unknown. This study sought to estimate the cost-effectiveness of the clopidogrel-aspirin regimen for acute TIA or minor stroke. METHODS AND RESULTS: A Markov model was created to determine the cost-effectiveness of treatment of acute TIA or minor stroke patients with clopidogrel-aspirin compared with aspirin alone. Inputs for the model were obtained from clinical trial data, claims databases, and the published literature. The main outcome measure was cost per quality-adjusted life-years (QALYs) gained. One-way and multivariable probabilistic sensitivity analyses were performed to test the robustness of the findings. Compared with aspirin alone, clopidogrel-aspirin resulted in a lifetime gain of 0.037 QALYs at an additional cost of CNY 1250 (US$ 192), yielding an incremental cost-effectiveness ratio of CNY 33 800 (US$ 5200) per QALY gained. Probabilistic sensitivity analysis showed that clopidogrel-aspirin therapy was more cost-effective in 95.7% of the simulations at a willingness-to-pay threshold recommended by the World Health Organization of CNY 105 000 (US$ 16 200) per QALY. CONCLUSIONS: Early 90-day clopidogrel-aspirin regimen for acute TIA or minor stroke is highly cost-effective in China. Although clopidogrel is generic, Plavix is brand in China. If Plavix were generic, treatment with clopidogrel-aspirin would have been cost saving.

Risk assessment of deep-vein thrombosis after acute stroke: a prospective study using clinical factors.

AIMS: Deep-vein thrombosis (DVT) represents a serious complication in acute stroke patients with pulmonary embolus (PE) as a potential outcome. Prediction of DVT may help with formulating a proper prevention strategy. To assess of the risk of deep venous thrombosis (DVT) in acute stroke patients, we developed and validated a clinical score in a cohort study. METHODS: Incidence of Deep Venous Thrombosis after Acute Stroke in China (INVENT-China) is a multicenter prospective cohort study. The potential predictive variables for DVT at baseline were collected, and the presence of DVT was evaluated using ultrasonography on the 14 ± 3 days. Data were randomly assigned to either a training data set or a test data set. Multivariate logistic regression analysis was used to develop risk scores to predict DVT in the training data set and the area under the receiver operating characteristic curve to validate the score in the test data set. RESULTS: From 2006-2007, 862 hospital-based acute stroke patients were enrolled in China. The overall incidence of DVT after acute stroke within two weeks was 12.4% (95%CI 10.3-14.7%). A seven-point score derived in the training data set (age [≥65 years = 1], sex [female gender = 1]), obesity [BMI ≥ 25 kg/m(2) = 1], active cancer [yes = 2], stroke subtype [cerebral hemorraghe = 1], muscle weakness [≥2 on Lower limb NIHSS score = 1] was highly predictive of 14-day risk of DVT(c statistic = 0.70, 95% CI, 0.64-0.76, P < 0.001), in the overall study population(c statistic = 0.65, 95% CI 0.59-0.70, P < 0.001). CONCLUSIONS: This clinical score may help identify acute stroke patients with high risk of DVT. In addition, it also serves as a platform to develop further models of DVT prediction in stroke patients based on clinical factors.