Driving stroke quality improvement at scale in EDs across a nationwide network of hospitals: strategies and interventions.

OBJECTIVES: Reducing the treatment time while increasing the proportion of eligible stroke patients who receive intravenous tissue plasminogen activator (tPA) has been a priority for many quality improvement efforts. Recent studies have primarily focused on identifying interventions that reduce door-to-needle (DTN) time, while comparatively little has been done to determine whether these interventions also improve tPA rates. METHODS: In order to investigate interventions related to process improvements, an electronic dashboard serving as a stroke performance tool was implemented to store and retrieve patient outcome data. These data were used to study the efficacy of interventions designed to facilitate triage of stroke patients in the ED, and determine the individual interventions associated with the most significant improvements in the fraction of patients receiving tPA and in reducing the DTN time. Stroke performance data from the dashboard collected over a 2-year period (2015-2017) from 89 US hospitals were analysed with respect to interventions implemented by individual facilities, as verified by a hospital survey. RESULTS: A statistically significant association was found between increases in the fraction of patients receiving tPA and reductions in DTN time over the study period. These improvements in outcomes were most strongly associated with process interventions that allocate stroke-specific physical and human resources in the ED, most notably a designated emergency room space for stroke, and with workflows that decrease the time to key checkpoints for determining a patient's eligibility for tPA. CONCLUSIONS: Data from the stroke performance tool was leveraged to identify the programmes and process interventions that lead to improved patient outcomes and allow EDs to better prioritise process interventions and resources.

Higher Incidence of Ischemic Stroke in Patients Taking Novel Oral Anticoagulants.

Background and Purpose- The increased use of novel oral anticoagulants (NOACs) to control atrial fibrillation is largely driven by the assumption that they are equally effective as warfarin at preventing ischemic stroke while putting patients at lower risk of hemorrhages. To test this hypothesis, a retrospective study of the relative incidence of strokes among patients taking NOACs versus those taking warfarin is performed. Methods- Relative stroke incidence in the 2 groups of patients was compared using odds ratios and Fisher exact tests for significance using a data set of 71 365 on NOACs and 59 546 patients on warfarin. In addition, the 7033 patients with a record of both warfarin and NOAC use were analyzed as a separate cohort. Results- There is a significantly higher (odds ratio=1.29, <0.001) frequency of ischemic strokes among patients prescribed NOACs compared with those on warfarin. The relative frequency of ischemic strokes was also higher for every individual NOAC compared with warfarin (these higher frequencies are statistically significant for dabigatran and apixaban, though not for edoxaban and rivaroxaban). There is a lower incidence of intracranial hemorrhages and nontraumatic hemorrhages in general among patients taking NOACs, consistent with the published literature. Comparisons of the demographic and clinical profiles of the patients taking NOACs to those on warfarin do not show significantly higher background stroke risk in NOAC patients; in fact, patients on NOACs tend to be at lower background risk overall for ischemic strokes. Conclusions- Because NOAC use is associated with higher ischemic stroke risk together with a lower risk of hemorrhages than warfarin use, it can be concluded that patients on warfarin are more strongly anticoagulated. The observed effect could be a secondary consequence of dosage control or alternatively a result of different anticoagulant effects among the different medications.

One-year outcomes of early-crossover patients in a cohort receiving nonoperative care for lumbar disc herniation.

OBJECTIVE The authors comprehensively studied the recovery course and 1-year outcomes of early-crossover patients who were randomized to the nonoperative care arm of the Leiden-The Hague Spine Intervention Prognostic Study. The primary goal was to gain insight into the differences in the recovery patterns of early-crossover patients and those treated nonoperatively; secondary goals were to identify predictors of good 1-year outcomes, and to understand when and why patients were likely to cross over. METHODS Individual EuroQol-5D scores were obtained at baseline and at 2, 4, 8, 12, 26, 38, and 52 weeks for 142 patients. Early-crossover patients were defined as those electing to undergo surgery during the first 12 weeks of treatment. Crossover and noncrossover groups were compared using Kruskal-Wallis, Wilcoxon-Mann-Whitney, and chi-square tests. Linear mixed-effects models were used to examine the growth trajectories of crossover and noncrossover groups. Recursive partitioning trees were used to model crossover events and the timing of crossover decisions. Multivariable logistic regression models were used to identify predictors of good 1-year outcomes. RESULTS Of the 142 patients randomized to receive prolonged nonoperative care, 136 were selected for the study. In this cohort, 43/136 (32%) opted for surgery, and 31/43 (72%) of crossover events occurred before the 12-week time point. Early-crossover patients had significantly greater functional impairment at Week 2 than noncrossover patients (p = 0.031), but experienced greater recovery by 26 weeks and better 1-year outcomes (p = 0.045). Patients who did not experience an improvement in their symptoms between 2 and 8 weeks were more likely to cross over (OR 3.5, 95% CI 1.2-10.1; p = 0.01). Recursive partitioning trees were able to identify crossover patients with 76% accuracy. Regression models suggested that better recovery at 26 weeks (p < 0.01) was predictive of good 1-year outcome; declining health status between Weeks 4 and 8 was negatively predictive of good outcome (p < 0.01). CONCLUSIONS This study is the first to comprehensively analyze the recovery and outcomes of crossover patients, and compare them to nonoperatively treated patients. The results suggest that patients who have a low EuroQol-5D score during the early weeks of treatment and who do not respond to nonoperative care during the first few weeks of treatment are most likely to cross over. Early-crossover patients experience a greater rate of recovery and more frequently have a good 1-year outcome when compared with nonoperatively treated patients. The current results motivate a broader investigation into the timing of surgery and the identification of patient populations that will be most benefited by early surgical treatment for lumbar disc herniation.