Impact of Intravenous Alteplase Door-to-Needle Times on 2-Year Mortality in Patients With Acute Ischemic Stroke.

Objective: We sought to determine whether administration of Intravenous Thrombolysis (IVT) to patients with Acute Ischemic Stroke (AIS) within 60 min from hospital arrival is associated with lower 2-year mortality. Methods: This retrospective study was conducted among patients receiving IVT in hospitals participating in the Georgia Coverdell Acute Stroke Registry (GCASR) from January 1, 2008 through June 30, 2018. Two-year mortality data was obtained by linking the 2008-2018 Georgia Discharge Data System data and the 2008-2020 Georgia death records. We analyzed the study population in two groups based on the time from hospital arrival to initiation of IVT expressed as Door to Needle time (DTN) in a dichotomized (DTN ≤ 60 vs. > 60 min) fashion. Results: The median age of patients was 68 years, 49.4% were females, and the median NIHSS was 9. DTN ≤60 min was associated with lower 30-day [odds ratio (OR), 0.62; 95% CI, 0.52-0.73; P < 0.0001], 1-year (OR, 0.71; 95% CI, 0.61-0.83; P < 0.0001) and 2-year (OR, 0.76; 95% CI, 0.65-0.88; P = 0.001) mortality as well as lower rates of sICH at 36 h (OR, 0.57; 95% CI, 0.43-0.75; P = 0.0001), higher rates of ambulation at discharge (OR, 1.38; 95% CI, 1.25-1.53; P < 0.0001) and discharge to home (OR, 1.36; 95% CI, 1.23-1.52; P < 0.0001). Conclusion: Faster DTN in patients with AIS was associated with lower 2-year mortality across all age, gender and race subgroups. These findings reinforce the need for intensifying quality improvement measures to reduce DTN in AIS patients.

Impact of Participation in a Telestroke Network on Clinical Outcomes.

BACKGROUND: A telestroke program, known as the Remote Evaluation for Acute Ischemic Stroke program, has been implemented in Georgia since 2003. This study examined whether a hospital's participation in a telestroke network was associated with improvement in clinical outcomes and quality indicators. METHODS AND RESULTS: An observational study was conducted using data from the Georgia Coverdell Acute Stroke Registry between September 2005 and September 2016 for patients aged ≥18 years with ischemic stroke. We use a difference-in-differences approach to compare the following clinical outcomes and quality indicators among those admitted at hospitals within and outside of the Remote Evaluation for Acute Ischemic Stroke network: tPA (tissue-type plasminogen activator) use, complications related to tPA use, door-to-needle time, ambulation at discharge, discharge status, and destination. Logistic regression models and a propensity score weighting approach were performed to adjust for patients' age, sex, race, insurance coverage, arrival mode, ambulatory status before the current stroke, stroke severity, medical history, admission time, and hospital bed size. A total of 25 494 patients with ischemic stroke admitted at 15 nonteaching hospitals located outside of the Atlanta metropolitan area were included in the analysis. After propensity score weighting, hospitals participated in a telestroke network was not associated with a significant increase in the rate of tPA use, while it was significantly associated with a modest decline in the rate of complications related to tPA (-5.9%; 95% CI, -9.2% to -2.6%). Telestroke participation showed no significant difference in other clinical outcomes and quality measures except for a marginally significant decrease in in-hospital mortality (-1.1%; 95% CI, -2.2% to -0.1%). CONCLUSIONS: Although a slight decrease in tPA complication was observed among hospitals participating in the telestroke network, overall the impact of telestroke participation on a hospital's stroke care quality was not statistically significant based on our observational study.

Quality of Care and Its Impact on One-Year Mortality: The Georgia Coverdell Acute Stroke Registry.

Although performance measures help monitor the process change in quality improvement, their utility in measuring long-term outcomes is uncertain. This study assessed the 1-year mortality of acute ischemic stroke patients treated by hospitals participating in the Georgia Coverdell Acute Stroke Registry. Using 10 nationally approved performance measures, quality of care was defined both as an all-or-none measure (defect-free care) and as a composite index. A generalized estimating equation was applied to assess the effect of quality of care on 1-year mortality. Defect-free care did not serve the purpose; however, the composite measure showed that patients who received the lowest and intermediate quality care, respectively, had a 3.94 (95% confidence interval: 3.27, 4.75; P < .0001) and a 1.38 (95% confidence interval: 1.12, 1.62; P = .002) times higher odds of dying in 1 year compared to those who got the best-quality stroke care. Therefore, hospitals should be encouraged to implement quality improvement activities for better long-term patient outcome.

The impact of IV alteplase on long-term patient survival: The Georgia Coverdell acute stroke registry's experience.

INTRODUCTION: Intravenous alteplase reduces disability and improves functionality among acute ischemic stroke patients. Two decades after its approval, only a small fraction of patients get the treatment, and demonstrating its impact on mortality may make a strong case for its wider use. This study assessed the impact of thrombolytic treatment by alteplase on 1-year mortality and readmission among acute ischemic stroke patients. METHOD: The 2008-2013 Georgia Coverdell Acute Stroke Registry data were linked with the 2008-2013 hospital discharge and the 2008-2014 death data in Georgia. Multiple imputation was applied; a propensity score measuring the probability of receiving intravenous alteplase was calculated and used for matching. A conditional logistic regression was applied to compare 1-year mortality and readmission among propensity score matched pairs. RESULTS: Overall, 20.3% of 9620 acute ischemic stroke patients died and 22.4% were readmitted in one year. The multivariable regression result showed that patients who did not receive IV alteplase had a 1.49 (95%CI: 1.09-2.04; p-value=0.01) times higher odds of dying at one year than those who were treated with the thrombolytic agent. Among patients discharged home, no statistically significant difference was documented in the odds of being readmitted at least once within 365days post-stroke discharge. DISCUSSION AND CONCLUSION: After accounting for patient differences and missing value, intravenous alteplase is associated with reduction in long-term mortality. The results of this study suggest that patients who are identified as eligible for intravenous alteplase need to be offered the treatment.

Hospitalists and intensivists in the medical ICU: a prospective observational study comparing mortality and length of stay between two staffing models.

BACKGROUND: A shortage of critical care specialists or intensivists, coupled with expanding United States critical care needs, mandates identification of alternate qualified physicians for intensive care unit (ICU) staffing. OBJECTIVE: To compare mortality and length of stay (LOS) of medical ICU patients cared for by a hospitalist or an intensivist-led team. DESIGN: Prospective observational study. SETTING: Urban academic community hospital affiliated with a major regional academic university. PATIENTS: Consecutive medical patients admitted to a hospitalist ICU team (n = 828) with selective intensivist consultation or an intensivist-led ICU teaching team (n = 528). MEASUREMENTS: Endpoints were ICU and in-hospital mortality and LOS, adjusted for patient differences with logistic and linear regression models and propensity scores. RESULTS: The odds ratio adjusted for disease severity for in-hospital mortality was 0.8 (95% confidence interval [CI]: 0.49, 1.18; P = 0.23) and ICU mortality was 0.8 (95% CI: 0.51, 1.32; P = 0.41), referent to the hospitalist team. The adjusted LOS was similar between teams (hospital LOS difference 0.9 days, P = 0.98; ICU LOS difference 0.3 days, P = 0.32). Mechanically ventilated patients with intermediate illness severity had lower hospital LOS (10.6 vs 17.8 days, P < 0.001) and ICU LOS (7.2 vs 10.6 days, P = 0.02), and a trend towards decreased in-hospital mortality (15.6% vs 27.5%, P = 0.10) in the intensivist-led group. CONCLUSIONS: The adjusted mortality and LOS demonstrated no statistically significant difference between hospitalist and intensivist-led ICU models. Mechanically ventilated patients with intermediate illness severity showed improved LOS and a trend towards improved mortality when cared for by an intensivist-led ICU teaching team.