Guidelines-Stroke Hospitals Research Articles

Twenty Years of Sustained Improvement in Quality of Care and Outcomes for Patients Hospitalized With Stroke or Transient Ischemic Attack: Data From The Get With The Guidelines-Stroke Program.

The Get With The Guidelines-Stroke program is a quality improvement initiative designed to enhance adherence to evidence-based stroke care. Since its inception in 2003, over 2800 hospitals in the United States have participated in the program. We examined patient characteristics, adherence to performance measures, and in-hospital outcomes in patients hospitalized for acute ischemic stroke, subarachnoid hemorrhage, intracerebral hemorrhage, and transient ischemic attack in The Get With The Guidelines-Stroke hospitals from 2003 through 2022. We quantified temporal changes in performance measure adherence and clinical outcomes over time. Performance measure denominators consisted of patients who were eligible, excluding those with contraindications. Over the 20 years of the program, a total of 7837 849 stroke cases (median age 71 years, 51.0% female; 69.2% ischemic strokes, 3.9% SAHs, 11.5% ICHs, and 15.3% TIAs) were entered into the registry. Except for antithrombotics at discharge, in which the baseline performance was >92%, there was sustained improvement in all performance metrics regardless of type of cerebrovascular event (P<0.01 for all). In patients with acute ischemic stroke, large improvements were observed for anticoagulation for atrial fibrillation (55.7% in 2003 to 97.2% in 2022), smoking cessation counseling (44.7%-97.8%), dysphagia screening (53.8%-83.5%), thrombolytic treatment for patients arriving by 3.5 hours, treat by 4.5 hours (15.2%-92.9%), door-to-needle time within 60 minutes (19.0%-75.3%), and endovascular door-to-puncture time within 90 minutes (54.7%-62.8%). Similar improvements were also observed for measures relevant to patients with subarachnoid hemorrhage, intracerebral hemorrhage, and transient ischemic attack. Multivariable analysis showed that there was a sustained increase in odds of receiving each performance measure over time, independent of patient and hospital characteristics for each type of cerebrovascular event. After risk adjustment, there were temporal trends that patients were less likely to be discharged to a skilled nursing facility, and, for ischemic stroke only, more likely to be discharged directly home. During the first 20 years, Get With The Guidelines-Stroke participation was associated with sustained improvement in evidence-based care and outcomes for patients with stroke and transient ischemic attack in the United States.

Abstract TP203: Effect of SARS-CoV2 Infection on Endovascular Thrombectomy Outcomes - Data From the Florida Stroke Registry

Introduction: The outcomes of endovascular thrombectomy (EVT) in SARS-CoV2 positive patients with acute ischemic stroke (AIS) are not well studied. In the large Florida Stroke Registry we compared in hospital and discharge outcomes of patients with target vessel occlusions treated endovascularly with versus without a SARS-CoV2 positive infection status during their hospitalization. Methods: Data from Get With the Guidelines-Stroke hospitals participating in the Florida Stroke Registry from March 2020 to December 2022 were reviewed. EVT patients with coding for SARS-CoV2 testing during their hospital stay were categorized into SARS-CoV2 positive or negative groups. Associations between SARS-CoV2 status and favorable EVT outcomes of good mRS (0-2) at discharge, discharge to home or to rehabilitation centre, and independent ambulation at discharge were examined using multivariate logistic regression modeling adjusting for demographics, vascular risk factors, and clinical characteristics with generalized estimating equations (GEE). Temporal analyses compared outcomes across the years 2020-2022. Results: A total of 8,778 patients underwent EVT, of these, 193 (2.25%) were SARS-CoV2 positive. The odds of mRS 0-2 and independent ambulation at discharge were OR 0.194 (CI 0.035,1.077) and OR 0.794 (CI 0.168,3.75) in SARS-CoV2 positive relative to negative EVT patients. Outcomes of mRS 0-2 (OR 0.194, CI 0.035,1.077) and ambulation at discharge (OR 0.794, CI 0.168,3.75) were shy of statistical significance. Accounting for baseline differences SARS-CoV2 positive patients were less likely to be discharged home or to a rehabilitation centre (OR 0.671, CI 0.488,0.921) in multivariable analysis with GEE. Temporal analysis of SARS-CoV2 positive patients showed no significant differences across the years studied. Conclusions: In this large muliticentre stroke registry the results suggest that favorable outcomes post thrombectomy may be negatively impacted by SARS-CoV2 infection. Temporal assessment showed similar results across the years studied. These findings provide novel insight from a large database to add to the emerging literature examining outcomes of concurrent SARS-CoV2 infection in the setting of EVT for target vessel occlusion AIS.

Sex Differences in Endovascular Therapy for Ischemic Stroke: Results From the Get With The Guidelines-Stroke Registry.

In 2015, endovascular therapy (EVT) for large vessel occlusions became standard of care for acute ischemic stroke. Lower utilization of IV alteplase has been reported in women, but whether sex differences in EVT use in the United States exists has not been established. We identified all acute ischemic stroke discharges from Get With The Guidelines-Stroke hospitals between 2012 and 2019 who were potentially eligible for EVT, based on National Institutes of Health Stroke Scale score ≥6 and arrival <6 hours, according to 2018 American Heart Association/ASA guidelines. Multivariable regression analyses were used to determine the association between sex and EVT utilization, and outcomes (including mortality, discharge home, functional status) after EVT. Separate analyses were conducted for the 2 time periods: 2012 to 2014, and 2015 to 2019. Of 302 965 patients potentially eligible for EVT, 42 422 (14%) received EVT. Before 2015, EVT treatment rates were 5.3% in women and 6.6% in men. From 2015 to 2019, treatment rates increased in both sexes to 16.7% in women and 18.5% in men. The adjusted odds ratio for EVT in women compared with men was 0.93 (95% CI, 0.87-0.99) before 2015, and 0.98 (95% CI, 0.96-1.01) after 2015. There were no significant sex differences in outcomes except that after 2015, women were less able to ambulate at discharge (adjusted odds ratio, 0.95 [95% CI, 0.95-0.99]) and had lower in-hospital mortality (adjusted odds ratio, 0.93 [95% CI, 0.88-0.99]). EVT utilization has increased dramatically in both women and men since EVT approval in 2015. Following statistical adjustment, women were less likely to receive EVT initially, but after 2015, women were as likely as men to receive EVT. After EVT, women were more likely to be disabled at discharge but less likely to experience in-hospital death compared with men.

Abstract 116: Unmet Need In Acute Ischemic Stroke Patients Not Treated With Alteplase

Introduction: Early administration of intravenous tissue plasminogen activator (IV alteplase) improves functional outcomes in patients with acute ischemic stroke (AIS), yet many patients are not treated with IV alteplase. There is a need to understand the reasons for non-treatment and the short- and long-term outcomes in this patient population. Methods: We analyzed patients ≥65 years old with a primary diagnosis of AIS presenting within 24 hours of time last known well (LKW) but not treated with IV alteplase from 1,630 Get With The Guidelines-Stroke Hospitals in the United States between January 2016 and December 2016. We report clinical characteristics, reasons for withholding treatment, in-hospital mortality, 90-day and 1-year outcomes including Medicare costs, stratified by time from LKW to presentation (≤4.5 hours, &gt;4.5-6 hours and &gt;6-24 hours). Results: Of 39,760 patients (median age 80 [25 th -75 th quartiles: 73-87], 56.7% female), 19,391 (48.8%) presented within 4.5 hours of LKW. In those with documented reasons for withholding IV alteplase, the most common reasons were rapid improvement of symptoms (3,985/14,782, 27.0%) and mild symptoms (3,791/14,782, 25.6%). In 1,100 out of 1,174 (93.7%) patients presenting in the &gt;3.0-4.5-hour time window, the most common reason for not treating was a delay in patient arrival. The most common discharge location for those presenting ≤4.5 hours since LKW was home (8,660/19,391, 44.7%). The 90-day mortality and re-admission rates were 18.9% and 23.0% in those presenting ≤4.5 hours since LKW, 19.0% and 22.2% in those presenting between 4.5 and 6 hours, and 19.1% and 23.2% in those presenting between 6 and 24 hours. Median 90-day total in-hospital costs remained relatively high at $9,471 (IQR: $5,622-$21,356) in patients presenting ≤4.5 hours since LKW. Conclusions: Patients within the GWTG-Stroke registry not treated with IV alteplase have a high risk of re-admission and mortality and have high total in-hospital and post-discharge costs. This study may inform future efforts to address the unmet need to improve the scope of IV alteplase delivery along with other aspects of AIS care and, consequently, outcomes in this patient population.

Abstract 35: Unmet Need In Acute Ischemic Stroke Patients Arriving After 4.5 Hours

Introduction: Many patients arrive beyond the guideline-recommended time window for treatment with IV alteplase. For most of these patients, few treatment options exist. There is a need to understand the characteristics, outcomes, and healthcare costs of patients in this population in order to develop new treatments options. Methods: We analyzed patients ≥65 years old with a primary diagnosis of AIS arriving within 24 hours of time last known well (LKW) but not treated with IV alteplase at Get With The Guidelines-Stroke Hospitals in the United States (Jan 2016 - Dec 2016). We report clinical characteristics, 90-day and 1-year outcomes including Medicare costs, stratified by time from LKW to arrival (≤4.5 hours, &gt;4.5-6 hours and &gt;6-24 hours). Results: Of 39,760 patients (80.0% White, 10.5% Black, 4.1% Hispanic, 2.2% Asian), 20,369 (51.2%) presented from 4.5 - 24 hours of LKW. Compared to patients arriving within ≤4.5 hours, patients arriving within 4.5 - 24 hours of LKW were more likely to be Black, Hispanic, or Asian (≤4.5 hours: 9.4% Black, 3.8% Hispanic, 1.9% Asian; &gt;4.5 - 6 hours: 11.7% Black, 4.1% Hispanic, 2.4% Asian; &gt;6 - 24 hours since LKW: 11.6% Black, 4.4% Hispanic, 2.6% Asian; p &lt; 0.001). The most common discharge location for those arriving within ≤4.5 hours was home; for those arriving &gt;4.5 hours since LKW the most common discharge location was inpatient rehab (IRF) or skilled nursing facility (SNF) (≤4.5 hours: 44.7% home vs 42.3% IRF or SNF; &gt;4.5 - 6 hours: 35.4% home vs 51.7% IRF or SNF; &gt;6 - 24 hours: 35.8% home vs 51.0% IRF or SNF). The 90-day and 1-year mortality rates were 18.9% and 30.0% in those arriving within ≤4.5 hours, 19.0% and 29.8% in those arriving between 4.5 - 6 hours, and 19.1% and 29.1% in those arriving between 6 - 24 hours. Median 90-day inpatient costs were highest among those arriving 6 - 24 hours from LKW (≤4.5 hours: $9,471 [IQR: 5,622-21,356]; &gt;4.5 - 6 hours: $10,884 [IQR: 6,036-25,992]; 6 -24 hours: $11,162 [6,073-26,372]). Conclusions: Results show the importance of timely hospital arrival, as well as a need to address racial disparities in arrival times, reduce costs, and develop new treatment options for patients with AIS arriving after 4.5 hours from last known well time.

Achieving More Rapid Door-to-Needle Times and Improved Outcomes in Acute Ischemic Stroke in a Nationwide Quality Improvement Intervention.

The benefits of tPA (tissue-type plasminogen activator) in acute ischemic stroke are time-dependent. However, delivery of thrombolytic therapy rapidly after hospital arrival was initially occurring infrequently in hospitals in the United States, discrepant with national guidelines. We evaluated door-to-needle (DTN) times and clinical outcomes among patients with acute ischemic stroke receiving tPA before and after initiation of 2 successive nationwide quality improvement initiatives: Target: Stroke Phase I (2010-2013) and Target: Stroke Phase II (2014-2018) from 913 Get With The Guidelines-Stroke hospitals in the United States between April 2003 and September 2018. Among 154 221 patients receiving tPA within 3 hours of stroke symptom onset (median age 72 years, 50.1% female), median DTN times decreased from 78 minutes (interquartile range, 60-98) preintervention, to 66 minutes (51-87) during Phase I, and 50 minutes (37-66) during Phase II (P<0.001). Proportions of patients with DTN ≤60 minutes increased from 26.4% to 42.7% to 68.6% (P<0.001). Proportions of patients with DTN ≤45 minutes increased from 10.1% to 17.7% to 41.4% (P<0.001). By the end of the second intervention, 75.4% and 51.7% patients achieved 60-minute and 45-minute DTN goals. Compared with the preintervention period, hospitals during the second intervention period (2014-2018) achieved higher rates of tPA use (11.7% versus 5.6%; adjusted odds ratio, 2.43 [95% CI, 2.31-2.56]), lower in-hospital mortality (6.0% versus 10.0%; adjusted odds ratio, 0.69 [0.64-0.73]), fewer bleeding complication (3.4% versus 5.5%; adjusted odds ratio, 0.68 [0.62-0.74]), and higher rates of discharge to home (49.6% versus 35.7%; adjusted odds ratio, 1.43 [1.38-1.50]). Similar findings were found in sensitivity analyses of 185 501 patients receiving tPA within 4.5 hours of symptom onset. A nationwide quality improvement program for acute ischemic stroke was associated with substantial improvement in the timeliness of thrombolytic therapy start, increased thrombolytic treatment, and improved clinical outcomes.

Frequency, Characteristics, and Outcomes of Endovascular Thrombectomy in Patients With Stroke Beyond 6 Hours of Onset in US Clinical Practice.

In 2018, 2 randomized controlled trials showed the benefit of endovascular thrombectomy (EVT) in acute ischemic stroke patients treated 6 to 24 hours from last known well using imaging-guided selection. However, little is known about outcomes in contemporary nontrial settings. We assessed the frequency of EVT and outcomes beyond 6 hours in the US Get With The Guidelines-Stroke clinical registry. We analyzed all acute ischemic stroke patients treated with EVT between January 1, 2009 and October, 1, 2018, at Get With The Guidelines-Stroke hospitals in the United States. We assessed trends over time in frequency of EVT beyond 6 hours, compared patient characteristics and outcomes between those treated within versus beyond 6 hours, and evaluated the associations between EVT time and outcomes. We identified 53 702 patients at 697 sites treated with EVT during the study period. Treatment after 6 hours from last known well occurred in 17 720 (33%) of all 53 702 EVT cases (median 4.7 hours, interquartile range, 3.3-7 hours). The proportion of EVT cases treated after 6 hours from last known well varied widely across sites (median 30%, interquartile range, 24%-38%). Compared with patients treated within 6 hours, those treated beyond six hours were younger, less likely to have atrial fibrillation, less likely to arrive by ambulance, had lower stroke severity, were less likely to be anticoagulated, and more likely to be treated at centers with higher EVT volumes. After adjusting for patient and hospital characteristics, patients receiving EVT beyond 6 hours had less favorable in-hospital mortality, ambulation at discharge, and discharge disposition compared to those treated within 6 hours. EVT is frequently performed for patients with ischemic stroke after 6 hours from last known well, accounting for one-third of cases nationally, and adjusted functional outcomes at discharge are worse in these patients compared to those treated with EVT within 6 hours. Further efforts are needed for optimal EVT outcomes in clinical practice settings.

Acute Ischemic Stroke in Patients With COVID-19

Background and Purpose: Studies suggest an increased risk of adverse outcomes among patients with acute ischemic stroke (AIS) and coronavirus disease 2019 (COVID-19). Methods: Using Get With The Guidelines–Stroke, we identified 41 971 patients (AIS/COVID-19: 1143; AIS/no COVID-19: 40 828) with AIS hospitalized between February 4, 2020 and June 29, 2020, from 458 Get With The Guidelines–Stroke hospitals with at least one COVID-19 case and evaluated clinical characteristics, treatment patterns, and outcomes. Results: Compared with patients with AIS/no COVID-19, those with AIS/COVID-19 were younger, more likely to be non-Hispanic Black, Hispanic, or Asian, more likely to present with higher National Institutes of Health Stroke Scale scores, and had greater proportions of large vessel occlusions. Rates of thrombolysis and thrombectomy were similar between the groups. Door to computed tomography (median 55 [18–207] versus 35 [14–99] minutes, P &lt;0.001), door to needle (59 [40–82] versus 46 [33–64] minutes, P &lt;0.001), and door to endovascular therapy (114 [74–169] versus 90 [54–133] minutes, P =0.002) times were longer in the AIS/COVID-19 cohort. In adjusted models, patients with AIS/COVID-19 had decreased odds of discharge with modified Rankin Scale score of ≤2 (odds ratio, 0.65 [95% CI, 0.52–0.81], P &lt;0.001) and increased odds of in-hospital mortality (odds ratio, 4.34 [95% CI, 3.48–5.40], P &lt;0.001). ConclusionS: This analysis demonstrates younger age, greater stroke severity, longer times to evaluation and treatment, and worse morbidity and mortality in patients with AIS/COVID-19 compared with those with AIS/no COVID-19.

Patterns of antidepressant therapy and clinical outcomes among ischaemic stroke survivors

Background and purposeDepression is common after stroke and is often treated with antidepressant medications (AD). ADs have also been hypothesised to improve stroke recovery, although recent randomised trials were neutral....

Target: Stroke Was Associated With Faster Intravenous Thrombolysis and Improved One-Year Outcomes for Acute Ischemic Stroke in Medicare Beneficiaries.

The benefit of intravenous thrombolytic therapy for acute ischemic stroke is time dependent. To assist hospitals in providing faster thrombolytic treatment, the American Heart Association launched target: stroke quality initiative in January 2010 which disseminated feasible strategies to shorten door-to-needle times for thrombolytic therapy. This study aimed to examine whether target: stroke was associated with improved door-to-needle times and 1-year outcomes. We analyzed Medicare beneficiaries aged ≥65 years receiving intravenous thrombolytic treatment for acute ischemic stroke at 1490 Get With The Guidelines-Stroke hospitals during January 2006 and December 2009 (preintervention, n=10 804) and January 2010 and December 2014 (postintervention, n=31 249). The median age was 80 years and 42.7% were male. The median door-to-needle times decreased from 80 minutes for the preintervention to 68 minutes for the postintervention (P<0.001). The proportion of patients receiving intravenous thrombolysis with door-to-needle times 45 minutes and 60 minutes increased from 9.6% and 24.8% for preintervention to 17.1% and 40.6% for postintervention, respectively (P<0.001). The annual rate of increase in the door-to-needle times of 60 minutes or less accelerated from 0.20% (95% CI, -0.43% to 0.83%) per each 4 quarters for preintervention to 5.68% (95% CI, 5.23%-6.13%) for postintervention (P<0.001) which was further confirmed in piecewise multivariable generalized estimating analysis (adjusted odds ratio, 1.27 [95% CI, 1.19-1.35]). Cox proportional hazards analysis, after adjusting for patient and hospital characteristics and within-hospital clustering, showed that target: stroke was associated with lower all-cause readmission (40.4% versus 44.1%; hazard ratio, 0.91 [95% CI, 0.88-0.95]), cardiovascular readmission (19.7% versus 22.9%; hazard ratio, 0.85 [95% CI, 0.80-0.89]), and composite of all-cause mortality or readmission (56.0% versus 58.4%; hazard ratio, 0.96 [95% CI, 0.93-1.00]). The risk decline in all-cause mortality dissipated after risk adjustment (adjusted hazard ratio, 0.98 [95% CI, 0.94-1.02]). Target: stroke quality initiative was associated with faster thrombolytic treatment times for acute ischemic stroke and modestly lower 1-year all-cause and cardiovascular readmissions.

Abstract WP300: Optimal Prehospital Stroke Triage is Highly Dependent on Individual Hospital Reperfusion Times

Background: Prehospital routing decisions for patients with suspected stroke depends on many factors. Past decision modeling analyses have incorporated patient and hospital characteristics such as age, stroke severity, and average door-to-reperfusion times. However, these models do not include actual hospital performance data. We sought to determine whether inclusion of actual hospital data for door-to-needle and door-to-puncture times for thrombolysis (tPA) and thrombectomy (EVT) affects optimal routing destinations. Methods: Our previously published simulation model incorporates geographic, patient, and hospital data to determine optimal transport destination, using a standard distribution of tPA and EVT times by hospital type (PSC vs CSC). We enhanced the model using actual hospital performance data on tPA and EVT treatment times from all Northeast Get with the Guidelines Stroke hospitals. We used 1000 patient locations based on census density with 10 levels of stroke severity at each location, running 2,000 simulations for each hypothetical scenario (20 million simulations per model version) to determine the optimal treatment destination. We compared model recommendations from the 2 versions to determine if the results changed with use of actual hospital data. Potential gains to patients were calculated using quality-adjusted life years. Results: Of the 10,000 simulated scenarios, 2170 scenarios (21.7%) had the same optimal destination in both model versions. Of the 7830 scenarios with changed recommendations, 542 (6.9%) scenarios had a change from PSC to CSC recommendation, 2927 (37.3%) from CSC to PSC, and 4361 (55.7%) changed within group from one PSC to another, or from one CSC to another. Likelihood and type of recommendation change did not vary significantly by stroke severity. Optimized hospital destination led to gains of up to 78 quality-adjusted days relative to the baseline model. Conclusion: Prehospital routing models for patients with suspected stroke may benefit from inclusion of actual hospital performance characteristics. In our model, this resulted in more than a third of patients switching from CSC to PSC and keeping initial care local. Further replication is needed to avoid patient harm and potential overtriage to CSC.

Abstract 159: Trends in Dual Antiplatelet Therapy Prescription Patterns for Secondary Prevention in Patients With Noncardioembolic Ischemic Stroke

Background: The recommendations for dual antiplatelet (DAPT aspirin + clopidogrel) for secondary stroke prevention has evolved over time. Following the publication of CHANCE trial (07/2013), the AHA/ASA updated the DAPT recommendations from Class III harm (10/2010) for patient with noncardioembolic ischemic stroke, to Class IIb benefit ≥ risk (02/2014), and Class IIa benefit &gt;&gt; risk (03/2018) for a subgroup of patients with minor stroke (NIHSS≤3). Subsequent to the last guideline update, the POINT trial (05/2018) provided further support for the effectiveness of DAPT. Methods: We evaluated antiplatelet prescription patterns of 1,024,074 noncardioembolic ischemic stroke survivors (median age 65 years and 46% women) eligible for antiplatelet therapy (no contraindications) and discharged from the Get With The Guidelines-Stroke Hospitals between Q1 2011 and Q1 2019. Results: Baseline patient characteristics were similar within the four periods: pre-CHANCE (01/2011-07/2013), pre-2014 guideline update (08/2013-02/2014), pre-POINT/2018 guideline update (03/2014-05/2018), and post-POINT (06/2018-03/2019). Use of DAPT gradually increased from 16.7% in the pre-CHANCE period, to 19.4% pre-2014 guideline update, 23.3% pre-POINT/2018 guideline update, and 29.8% post-POINT period (p&lt;0.001, Figure). Yet increase in DAPT use was observed over time for individuals with NIHSS≤3 (17.1%, 19.9%, 24.1%, and 31.4%, p&lt;0.001) and those with NIHSS&gt;3 (18.7%, 22.8%, 28.3%, and 28.3%, p&lt;0.001). Conclusions: A sustained increase in DAPT use for secondary stroke prevention was observed after publication of pivotal trials and AHA guideline updates. While recommended for minor strokes or TIA only, such increase was also observed in ischemic stroke patients with NIHSS&gt;3, where the risk-benefit ratio of DAPT remains to be established.

Safety and Outcomes of Intravenous tPA in Acute Ischemic Stroke Patients With Prior Stroke Within 3 Months: Findings From Get With The Guidelines-Stroke.

Background Guidelines recommend against the use of intravenous tPA (tissue-type plasminogen activator; IV tPA) in acute ischemic stroke patients with prior ischemic stroke within 3 months. However, there are limited data on the safety of IV tPA in this population. Methods and Results A retrospective observational study of patients ≥66 years of age linked to Medicare claims and treated with IV tPA at Get With The Guidelines-Stroke hospitals (February 2009 to December 2015). We identified 293 patients treated with IV tPA who had a prior ischemic stroke within 3 months and 30 655 with no history of stroke. Patients with prior stroke had a higher stroke severity (median National Institutes of Health Stroke Scale, 11 [6-19] versus 11 [6-18]; absolute standardized difference, 11.2%) and a higher prevalence of cardiovascular comorbidities. Patients with prior stroke had a higher unadjusted risk for symptomatic intracranial hemorrhage (7.7% versus 4.8%) and in-hospital mortality (12.6% versus 8.9%), but these differences were not statistically significant after adjustment. When stratified by prespecified time epochs, the elevated risk for symptomatic intracranial hemorrhage was seen only within the first 14 days (16.3% versus 4.8%; adjusted odds ratio [aOR], 3.7 [95% CI, 1.62-8.43]) but not in other epochs (2.1% versus 4.8%; aOR, 0.38 [95% CI, 0.05-2.79] for 15-30 days and 7.4% versus 4.8%; aOR, 1.36 [95% CI, 0.77-2.40] for 31-90 days). In addition, patients with prior stroke were significantly more likely to have a combined outcome of in-hospital mortality or discharge to hospice (25.9% versus 17.0%; aOR, 1.70 [95% CI, 1.21-2.38]), less likely to be discharged to home (28.3% versus 32.3%; aOR, 0.72 [95% CI, 0.54-0.98]), or to have good functional outcomes at discharge (modified Rankin Scale, 0-1; 11.3% versus 20.0%; aOR, 0.46 [95% CI, 0.24-0.89]). Conclusions Stroke providers need to continue to be vigilant about the safety of IV tPA in patients with prior stroke, particularly those with an event in the previous 14 days.

Abstract WMP85: Clinical Effectiveness of Direct Oral Anticoagulants (DOACs) vs. Warfarin in Older Ischemic Stroke Patients With Atrial Fibrillation: Findings From Patient-Centered Research Into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) Study

Introduction: Direct oral anticoagulants (DOACs) are increasingly used as alternatives to warfarin for secondary prevention in ischemic stroke patients with atrial fibrillation. Despite demonstrated efficacy in clinical trials, there are few real-world experiences of DOACs vs. warfarin in community practice. Methods: We analyzed ischemic stroke survivors with atrial fibrillation discharged from the Get With The Guidelines Stroke hospitals between 2011-2014 and linked to Medicare claims for longitudinal outcomes through 2015. A propensity score overlap weighting method was used to compare DOACs vs. warfarin. The primary outcomes were major adverse cardiovascular events (MACE) and home time, a patient-centered outcome reflecting desire of “being alive at home, without recurrent stroke, or being hospitalized for complications.” Results: Among 11,662 stroke survivors (median age 80), 4,041 (34.7%) were discharged on DOACs (dabigatran, rivaroxaban, or apixaban) and 7,621 on warfarin. Except for NIHSS (median 4 [IQR 1-9] vs. 5 [2-11]), baseline demographics, medical history, and clinical characteristics were similar between two cohorts. Compared with warfarin, patients discharged on DOACs were less likely to experience MACE (33.95% vs. 40.36% per year, adjusted hazard ratio 0.89, 99% CI 0.83-0.96) and had more days at home (mean 287 vs. 263 days during the first year post discharge, adjusted difference 15.6 days, 99% CI 9.0-22.1) ( Table ). Additionally, there were fewer deaths, all-cause readmissions, cardiovascular readmissions, hemorrhagic strokes, and bleeding hospitalizations in DOAC-treated patients, although no significant differences in fatal bleeding, ischemic stroke readmission, systemic embolism, pneumonia, or sepsis (two negative outcome controls) between the two cohorts. Conclusions: In ischemic stroke survivors with atrial fibrillation, DOACs were associated with improved long-term clinical outcomes compared with warfarin.

Components and Trends in Door to Treatment Times for Endovascular Therapy in Get With The Guidelines-Stroke Hospitals.

Endovascular therapy (EVT) is standard of care in patients with acute disabling ischemic stroke attributable to large-vessel occlusion and is more effective when delivered quickly. It is currently unclear whether time targets achieved in clinical trials can be achieved in clinical practice. We describe interval times from patient arrival in the emergency department (door) to first pass (treatment initiation) in patients receiving EVT within Get With The Guidelines-Stroke hospitals and analyze patient- and hospital-level variables associated with these times. Data are from sites participating fully as Comprehensive Stroke Centers within Get With The Guidelines-Stroke hospitals from October 2014 to September 2016. Workflow times analyzed include door to imaging, imaging to arterial access, arterial access to first pass, and the composite door to first pass time. Data are described overall and by calendar-year quarters. Multivariable modeling was used to identify patient- and hospital-level variables associated with workflow times. Among 2929 patients with EVT from 195 hospitals (median age, 71 years [interquartile range {IQR}, 60-81]; 50.7% female; median baseline National Institute of Health Stroke Score, 17 [IQR, 12-22]; median annual EVT administration number, 16 [IQR, 10-27]), median door to first pass time was 130 minutes (IQR, 101-170 minutes), door to imaging time was 12 minutes (IQR, 7-20 minutes), imaging to arterial puncture time was 93 minutes (IQR, 68-126 minutes), and arterial puncture to first pass time was 18 minutes (IQR, 4-31 minutes). Overall, 3% patients achieved a door to first pass time ≤60 minutes. A statistically significant linear time trend was noted for door to first pass time (quarter 4 year 2014 median time, 134.5 minutes to quarter 3 year 2016 median time, 128 minutes, P=0.002). In multivariable analysis, older age, arrival during nonregular hours, and history of diabetes mellitus were associated with longer door to first pass time. Hospitals achieving shorter door to intravenous alteplase administration (door to needle) times were more likely to achieve faster door to first pass time ( P<0.001). Each 5 cases/y increase in EVT case volume was associated with a 3% shorter door to first pass time, up to a case volume of 40 per year ( P<0.001). Although EVT treatment times are modestly improving, additional efforts are needed to streamline workflow so that the true potential of this treatment is realized. These data may inform benchmark goals for EVT workflow times.

Unexplained Variation for Hospitals' Use of Inpatient Rehabilitation and Skilled Nursing Facilities After an Acute Ischemic Stroke.

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. 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. 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). There is marked unexplained variation among hospitals in their use of IRF versus SNF poststroke even after accounting for clinical characteristics and geographic availability. URL: https://clinicaltrials.gov. Unique identifier: NCT02284165.

Association Between Previous Use of Antiplatelet Therapy and Intracerebral Hemorrhage Outcomes.

Although the use of antiplatelet therapy (APT) is associated with the risk of intracerebral hemorrhage (ICH), there are limited data on prestroke APT and outcomes, particularly among patients on combination APT (CAPT). We hypothesized that the previous use of antiplatelet agents is associated with increased mortality in ICH. We analyzed data of 82 576 patients with ICH who were not on oral anticoagulant therapy from 1574 Get with the Guidelines-Stroke hospitals between October 2012 and March 2016. Patients were categorized as not on APT, on single-APT (SAPT), and CAPT before hospital presentation with ICH. We described baseline characteristics, comorbidities, hospital characteristics and outcomes, overall and stratified by APT use. Before the diagnosis of ICH, 65.8% patients were not on APT, 29.5% patients were on SAPT, and 4.8% patients were on CAPT. There was an overall modest increased in-hospital mortality in the APT group versus no APT group (24% versus 23%; adjusted odds ratio, 1.05; 95% confidence interval, 1.01-1.10). Although patients on SAPT and CAPT were older and had higher risk profiles in terms of comorbidities, there was no significant difference in the in-hospital mortality among patients on SAPT versus those not on any APT (23% versus 23%; adjusted odds ratio, 1.01; 95% confidence interval, 0.97-1.05). However, in-hospital mortality was higher among those on CAPT versus those not on APT (30% versus 23%; adjusted odds ratio, 1.50; 95% confidence interval, 1.39-1.63). Our study suggests that among patients with ICH, previous use of CAPT, but not SAPT, was associated with higher risk for in-hospital mortality.

Abstract 30: Door-to-puncture and First Pass Times for Endovascular Thrombectomy: Predictors and Changes Over Time in GWTG-stroke

Background and Purpose: Endovascular thrombectomy (EVT) is now standard of care in eligible patients with acute disabling ischemic stroke, and is more effective when delivered quickly. It is currently unclear whether time targets achieved in clinical trials can also be achieved in routine clinical practice. Here, we describe interval times from stroke onset to patient arrival in emergency room (door) to first pass/initiation of treatment in patients receiving EVT within Get With The Guidelines-Stroke hospitals (GWTG-S). Methods: Data are from sites participating fully as Comprehensive Stroke Centers within GWTG-S from 8/2014-3/2016. Analyzed work flow times include stroke onset to door , door to imaging, imaging to arterial access, arterial access to first pass time (defined as the earliest of either deployment of a mechanical reperfusion device or intra-arterial alteplase initiated) and the composite door-to-first-pass time. Data are described overall and analyzed by calendar year quarters. Trends are tested using the Cochran-Mantel-Haenszel test. Results: Data are reported from 1891 patients from 172 hospitals. Median time from stroke onset to door was 77 mins (IQR 46-144 min), imaging to arterial access was 91 min (64-126 min), and arterial access to first pass time was 18 min (4-31 min) (Figure). Median door-to-first-pass time was 129 min (IQR 97-171 min). Only 5.3% had a door-to-first-pass time &lt;60 minutes while 15.1% achieved this time in &lt;90 minutes. Slight improvements were noted in door-to-first pass (p=0.01) and imaging to arterial access time (p=0.04) by calendar quarter. Provision of IV alteplase was associated with longer imaging-to-arterial access time (median 96 vs. 85 minutes, p&lt;0.001). Conclusion: Although workflow is improving, efforts need to continue on streamlining workflow and saving time so that the true potential of EVT is realized. These data may inform benchmark goals for EVT workflow times.

Use of Strategies to Improve Door-to-Needle Times With Tissue-Type Plasminogen Activator in Acute Ischemic Stroke in Clinical Practice: Findings from Target: Stroke.

The implementation of Target: Stroke Phase I, the first stage of the American Heart Association's national quality improvement initiative to accelerate door-to-needle (DTN) times, was associated with an average 15-minute reduction in DTN times. Stroke phase II was launched in April 2014 with a goal of promoting further reduction in treatment times for tissue-type plasminogen activator (tPA) administration. We conducted a second survey of Get With The Guidelines-Stroke hospitals regarding strategies used to reduce delays after Target: Stroke and quantify their association with DTN times. A total of 16 901 ischemic stroke patients were treated with intravenous tPA within 4.5 hours of symptom onset from 888 surveyed hospitals between June 2014 and April 2015. The patient-level median DTN time was 56 minutes (interquartile range, 42-75), with 59.3% of patients receiving intravenous tPA within 60 minutes and 30.4% within 45 minutes after hospital arrival. Most hospitals reported routinely using a majority of Target: Stroke key practice strategies, although direct transport of patients to computed tomographic/magenetic resonance imaging scanner, premix of tPA ahead of time, initiation of tPA in brain imaging suite, and prompt data feedback to emergency medical services providers were used less frequently. Overall, we identified 16 strategies associated with significant reductions in DTN times. Combined, a total of 20 minutes (95% confidence intervals 15-25 minutes) could be saved if all strategies were implemented. Get With The Guidelines-Stroke hospitals have initiated a majority of Target: Stroke-recommended strategies to reduce DTN times in acute ischemic stroke. Nevertheless, certain strategies were infrequently practiced and represent a potential immediate target for further improvements.

Abstract 240: Regional Variation in 30-Day Ischemic Stroke Mortality and Readmissions in Get With the Guidelines-Stroke Hospitals

Objective: To explore regional variation and correlation between 30-day ischemic stroke mortality and readmissions in ischemic stroke patients treated at Get With The Guidelines (GWTG)-Stroke hospitals. Methods: Hospital-level 30-day ischemic stroke mortality and readmission rates were generated by linking GWTG-Stroke national registry data (2007-11) to Medicare fee-for-service data. We then aggregated GWTG-Stroke hospitals into hospital referral regions (HRR) as defined by the Dartmouth Atlas. Frequency-weighted 30-day event rates were estimated for each HRR, which were risk-adjusted using HRR-level patient and hospital characteristics. A Pearson correlation coefficient (r) was used to estimate the linear relationship between mortality and readmission rates at the HRR level. Results: There were 429,631 ischemic stroke patients at least 65 years of age treated at 1,344 GWTG-Stroke hospitals in 282 different HRRs. The average HRR-level risk adjusted 30-day mortality rate was 10.3% (SD=1.1%), with range 7.4% to 15.6%. The average HRR-level risk adjusted readmission rate was 13.2% (SD=1.4%), with range 9.7% to 23.3%. HRR-level maps suggest that some regions with higher than average mortality - such as the Mountain West and Upper Midwest regions - had lower than average readmission rates. (Figure 1) There was a modest, but statistically significant negative correlation between 30-day mortality and readmission rates (r = -0.23, p&lt;0.0001). (Figure 2) Conclusions: HRR-level 30-day ischemic stroke mortality and readmission rates exhibit substantial regional variation and are inversely correlated. Further research is ongoing to determine the origin of the regional variation and correlation between 30-day event rates.