Mary G George

Abstract: BACKGROUND AND PURPOSE: The formation and certification of Primary Stroke Centers has progressed rapidly since the Brain Attack Coalition's original recommendations in 2000. The purpose of this article is to revise and update our recommendations for Primary Stroke Centers to reflect the latest data and experience. METHODS: We conducted a literature review using MEDLINE and PubMed from March 2000 to January 2011. The review focused on studies that were relevant for acute stroke diagnosis, treatment, and care. Original references as well as meta-analyses and other care guidelines were also reviewed and included if found to be valid and relevant. Levels of evidence were added to reflect current guideline development practices. RESULTS: Based on the literature review and experience at Primary Stroke Centers, the importance of some elements has been further strengthened, and several new areas have been added. These include (1) the importance of acute stroke teams; (2) the importance of Stroke Units with telemetry monitoring; (3) performance of brain imaging with MRI and diffusion-weighted sequences; (4) assessment of cerebral vasculature with MR angiography or CT angiography; (5) cardiac imaging; (6) early initiation of rehabilitation therapies; and (7) certification by an independent body, including a site visit and disease performance measures. CONCLUSIONS: Based on the evidence, several elements of Primary Stroke Centers are particularly important for improving the care of patients with an acute stroke. Additional elements focus on imaging of the brain, the cerebral vasculature, and the heart. These new elements may improve the care and outcomes for patients with stroke cared for at a Primary Stroke Center.

Abstract: OBJECT: Randomized trials have demonstrated the efficacy of craniectomy for the treatment of malignant cerebral edema following ischemic stroke. We sought to determine the prevalence and outcomes related to this by using a national database. METHODS: Patient discharges with ischemic stroke as the primary diagnosis undergoing craniectomy were queried from the US Nationwide Inpatient Sample from 1999 to 2008. A subpopulation of patients was identified that underwent thrombolysis. Two primary end points were examined: in-hospital mortality and discharge to home/routine care. To facilitate interpretations, adjusted prevalence was calculated from the overall prevalence and two age-specific logistic regression models. The predictive margin was then generated using a multivariate logistic regression model to estimate the probability of in-hospital mortality after adjustment for admission type, admission source, length of stay, total hospital charges, chronic comorbidities, and medical complications. RESULTS: After excluding 71,996 patients with the diagnosis of intracranial hemorrhage and posterior intracranial circulation occlusion, we identified 4,248,955 adult hospitalizations with ischemic stroke as a primary diagnosis. The estimated rates of hospitalizations in craniectomy per 10,000 hospitalizations with ischemic stroke increased from 3.9 in 1999-2000 to 14.46 in 2007-2008 (p for linear trend<0.001). Patients 60+ years of age had in-hospital mortality of 44% while the 18-59 year old group was found to be 24%(p = 0.14). Outcomes were comparable if recombinant tissue plasminogen activator had been administered. CONCLUSIONS: Craniectomy is being increasingly performed for malignant cerebral edema following large territory cerebral ischemia. We suspect that the increase in the annual incidence of DC for malignant cerebral edema is directly related to the expanding collection of evidence in randomized trials that the operation is efficacious when performed in the correct patient population. In hospital mortality is high for all patients undergoing this procedure.

Abstract: OBJECTIVE: The aim of this study was to determine acute stroke hospitalization rates for children and young adults and the prevalence of stroke risk factors among children and young adults hospitalized for acute stroke. METHODS: The study population consisted of 1995-2008 hospitalizations from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Subarachnoid hemorrhage, intracerebral hemorrhage, and ischemic stroke hospitalizations were identified by the primary International Classification of Diseases, 9th ed, Clinical Modification (ICD-9-CM) code. Seven consecutive 2-year time intervals were selected. Three age groups were utilized: 5 to 14 years, 15 to 34 years, and 35 to 44 years. Stroke risk factors and comorbidities among those hospitalized with acute stroke were identified by secondary ICD-9-CM codes. RESULTS: During the period of study, the prevalence of hospitalizations of acute ischemic stroke increased among all age and gender groups except females aged 5 to 14 years. Females aged 15 to 34 years and males and females aged 35 to 44 years showed a decrease in the prevalence of hospitalizations for subarachnoid hemorrhage, whereas females aged 5 to 14 years showed increases for subarachnoid hemorrhage. Hypertension, diabetes, obesity, lipid disorders, and tobacco use were among the most common coexisting conditions, and their prevalence increased from 1995 to 2008 among adolescents and young adults (aged 15-44 years) hospitalized with acute ischemic stroke. INTERPRETATION: Increases in the prevalence of ischemic stroke hospitalizations and coexisting traditional stroke risk factors and health risk behaviors were identified among acute ischemic stroke hospitalizations in young adults. Our results from national surveillance data accentuate the need for public health initiatives to reduce risk factors for stroke among adolescents and young adults. ANN NEUROL 2011;

Abstract: BACKGROUND AND PURPOSE: Stroke is an important contributor to maternal morbidity and mortality, but there are no recent data on trends in pregnancy-related hospitalizations that have involved a stroke. This report describes stroke hospitalizations for women in the antenatal, delivery, and postpartum periods from 1994 to 1995 to 2006 to 2007 and analyzes the changes in these hospitalizations over time. METHODS: Hospital discharge data were obtained from the Nationwide Inpatient Sample, developed as part of the Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality. Pregnancy-related hospitalizations with stroke were identified according to the International Classification of Diseases, Ninth Revision. All statistical analyses accounted for the complex sampling design of the data source. RESULTS: Between 1994 to 1995 and 2006 to 2007, the rate of any stroke (subarachnoid hemorrhage, intracerebral hemorrhage, ischemic stroke, transient ischemic attack, cerebral venous thrombosis, or unspecified) among antenatal hospitalizations increased by 47% (from 0.15 to 0.22 per 1000 deliveries) and among postpartum hospitalizations by 83% (from 0.12 to 0.22 per 1000 deliveries) while remaining unchanged at 0.27 for delivery hospitalizations. In 2006 to 2007, approximately 32% and 53% of antenatal and postpartum hospitalizations with stroke, respectively, had concurrent hypertensive disorders or heart disease. Changes in the prevalence of these 2 conditions from 1994 to 1995 to 2006 to 2007 explained almost all of the increase in postpartum hospitalizations with stroke during the same period. CONCLUSIONS: Our results have demonstrated an increasing trend in the rate of pregnancy-related hospitalizations with stroke in the United States, especially during the postpartum period, from 1994 to 1995 to 2006 to 2007.

Abstract: BACKGROUND AND PURPOSE: The common medical complications after ischemic stroke are associated with increased mortality and resource use. METHOD: The study population consisted of 1 150 336 adult hospitalizations with ischemic stroke as a primary diagnosis included in the 1998 to 2007 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Multiple logistic regression analyses were used to examine changes between 1998 to 1999 and 2006 to 2007 in the prevalence of acute myocardial infarction, pneumonia, deep venous thrombosis, pulmonary embolism, or urinary tract infection, in-hospital mortality, and length of stay. RESULTS: In 2006 to 2007, the prevalence of hospitalizations with a secondary diagnosis of acute myocardial infarction, pneumonia, deep venous thrombosis, pulmonary embolism, and urinary tract infection was 1.6%, 2.9%, 0.8%, 0.3%, and 10.1%, respectively. The adjusted ORs for a hospitalization in 2006 to 2007 complicated by acute myocardial infarction, deep venous thrombosis, pulmonary embolism, or urinary tract infection, using 1998 to 1999 as the referent, were 1.39, 1.68, 2.39, and 1.18, respectively. The odds of pneumonia did not change significantly between 1998 to 1999 and 2006 to 2007. In-hospital mortality was significantly lower in 2006 to 2007 than in 1998 to 1999. Despite the overall length of stay decreasing significantly from 1998 to 1999 to 2006 to 2007, it remained the same for hospitalizations with acute myocardial infarction, pneumonia, deep vein thrombosis, and pulmonary embolism. CONCLUSIONS: Although in-hospital mortality decreased over the study period, 4 of the 5 complications were more common in 2006 to 2007 than they were 8 years earlier with the largest increase observed for deep venous thrombosis and pulmonary embolism.

Abstract: BACKGROUND AND PURPOSE: Dysphagia screening before oral intake (DS) is a stroke care quality indicator. The value of DS is unproven. Quality adherence and outcome data from the Paul Coverdell National Acute Stroke Registry were examined to establish value of DS. METHODS: Adherence to the DS quality indicator was examined in patients with stroke discharged from Paul Coverdell National Acute Stroke Registry hospitals between March 1 and December 31, 2009. Patients were classified as unscreened (US), screened and passed (S/P), and screened and failed. Associations between screening status and pneumonia rate were assessed by logistic regression models after adjustment for selected variables. RESULTS: A total of 18 017 patients with stroke discharged from 222 hospitals in 6 states were included. A total of 4509 (25%) were US; 8406 (47%) were S/P, and 5099 (28%) were screened and failed. Compared with US patients, screened patients were significantly more impaired. Pneumonia rates were: US 4.2%, S/P 2.0%, and screened and failed 6.8%. After adjustment for demographic and clinical features, US patients were at a higher risk of pneumonia (OR, 2.2; 95% CI, 1.7 to 2.7) compared with S/P patients. CONCLUSIONS: Data suggest that patients are selectively screened based on stroke severity. Pneumonia rate was higher in US patients compared with S/P patients. Clinical judgment regarding who should be screened is imperfect. S/P patients have a lower pneumonia rate indicating that DS adds accuracy in predicting pneumonia risk. The Joint Commission recently retired DS as a performance indicator for Primary Stroke Center certification. These results suggest the need to implement a DS performance measure for patients with acute stroke.

Abstract: BACKGROUND AND PURPOSE: There are limited data on the causes and severity of subsequent stroke in patients presenting initially with TIA or stroke attributed to intracranial arterial stenosis. METHODS: We evaluated the location, type (lacunar vs nonlacunar), cause, and severity of stroke in patients who had an ischemic stroke endpoint in the Warfarin Aspirin Symptomatic Intracranial Disease (WASID) trial. RESULTS: Of the 569 patients enrolled in the WASID trial, 106 patients (18.6%) had an ischemic stroke during a mean follow-up of 1.8 years. Stroke occurred in the territory of the symptomatic artery in 77 (73%) of 106 patients. Among the 77 strokes in the territory, 70 (91%) were nonlacunar and 34 (44%) were disabling. Stroke out of the territory of the symptomatic artery occurred in 29 (27%) of 106 patients. Among these 29 strokes, 24 (83%) were nonlacunar, 14 (48%) were attributed to previously asymptomatic intracranial stenosis, and 9 (31%) were disabling. CONCLUSIONS: Most subsequent strokes in patients with symptomatic intracranial artery stenosis are in the same territory and nonlacunar, and nearly half of the strokes in the territory are disabling. The most commonly identified cause of stroke out of the territory was a previously asymptomatic intracranial stenosis. Penetrating artery disease was responsible for a low number of strokes.

Abstract:

Abstract: PROBLEM/CONDITION: Each year, approximately 795,000 persons in the United States experience a new or recurrent stroke. Data from the prototype phase (2001-2004) of the Paul Coverdell National Acute Stroke Registry (PCNASR) suggested that numerous acute stroke patients did not receive treatment according to established guidelines. REPORTING PERIOD: This report summarizes PCNASR data collected during 2005-2007 from Georgia, Illinois, Massachusetts, and North Carolina, the first states to have PCNASRs implemented in and led by state health departments. DESCRIPTION OF SYSTEM: PCNASR was established by CDC in 2001 to track and improve the quality of hospital-based acute stroke care. The prototype phase (2001-2004) registries were led by CDC-funded clinical investigators in academic and medical institutions, whereas the full implementation of the 2005-2007 statewide registries was led by CDC-funded state health departments. Health departments in each state recruit hospitals to collect data. To be included in PCNASR, patients must be aged >or=18 years and have a clinical diagnosis of acute ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, or transient ischemic attack (TIA) or an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code indicative of a stroke or TIA. Data for patients who are already hospitalized at the time of stroke are not included. The following 10 performance measures of care, based on established guidelines for care of acute stroke patients, were developed by CDC in partnership with neurologists who specialize in stroke care: 1) received deep venous thrombosis prophylaxis, 2) received antithrombotic therapy at discharge, 3) received anticoagulation therapy for atrial fibrillation, 4) received tissue plasminogen activator (among eligible patients), 5) received antithrombotic therapy within 48 hours of admission or by the end of the second hospital day, 6) received lipid level testing, 7) received dysphagia screening, 8) received stroke education, 9) received smoking cessation counseling, and 10) received assessment for rehabilitation services. Adherence to these performance measures of care was calculated using predefined inclusion and exclusion criteria. RESULTS: A total of 195 hospitals from Georgia, Illinois, Massachusetts, and North Carolina contributed data to PCNASR during 2005-2007, representing 56,969 patients. Approximately half (53.3%) the cases of stroke in the registry occurred among females. A total of 2.5% of cases were among Hispanics; however, the proportion varied significantly by state. Cases among black patients ranged from 5.6% in Massachusetts to 35.8% in Georgia. The age at which patients experienced stroke varied significantly by state. On average, patients were oldest in Massachusetts (median age: 77 years) and youngest in Georgia (median age: 67 years). Overall, the clinical diagnosis for registry stroke cases was hemorrhagic stroke (13.8% of cases), ischemic stroke (56.2%), ill-defined stroke (i.e., medical record did not specify ischemic or hemorrhagic stroke; 7.3%), and TIA (21.6%). A total of 18.5% of patients with stroke symptoms arrived at the hospital within 2 hours of symptom onset; however, the time from onset of symptoms to hospital arrival was not recorded or was not known for the majority (57.8%) of patients. Of the 56,969 patients, 47.6% were transported by emergency medical services (EMS) from the scene of symptom onset, 11.1% were transferred by EMS from another hospital, and 39.4% used private or other transportation. Adherence to acute stroke care measures defined by PCNASR were as follows: received antithrombotic therapy at discharge (97.6%), received antithrombotic therapy within 48 hours of admission or by the end of the second hospital day (94.6%), assessed for rehabilitation services (90.1%), received deep venous thrombosis prophylaxis (85.5%), received anticoagulation therapy for atrial fibrillation (82.5%), received smoking cessation counseling (78.6%), received lipid level testing (69.9%), received stroke education (58.8%), received dysphagia screening (56.7%), and received tissue plasminogen activator (among eligible patients) (39.8%). INTERPRETATION: Between 2001-2004 (prototype phase) and 2005-2007 (implementation by state health departments), substantial improvement occurred in dysphagia screening, lipid testing, smoking cessation counseling, and antithrombotic therapy prescribed at discharge. These initial improvements indicate that a surveillance system to track and improve the quality of hospital-based stroke care can be led successfully by state health departments, although further evaluations over time are needed. Despite these improvements, additional increases are needed in adherence to these and other performance measures. Nearly 40% of stroke patients did not use EMS services for transport to hospitals, and no change occurred in the proportion of patients who arrived at the hospital in time to receive thrombolytic therapy for ischemic stroke. Patients who are not promptly transported to hospitals after symptom onset are ineligible for thrombolytic therapy and other timely interventions for acute stroke. PUBLIC HEALTH ACTIONS: Results from PCNASR indicate the need for additional public health measures to inform the public of the need for timely activation of EMS services for signs and symptoms of stroke. In addition, low rates of adherence to certain measures of stroke care underscore the need for continuing coordinated programs to improve stroke quality of care. Additional analyses are needed to assess improvements in adherence to guidelines over time.

Abstract:

Abstract: This study aims to assess and compare the completeness and reliability of data collected by prospective and retrospective methods for the Paul Coverdell National Acute Stroke Registry. The prototypes consisted of eight states that used the same data elements but differed in their collection approach. Three prototypes employed retrospective case ascertainment (n=1218), and five prototypes used prospective or a combination of prospective and retrospective case ascertainment (n=1602). RTI International performed an audit analysis of the eight prototypes. Completeness, exact match, and discrepancy analyses were performed with data elements grouped into 12 categories for this analysis. A sample of 2820 (37.6%) from a total of 7494 records from 91 hospitals was studied. The "in-hospital complications" section had the highest percentage of completeness (99.6%), followed by "demographic data" (97.7%), and "in-hospital diagnostic procedures" (93.4%). The section with the lowest percentage of completeness was "thrombolytic treatment" (53.5%), followed by "reasons for nontreatment with thrombolytics" (57.1%), and "signs and symptoms onset" (63.5%). Across all prototype elements, exact matches with audit data ranged from 62.8% to 95.9%. Documentation of the date/time of stroke onset and of arrival in the emergency department had a high number of discrepancies with audit data, with exact match percentages of 69.7% and 64.5%, respectively. No significant difference was found between retrospective and prospective case ascertainment in completeness or matching with audit data. Combined retrospective and prospective data-collection approaches for different types of data elements may be best in terms of both completeness and accuracy.

Abstract: