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1.
J Neurointerv Surg ; 2020 Mar 13.
Artículo en Inglés | MEDLINE | ID: mdl-32169931

RESUMEN

BACKGROUND: Rates of intra-arterial revascularization treatments (IAT) for acute ischemic stroke (AIS) are increasing in the USA. Using a multi-state stroke registry, we studied the trend in IAT use among patients with AIS over a period spanning 11 years. We examined the impact of IAT rates on hospital procedure volumes and patient outcome after stroke. METHODS: We used data from the Paul Coverdell National Acute Stroke Program (PCNASP) and explored trends in IAT between 2008 and 2018. Patient outcomes were examined by rates of IAT procedures across hospitals. Specifically, outcomes were compared across low-volume (<15 IAT per year), medium-volume (15-30 IAT per year), and high-volume hospitals (>30 IAT per year). Favorable outcome was defined as discharge to home. RESULTS: There were 612 958 patients admitted with AIS to 687 participating hospitals within the PCNASP during this study. Only 2.9% of patients (mean age 68.5 years, 49.3% women) received IAT. The percent of patients with AIS receiving IAT increased from 1% in 2008 to 5.3% in 2018 (p<0.001). The proportion of low-volume hospitals decreased over time (p<0.001), and the proportions of medium-volume (p=0.007) and high-volume hospitals (p<0.001) increased between 2008 and 2018. When compared with medium-volume hospitals, high-volume hospitals had a higher (p<0.0001) and low-volume hospitals had a lower (p<0.0001) percent of patients discharged to home. CONCLUSION: High-volume hospitals were associated with a higher rate of favorable outcome. With the increased use of IAT among patients with AIS, the proportion of low-volume hospitals performing IAT significantly decreased.

3.
Stroke ; 51(3): 729-735, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32078487
4.
J Neurointerv Surg ; 2019 Oct 25.
Artículo en Inglés | MEDLINE | ID: mdl-31653755

RESUMEN

BACKGROUND: The intra-arterial treatment (IAT) of acute ischemic stroke (AIS) is now evidence-based and given the highest level of recommendation among eligible patients. Using a multi-state stroke registry, we studied the trend in IAT among patients with AIS over 11 years and its impact on the utilization of intravenous thrombolysis (IVT) within the same 11 years. METHODS: Using data from the Paul Coverdell National Acute Stroke Program (PCNASP), we studied trends in IVT and IAT for patients with AIS between 2008 and 2018. Trends over time were examined for rates of IVT only, IAT only, or a combination of IVT and IAT (IVT+IAT). Favorable outcome was defined as discharge to home. RESULTS: During the study period there were 595 677 patients (mean age 70.4 years, 50.4% women) from 646 participating hospitals with a clinical diagnosis of AIS in the PCNASP. Trends for IVT only, IAT only, and IVT+IAT all significantly increased over time (P<0.001). Total use of IVT and IAT increased from 7% in 2008 to 19.1% in 2018. The rate of patients discharged to home increased significantly over time among all treatment groups (P<0.001). CONCLUSION: In our large registry-based analysis, we observed a significant increase in the use of IAT for the treatment of AIS, with continued increases in the use of IVT. Concurrently, the percent of patients with favorable outcomes continued to increase.

5.
Artículo en Inglés | MEDLINE | ID: mdl-31607635

RESUMEN

Despite the premature heart disease mortality rate among adults aged 25-64 decreasing by 70% since 1968, the rate has remained stagnant from 2011 on and, in 2017, still accounted for almost 1-in-5 of all deaths among this age group. Moreover, these overall findings mask important differences and continued disparities observed by demographic characteristics and geography. For example, in 2017, rates were 134% higher among men compared to women and 87% higher among blacks compared to whites, and, while the greatest burden remained in the southeastern US, almost two-thirds of all US counties experienced increasing rates among adults aged 35-64 during 2010-2017. Continued high rates of uncontrolled blood pressure and increasing prevalence of diabetes and obesity pose obstacles for re-establishing a downward trajectory for premature heart disease mortality; however, proven public health and clinical interventions exist that can be used to address these conditions.

6.
Stroke ; 50(8): 1959-1967, 2019 08.
Artículo en Inglés | MEDLINE | ID: mdl-31208302

RESUMEN

Background and Purpose- International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification (ICD-9-CM and ICD-10-CM) codes are often used for disease surveillance. We examined changes in concordance between ICD-CM codes and clinical diagnoses before and after the transition to ICD-10-CM in the United States (October 1, 2015), and determined if there were systematic variations in concordance by patient and hospital characteristics. Methods- We included Paul Coverdell National Acute Stroke Program patient discharges from 2014 to 2017. Concordance between ICD-CM codes and the clinical diagnosis documented by the physician (assumed as accurate) was calculated for each diagnosis category: ischemic stroke, transient ischemic attack, subarachnoid hemorrhage, and intracerebral hemorrhage. Results- In total, 314 857 patient records were included in the analysis (n=280 hospitals), 55.9% of which were obtained after the transition to ICD-10-CM. While concordance was generally high, a small, and temporary decline occurred from the last calendar quarter of ICD-9-CM (average unadjusted concordance =92.8%) to the first quarter of ICD-10-CM use (91.0%). Concordance differed by diagnosis category and was generally highest for ischemic stroke. In the analysis of ICD-10-CM records, disagreements often occurred between ischemic stroke and transient ischemic attack records and between subarachnoid and intracerebral hemorrhage records. Compared with the smallest hospitals (≤200 beds), larger hospitals had significantly higher odds of concordance (ischemic stroke adjusted odds ratio for ≥400 beds, 1.7; 95% CI, 1.5-1.9). Conclusions- This study identified a small and transient decline in concordance between ICD-CM codes and stroke clinical diagnoses during the coding transition, indicating no substantial impact on the overall identification of stroke patients. Researchers and policymakers should remain aware of potential changes in ICD-CM code accuracy over time, which may affect disease surveillance. Systematic variations in the accuracy of codes by hospital and patient characteristics have implications for quality-of-care studies and hospital comparative assessments.

7.
Prev Chronic Dis ; 16: E52, 2019 04 25.
Artículo en Inglés | MEDLINE | ID: mdl-31022369

RESUMEN

INTRODUCTION: Little is known about trends in the overall combined burden of fatal and nonfatal cerebrovascular disease events in the United States. Our objective was to describe the combined burden by age, sex, and region from 2006 through 2014. METHODS: We used data on adults aged 35 and older from 2006 through 2014 Nationwide Emergency Department Sample, National Inpatient Sample of the Healthcare Cost and Utilization Project, and the National Vital Statistics System. We calculated age-standardized cerebrovascular disease event rates by using the 2010 US Census population. Trends in rates were assessed by calculating the relative percentage change (RPC) between 2006 and 2014, and by using Joinpoint to obtain P values for overall trends. RESULTS: The age-standardized rate increased significantly for total cerebrovascular disease events (primary plus comorbid events) from 1,050 per 100,000 in 2006 to 1,147 per 100,000 in 2014 (P < .05 for trend). Treat-and-release emergency department visits with comorbid cerebrovascular disease events increased significantly, from 114 per 100,000 in 2006 to 213 per 100,000 in 2014 (RPC of 87%, P < .05 for trend). Significant rate increases were identified among adults aged 35 to 64 with an RPC of 19% in primary cerebrovascular disease events, 48% in comorbid cerebrovascular disease events, and 36% in total events. CONCLUSION: Our findings have important implications for the increasing cerebrovascular disease burden among adults aged 35 to 64. Focused prevention strategies should be implemented, especially among young adults who may be unaware of existing modifiable risk factors.


Asunto(s)
Factores de Edad , Trastornos Cerebrovasculares/economía , Trastornos Cerebrovasculares/epidemiología , Costo de Enfermedad , Geografía , Factores Sexuales , Adulto , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Prevalencia , Estados Unidos/epidemiología
8.
Circ Cardiovasc Qual Outcomes ; 11(12): e004981, 2018 12.
Artículo en Inglés | MEDLINE | ID: mdl-30557047

RESUMEN

BACKGROUND: The clinical benefit of intravenous (IV) alteplase in acute ischemic stroke is time dependent. We assessed the overall temporal changes in door-to-needle (DTN) time and examine the factors associated with DTN time ≤60 and ≤45 minutes. METHODS AND RESULTS: A total of 496 336 acute ischemic stroke admissions were identified in the Paul Coverdell National Acute Stroke Program from 2008 to 2017. We used generalized estimating equations models to examine the factors associated with DTN time ≤60 and ≤45 minutes, and calculated adjusted odds ratios and 95% CI. Between 2008 and 2017, the percentage of acute ischemic stroke patients who received IV alteplase including those transferred, increased from 6.4% to 15.3%. After excluding those who received IV alteplase at an outside hospital, a total of 39 737 (8%) acute ischemic stroke patients received IV alteplase within 4.5 hours of the time the patient last known to be well. Significant increases were seen in DTN time ≤60 minutes (26.4% in 2008 to 66.2% in 2017, P<0.001), as well as DTN time ≤45 minutes (10.7% in 2008 to 40.5% in 2017, P<0.001). Patients aged 55 to 84 years were more likely to receive IV alteplase within 60 minutes, while those aged 55 to 74 years were more likely to receive IV alteplase within 45 minutes, as compared with those aged 18 to 54 years. Arrival by emergency medical service, and patients with severe stroke were more likely to receive IV alteplase within 60 and 45 minutes. Conversely, women, black patients as compared with white, and patients with a medical history of diseases associated with stroke were less likely to receive DTN time ≤60 or 45 minutes. CONCLUSIONS: Rapid improvements in DTN time were observed in the Paul Coverdell National Acute Stroke Program; however, opportunities to reduce disparities remain.


Asunto(s)
Isquemia Encefálica/tratamiento farmacológico , Fibrinolíticos/administración & dosificación , Mejoramiento de la Calidad , Indicadores de Calidad de la Atención de Salud , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica , Tiempo de Tratamiento , Activador de Tejido Plasminógeno/administración & dosificación , Administración Intravenosa , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico , Femenino , Fibrinolíticos/efectos adversos , Disparidades en Atención de Salud , Humanos , Masculino , Persona de Mediana Edad , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Terapia Trombolítica/efectos adversos , Factores de Tiempo , Activador de Tejido Plasminógeno/efectos adversos , Resultado del Tratamiento , Estados Unidos , Adulto Joven
9.
J Am Med Inform Assoc ; 25(12): 1634-1642, 2018 12 01.
Artículo en Inglés | MEDLINE | ID: mdl-30541125

RESUMEN

Background: The prevalence of moderate or complex (moderate-complex) congenital heart defects (CHDs) among adults is increasing due to improved survival, but many patients experience lapses in specialty care or their CHDs are undocumented in the medical system. There is, to date, no efficient approach to identify this population. Objective: To develop and assess the performance of a risk score to identify adults aged 20-60 years with undocumented specific moderate-complex CHDs from electronic health records (EHR). Methods: We used a case-control study (596 adults with specific moderate-complex CHDs and 2384 controls). We extracted age, race/ethnicity, electrocardiogram (EKG), and blood tests from routine outpatient visits (1/2009 through 12/2012). We used multivariable logistic regression models and a split-sample (4: 1 ratio) approach to develop and internally validate the risk score, respectively. We generated receiver operating characteristic (ROC) c-statistics and Brier scores to assess the ability of models to predict the presence of specific moderate-complex CHDs. Results: Out of six models, the non-blood biomarker model that included age, sex, and EKG parameters offered a high ROC c-statistic of 0.96 [95% confidence interval: 0.95, 0.97] and low Brier score (0.05) relative to the other models. The adult moderate-complex congenital heart defect risk score demonstrated good accuracy with 96.4% sensitivity and 80.0% specificity at a threshold score of 10. Conclusions: A simple risk score based on age, sex, and EKG parameters offers early proof of concept and may help accurately identify adults with specific moderate-complex CHDs from routine EHR systems who may benefit from specialty care.


Asunto(s)
Algoritmos , Electrocardiografía , Registros Electrónicos de Salud , Cardiopatías Congénitas/diagnóstico , Adulto , Factores de Edad , Biomarcadores , Estudios de Casos y Controles , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Curva ROC , Riesgo , Factores Sexuales , Adulto Joven
10.
MMWR Morb Mortal Wkly Rep ; 67(35): 983-991, 2018 Sep 07.
Artículo en Inglés | MEDLINE | ID: mdl-30188885

RESUMEN

INTRODUCTION: Despite decades-long reductions in cardiovascular disease (CVD) mortality, CVD mortality rates have recently plateaued and even increased in some subgroups, and the prevalence of CVD risk factors remains high. Million Hearts 2022, a 5-year initiative, was launched in 2017 to address this burden. This report establishes a baseline for the CVD risk factors targeted for reduction by the initiative during 2017-2021 and highlights recent changes over time. METHODS: Risk factor prevalence among U.S. adults was assessed using data from the National Health and Nutrition Examination Survey, National Survey on Drug Use and Health, and National Health Interview Survey. Multivariate analyses were performed to assess differences in prevalence during 2011-2012 and the most recent cycle of available data, and across subgroups. RESULTS: During 2013-2014, the prevalences of aspirin use for primary and secondary CVD prevention were 27.4% and 74.9%, respectively, and of statin use for cholesterol management was 54.5%. During 2015-2016, the average daily sodium intake was 3,535 mg/day and the prevalences of blood pressure control, combustible tobacco use, and physical inactivity were 48.5%, 22.3%, and 29.1%, respectively. Compared with 2011-2012, significant decreases occurred in the prevalences of combustible tobacco use and physical inactivity; however, a decrease also occurred for aspirin use for primary or secondary prevention. Disparities in risk factor prevalences were observed across age groups, genders, and racial/ethnic groups. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Millions of Americans have CVD risk factors that place them at increased risk for having a cardiovascular event, despite the existence of proven strategies for preventing or managing CVD risk factors. A concerted effort to implement these strategies will be needed to prevent one million acute cardiovascular events during the 5-year initiative.


Asunto(s)
Enfermedades Cardiovasculares/epidemiología , Adulto , Anciano , Enfermedades Cardiovasculares/prevención & control , Femenino , Encuestas Epidemiológicas , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Factores de Riesgo , Estados Unidos/epidemiología
11.
Prev Chronic Dis ; 15: E73, 2018 06 07.
Artículo en Inglés | MEDLINE | ID: mdl-29885674

RESUMEN

Approximately 1 in 3 US adults has hypertension, but only half have their blood pressure controlled. We identified characteristics of health care practices and systems (hereinafter practices) effective in achieving control rates at or above 70% by using data collected via applications submitted from April through June 2017 for consideration in the Million Hearts Hypertension Control Challenge. We included 96 practices serving 635,000 patients with hypertension across 34 US states in the analysis. Mean hypertension control rate was 77.1%; 27.1% of practices had a control rate of 80% or greater. Although many practices served large populations with multiple risk factors for uncontrolled hypertension, high control rates were achieved with implementation of evidenced-based strategies.


Asunto(s)
Hipertensión/terapia , Antihipertensivos/uso terapéutico , Presión Sanguínea , Determinación de la Presión Sanguínea , Prestación de Atención de Salud , Registros Electrónicos de Salud , Humanos , Hipertensión/epidemiología , Pautas de la Práctica en Medicina , Prevalencia , Población Rural , Estados Unidos/epidemiología , Población Urbana
15.
MMWR Morb Mortal Wkly Rep ; 66(45): 1248-1251, 2017 Nov 17.
Artículo en Inglés | MEDLINE | ID: mdl-29145353

RESUMEN

Adherence to prescribed medications is associated with improved clinical outcomes for chronic disease management and reduced mortality from chronic conditions (1). Conversely, nonadherence is associated with higher rates of hospital admissions, suboptimal health outcomes, increased morbidity and mortality, and increased health care costs (2). In the United States, 3.8 billion prescriptions are written annually (3). Approximately one in five new prescriptions are never filled, and among those filled, approximately 50% are taken incorrectly, particularly with regard to timing, dosage, frequency, and duration (4). Whereas rates of nonadherence across the United States have remained relatively stable, direct health care costs associated with nonadherence have grown to approximately $100-$300 billion of U.S. health care dollars spent annually (5,6). Improving medication adherence is a public health priority and could reduce the economic and health burdens of many diseases and chronic conditions (7).


Asunto(s)
Enfermedad Crónica/tratamiento farmacológico , Cumplimiento de la Medicación/estadística & datos numéricos , Medicamentos bajo Prescripción/uso terapéutico , Difusión de Innovaciones , Humanos , Resultado del Tratamiento , Estados Unidos
16.
Am J Prev Med ; 53(6S2): S205-S212, 2017 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-29153122

RESUMEN

INTRODUCTION: Studies have demonstrated that intravenous recombinant tissue plasminogen activator (IV rtPA) is a cost-effective treatment for acute ischemic stroke. Age-specific cost effectiveness has not been well examined. This study estimated age-specific incremental cost-effectiveness ratios (ICERs) of IV rtPA treatment versus no IV rtPA. METHODS: A Markov model was developed to examine the economic impact of IV rtPA over a 20-year time horizon on four age groups (18-44, 45-64, 65-80, and ≥81 years) from the U.S. healthcare sector perspective. The model used health outcomes from a national stroke registry adjusted by parameters from previous literature and current hospitalization costs in 2013 U.S. dollars. Long-term annual costs and quality-adjusted life years (QALYs) in the years after a stroke were discounted at 3% per year. Incremental costs, incremental QALYs, and ICERs were estimated and sensitivity analyses were conducted between 2015 and 2017. RESULTS: Use of IV rtPA gained 0.55 QALYs and cost $3,941 more than no IV rtPA for stroke patients aged ≥18 years over a 20-year time horizon. IV rtPA was a dominant strategy compared to no IV rtPA for patients aged 18-44 and 45-64 years. For patients aged 65-80 years, IV rtPA gained 0.44 QALYs and cost $4,872 more than no IV rtPA (ICER=$11,132/QALY). For patients aged ≥81 years, ICER was estimated at $48,676/QALY. CONCLUSIONS: IV rtPA saved costs and improved health outcomes for patients aged 18-64 years and was cost effective for those aged ≥65 years. These findings support the use of IV rtPA.


Asunto(s)
Isquemia Encefálica/tratamiento farmacológico , Análisis Costo-Beneficio , Fibrinolíticos/economía , Accidente Cerebrovascular/tratamiento farmacológico , Activador de Tejido Plasminógeno/economía , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/economía , Isquemia Encefálica/epidemiología , Femenino , Fibrinolíticos/uso terapéutico , Costos de la Atención en Salud/estadística & datos numéricos , Hospitalización/economía , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Modelos Económicos , Años de Vida Ajustados por Calidad de Vida , Proteínas Recombinantes/economía , Proteínas Recombinantes/uso terapéutico , Sistema de Registros/estadística & datos numéricos , Accidente Cerebrovascular/economía , Accidente Cerebrovascular/epidemiología , Activador de Tejido Plasminógeno/uso terapéutico , Resultado del Tratamiento , Estados Unidos/epidemiología , Adulto Joven
17.
Am J Cardiol ; 120(11): 1966-1973, 2017 Dec 01.
Artículo en Inglés | MEDLINE | ID: mdl-28964382

RESUMEN

The prevalence of atrial fibrillation (AF) is increasing in the United States as the population ages, but national surveillance is lacking. This cross-sectional study (2006 to 2014) analyzed data from the Healthcare Cost and Utilization Project's Nationwide Emergency Department Sample, the National (Nationwide) Inpatient Sample, and the National Vital Statistics System. Event totals were estimated independently for emergency department (ED) visits, hospitalizations, and mortality, and then collectively after applying criteria to identify mutually exclusive events. Rates were calculated for AF as primary diagnosis or underlying cause of death (primary AF), as well as secondary diagnosis or contributing cause of death (co-morbid AF), and standardized by age to the 2010 US population. From 2006 to 2014, event rates increased for primary AF (249 to 268 per 100,000) and co-morbid AF (1,473 to 1,835 per 100,000). In 2014, an estimated 599,790 ED visits, 453,060 hospitalizations, and 21,712 deaths listed AF as primary. A total of 684,470 mutually exclusive primary AF and 4,695,997 mutually exclusive co-morbid AF events occurred. Among ED visits and hospitalizations with primary AF, the most common secondary diagnoses were hypertension, heart failure, ischemic heart disease, and diabetes. The mean cost per hospitalization with primary AF was $8,819. Mean costs were higher for those with co-morbid AF versus those without co-morbid AF among hospitalizations with a primary diagnosis of ischemic heart disease, heart failure, stroke, hypertension, or diabetes (all p ≤0.01). In conclusion, with the substantial health and economic impact of AF and an aging US population, improved diagnosis, prevention, management, and surveillance of AF are increasingly important.


Asunto(s)
Fibrilación Atrial/mortalidad , Servicio de Urgencia en Hospital/estadística & datos numéricos , Predicción , Costos de Hospital/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Pacientes Internos/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/economía , Fibrilación Atrial/terapia , Estudios Transversales , Servicio de Urgencia en Hospital/economía , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria/tendencias , Hospitalización/economía , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estados Unidos/epidemiología , Adulto Joven
18.
MMWR Morb Mortal Wkly Rep ; 66(35): 933-939, 2017 Sep 08.
Artículo en Inglés | MEDLINE | ID: mdl-28880858

RESUMEN

INTRODUCTION: The prominent decline in U.S. stroke death rates observed for more than 4 decades has slowed in recent years. CDC examined trends and patterns in recent stroke death rates among U.S. adults aged ≥35 years by age, sex, race/ethnicity, state, and census region. METHODS: Trends in the rates of stroke as the underlying cause of death during 2000-2015 were analyzed using data from the National Vital Statistics System. Joinpoint software was used to identify trends in stroke death rates, and the excess number of stroke deaths resulting from unfavorable changes in trends was estimated. RESULTS: Among adults aged ≥35 years, age-standardized stroke death rates declined 38%, from 118.4 per 100,000 persons in 2000 to 73.3 per 100,000 persons in 2015. The annual percent change (APC) in stroke death rates changed from 2000 to 2015, from a 3.4% decrease per year during 2000-2003, to a 6.6% decrease per year during 2003-2006, a 3.1% decrease per year during 2006-2013, and a 2.5% (nonsignificant) increase per year during 2013-2015. The last trend segment indicated a reversal from a decrease to a statistically significant increase among Hispanics (APC = 5.8%) and among persons in the South Census Region (APC = 4.2%). Declines in stroke death rates failed to continue in 38 states, and during 2013-2015, an estimated 32,593 excess stroke deaths might not have occurred if the previous rate of decline could have been sustained. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Prior declines in stroke death rates have not continued in recent years, and substantial variations exist in timing and magnitude of change by demographic and geographic characteristics. These findings suggest the importance of strategically identifying opportunities for prevention and intervening in vulnerable populations, especially because effective and underused interventions to prevent stroke incidence and death are known to exist.


Asunto(s)
Accidente Cerebrovascular/mortalidad , Estadísticas Vitales , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Mortalidad/tendencias , Estados Unidos/epidemiología
19.
Stroke ; 48(10): 2836-2842, 2017 10.
Artículo en Inglés | MEDLINE | ID: mdl-28830975

RESUMEN

BACKGROUND AND PURPOSE: Rehabilitation is recommended after a stroke to enhance recovery and improve outcomes, but hospital's use of inpatient rehabilitation facilities (IRFs) or skilled nursing facility (SNF) and the factors associated with referral are unknown. METHODS: We analyzed clinical registry and claims data for 31 775 Medicare beneficiaries presenting with acute ischemic stroke from 918 Get With The Guidelines-Stroke hospitals who were discharged to either IRF or SNF between 2006 and 2008. Using a multilevel logistic regression model, we evaluated patient and hospital characteristics, as well as geographic availability, in relation to discharge to either IRF or SNF. After accounting for observed factors, the median odds ratio was reported to quantify hospital-level variation in the use of IRF versus SNF. RESULTS: Of 31 775 patients, 17 662 (55.6%) were discharged to IRF and 14 113 (44.4%) were discharged to SNF. Compared with SNF patients, IRF patients were younger, more were men, had less health-service use 6 months prestroke, and had fewer comorbid conditions and in-hospital complications. Use of IRF or SNF varied significantly across hospitals (median IRF use, 55.8%; interquartile range, 34.8%-75.0%; unadjusted median odds ratio, 2.59; 95% confidence interval, 2.44-2.77). Hospital-level variation in discharge rates to IRF or SNF persisted after adjustment for patient, clinical, and geographic variables (adjusted median odds ratio, 2.87; 95% confidence interval, 2.68-3.11). CONCLUSIONS: There is marked unexplained variation among hospitals in their use of IRF versus SNF poststroke even after accounting for clinical characteristics and geographic availability. CLINICAL TRIAL REGISTRATION: URL: https://clinicaltrials.gov. Unique identifier: NCT02284165.


Asunto(s)
Isquemia Encefálica/terapia , Hospitalización , Instituciones de Cuidados Especializados de Enfermería/estadística & datos numéricos , Rehabilitación de Accidente Cerebrovascular/estadística & datos numéricos , Accidente Cerebrovascular/terapia , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiología , Femenino , Hospitalización/tendencias , Humanos , Masculino , Sistema de Registros , Instituciones de Cuidados Especializados de Enfermería/normas , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/epidemiología , Rehabilitación de Accidente Cerebrovascular/normas
20.
Stroke Vasc Neurol ; 2(2): 73-83, 2017.
Artículo en Inglés | MEDLINE | ID: mdl-28736623

RESUMEN

BACKGROUND: Intravenous recombinant tissue plasminogen activator (IV rtPA) is recommended treatment for acute ischemic stroke patients, but the cost-effectiveness of IV rtPA within different time windows after the onset of acute ischemic stroke is not well reviewed. AIMS: To conduct a literature review of the cost-effectiveness studies about IV rtPA by treatment times. SUMMARY OF REVIEW: A literature search was conducted using MEDLINE, EMBASE, CINAHL and Cochrane Library, with the key words acute ischemic stroke, tissue plasminogen activator, cost, economic benefit, saving, and incremental cost-effectiveness analysis. The review is limited to original research articles published during 1995-2016 in English-language peer-reviewed journals. We found 16 studies meeting our criteria for this review. Nine of them were cost-effectiveness studies of IV rtPA treatment within 0-3 hours after stroke onset, 2 studies within 3-4.5 hours, 3 studies within 0-4.5 hours, and 2 study within 0-6 hours. IV rtPA is a cost-saving or a cost-effectiveness strategy from most of the study results. Only one study showed incremental cost-effectiveness ratio of IV rtPA within one year was marginally above $50,000 per QALY threshold. IV rtPA within 0-3 hours after stroke led to cost savings for lifetime or 30 years, and IV rtPA within 3-4.5 hours after stroke increased costs but still was cost-effective. CONCLUSIONS: The literature generally showed that intravenous IV rtPA was a dominant or a cost-effective strategy compared to traditional treatment for acute ischemic stroke patients without IV rtPA. The findings from the literature lacked generalizability because of limited data and various assumptions.

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