Abstract 88: Feasibility of a Novel Model of Subacute Stroke Care in a Resource-Constrained Setting

Abstract

Background: Los Angeles County (LAC) is the largest county in the US, with a population of 10 million. Despite a substantial proportion of uninsured/underinsured patients, the county has only 4 public hospitals. These hospitals are overcrowded, have limited resources, and lack stroke units. To address the delays in emergency departments (EDs), prolonged hospital admissions, inadequate diagnostic evaluations, and inconsistent initiation of secondary stroke prevention medications in the LAC public hospital system, we developed a stroke unit (ASTK) at a county rehabilitation hospital. After an exam by a neurology resident, Head CT, and screening by the ASTK neurology attending, stroke patients who were ineligible for thrombolysis, did not require neurosurgical intervention nor intensive care were transferred directly from other LAC hospital EDs to ASTK. Methods: Demographic characteristics, vascular risk factors, premorbid medication use, processes of care, stroke mechanism (modified TOAST), discharge medications, and discharge destination were assessed for 440 ischemic stroke patients consecutively admitted to ASTK from 10/2007 until 5/2011. Results: The mean age was 58.9 (SD 10.6) years; 61% were male; 58% were Hispanic, 20% were Asian, 13% were black, and 7% were white; 66% had Medicaid,10% had Medicare, 2% had an HMO, 1% had private insurance, and 21% did not have insurance. With respect to vascular risk factors, 71% had hypertension, 44% had diabetes, 33% had dyslipidemia, and 37% were smokers. On admission, only a minority were taking antithrombotics, antihypertensives, or statins. On admission, the median NIHSS was 3 (range 0-22), mean systolic blood pressure was 152 mm Hg, BMI was 28 kg/m 2 , total cholesterol was 187 mg/dL, LDL was 118 mg/dL, HDL was 36 mg/dL, and glycosylated hemoglobin was 7.6%. Almost all patients received an MRI brain (94%), MRA head and neck (91%), transthoracic echocardiogram (96%), 24 hour Holter (96%), and rehabilitation evaluation (92%). The stroke mechanisms included 20% large vessel, 35% small vessel, 7% cardioembolic, 13% >1 possible etiology, 23% cryptogenic, and 3% other. The mortality rate was 0% and 4% of patients were transferred to higher level of care (most for urgent carotid endarterectomy/stent). Most patients (72%) were discharged home, whereas 12% needed inpatient rehabilitation. The mean length of stay was 4 days. At discharge, 97% were discharged on an antithrombotic, 71% on an ACE inhibitor or ARB, 33% on a thiazide diuretic, and 94% on a statin. Conclusions: In this resource-constrained, safety-net hospital setting, serving a racial-ethnically diverse patient population with limited access to care and poorly controlled vascular risk factors, it was feasible to provide inpatient care to patients with mild/moderate strokes at a rehabilitation hospital. This may serve as a model of care for other healthcare settings.