Hospitalization For Acute Ischemic Stroke Research Articles

Interhospital Transfers for Endovascular Therapy for Acute Ischemic Stroke.

Background and Purpose- Multiple randomized clinical trials have demonstrated the superiority of endovascular therapy (ET) for large vessel occlusion acute ischemic stroke (AIS). Few centers can provide ET, and significant debate exists about the most efficient and effective ways to provide ET. We sought to assess real-world utilization of ET, the extent to which patients are transferred from one hospital to another for therapy and the implications of transfer status on outcomes. Methods- We used the 2015 to 2016 Healthcare Cost and Utilization Project Nationwide Readmissions Database, which contains nationwide data on nearly half of US admissions. We identified index AIS admissions, vascular risk factors, and treatment with intravenous thrombolysis and ET using International Classification of Disease, Ninth Revision, and International Classification of Disease, Tenth Revision Clinical Modification codes. Main predictors of outcome were treatment with ET and whether there was an interhospital transfer during the index AIS hospitalization. Among patients with AIS readmitted within 30 days, we examined 3 main outcomes: total charges, length of stay, and in-hospital mortality. Results- A total of 23 121 AIS admissions were treated with ET and 874 229 without. Over 5% of patients who received ET were transferred during the index admission compared with <2% of those not treated with ET. Length of stay and total charges were significantly higher in patients transferred (12.3 versus 9.6 days and $233 626 versus $182 881, respectively). More patients treated with ET who were not transferred to the index hospital were discharged home (25.3% versus 44.4%), and ≈25% of patients transferred for ET died during the hospitalization compared with 15.5% not transferred. Conclusions- The minority of all patients with AIS receive ET. The majority of patients who receive ET present directly to the center that performs the procedure, and those transferred for ET have higher length of stay, cost, and mortality that those not transferred.

Temporal Trends in the Use of Acute Recanalization Therapies for Ischemic Stroke in Patients with Cancer

Objective: We sought to characterize the US nationwide temporal trends in recanalization therapy utilization for ischemic stroke among patients with and without cancer. Methods: We identified all acute ischemic stroke (AIS) hospitalizations in the National Inpatient Sample from January 1, 1998 to September 30, 2015. The primary exposure was solid or hematologic cancer. The primary outcome was use of intravenous thrombolysis. The secondary outcome was use of endovascular therapy (EVT). Results: Among 9,508,804 AIS hospitalizations, 503,510 (5.3%) involved cancer patients. Intravenous thrombolysis use among ischemic stroke patients with cancer increased from .01% (95% confidence interval [CI], .00%-.02%) in 1998 to 4.91% (95% CI, 4.33%-5.48%) in 2015, whereas intravenous thrombolysis use among ischemic stroke patients without cancer increased from .02% (95% CI, .01%-.02%) in 1998 to 7.22% (95% CI, 6.98%-7.45%) in 2015. The demographic- and comorbidity-adjusted odds ratio/year of receiving intravenous thrombolysis was similar in patients with cancer (1.21; 95% CI, 1.20-1.23) versus those without (1.20; 95% CI, 1.19-1.21). EVT use among ischemic stroke patients with cancer increased from .05% (95% CI, .02%-.07%) in 2006 to 1.90% (95% CI, 1.49%-2.31%) in 2015, whereas EVT use among ischemic stroke patients without cancer increased from .09% (95% CI, .00%-.18%) in 2006 to 1.88% (95% CI, 1.68%-2.09%) in 2015. Conclusions: Among 9.5 million AIS hospitalizations, patients with cancer received intravenous thrombolysis about two thirds as often as patients without cancer. This difference persisted over time despite increased utilization in both groups. EVT utilization was similar between cancer and non–cancer AIS patients.

Abstract 147: The Trend of In-hospital Complications During Acute Ischemic Stroke Hospitalization Among US Elderly

Background: Stroke is the fifth leading cause of death in the United States and the leading cause of long-term disability in adult. Many efforts have been devoted to improve the stroke quality of care. We aimed to examine the recent rate and trend of in-hospital complications among U.S. elderly who were hospitalized for acute ischemic stroke from 2009 to 2013. Methods: We examined the prevalence and trend of in-hospital pneumonia, urinary tract infection (UTI), deep vein thrombosis (DVT) and pulmonary embolization (PE) among Medicare beneficiaries aged 65 years and older who were hospitalized between January 2009 and December 2013 with a primary discharge diagnosis of acute ischemic stroke. The data of patient information were obtained from the Medicare Provider Analysis and Review file. The in-hospital complications were identified using the ICD-9 CM codes that have been previously validated. Results: A total of 1,070,574 Medicare beneficiaries were hospitalized for ischemic stroke between 2009 and 2013. The in-hospital pneumonia decreased from 17507 (7.7%) in 2009 to 14078 (6.8%) in 2013, an 11.7% decrease. The in-hospital UTI decreased from 34356 (15%) in 2009 to 29134 (14.1%) in 2013, a 6% decrease. The in-hospital DVT increased from 2263 (1.0%) in 2009 to 2605 (1.3%), a 30% increase. The in-hospital PE increased from 754 (0.3%) in 2009 to 800 (0.4%) in 2013, a 33% increase. Conclusion: Among Medicare beneficiaries who were hospitalized for acute ischemic stroke from 2009 to 2013, the prevalence of in-hospital pneumonia and UTI decreased while DVT and PE dramatically increased. These results call for further interventions to prevent in-hospital thrombotic complications.

Abstract WP212: Trends in Acute Ischemic Stroke Hospitalizations by Age Groups, Length of Stay, Mortality and Hospital Costs in the United States From 2000-2014

Background and Purpose: Acute Ischemic Stroke (AIS) is a significant cause of long term disability. The primary objective of our study was to analyze the trends in AIS hospitalizations by age groups, Length of Stay (LOS), Mortality and hospital costs in the United States over a 15-year period from the years 2000 to 2014. Methods: Nationwide inpatient sample (NIS) database was used to identify AIS admissions in all patients from 2000 to 2014 using ICD-9-CM codes 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91, and 436 as the principal discharge diagnosis. NIS is the largest all-payer inpatient care database in the United States, containing data on more than 7 million hospital stays. It has a large sample size which is ideal for developing national and regional estimates. Results: A total of 554,226,249 discharges with a diagnosis of AIS were analyzed from 2000 to 2014 from the NIS database. Hospitalization rates for AIS increased significantly from years 2000 to 2014 for ages 18-44 (relative percentage change (RPC): +33.75%) and ages 45-64(RPC: +41.21%). Hospitalization rates for AIS have significantly decreased in the age group 65-84 (RPC: -16.69%). In-hospital mortality decreased from 6.97% in 2000 to 4.4% in 2014. Mean LOS has decreased from 6.19 days to 4.2 days during the same period. Mean hospital costs have gone up from $6,975 to $12,322. Conclusion: Overall in-hospital mortality and LOS associated with AIS has decreased over the years. AIS US hospitalizations have significantly increased in the age groups from 18-64 while there was a significant decrease in the rate of hospitalizations in the age groups 65-84. Further research needs to be done to identify the risk factors contributing to a substantial rise in AIS hospitalizations in young to middle age adults.

Abstract WP254: Predictors of Atrial Fibrillation Detection by Mobile Cardiac Output Telemetry After Hospital Discharge for Acute Ischemic Stroke

Background: Patients with cryptogenic stroke without atrial fibrillation (AF) detected in the hospital often undergo 30-day mobile cardiac outpatient telemetry (MCOT) to increase the AF detection rate. We sought to determine the clinical and transthoracic echocardiogram (TTE) characteristics associated with AF detection by MCOT. Methods: We analyzed a cohort of admissions from 2005 to 2016 with an acute ischemic stroke diagnosis, an inpatient TTE, and an MCOT performed upon discharge. Each admission was treated as a unique observation. Cases with subsequent AF vs. no AF on MCOT were compared by Chi-squared tests if variables were categorical and t-tests if continuous. A multivariable stepwise logistic regression model was created to determine the predictors of AF detection as a function of variables which were significant in univariate analysis and not significantly collinear. Results: Of the 4,880 inpatient hospitalizations for acute ischemic stroke with an TTE performed during admission, there were 283 cases which underwent MCOT (10.4 cases/year in 2005-2014, 90 cases/year in 2015-2016). There were 23 (8.10%) cases of AF on MCOT, and they were more likely to be older, white, admitted earlier during the study, and have larger left atrial anterior-posterior and medial-lateral dimensions (Table). A multivariable model demonstrated that age greater than the median of 66 yr (OR 3.25, 1.21-8.74) and left atrial anterior-posterior dimension greater than the median of 40cm (OR 5.86, 2.38-14. 43) were strong predictors of AF detection by MCOT (c-statistic 0.78). Conclusions: We observed low rates of AF on 30-day MCOT post-discharge. Left atrial anatomic dimension is predictive of a higher rate of early AF detection after adjusting for age. This TTE feature, coupled with clinical information, may improve patient selection for MCOTs and potentially avoid the need for more expensive implantable loop monitors in those for whom MOCT does not yield an answer.

Abstract WP112: Trends of Hospitalization for Intravascular Thrombolysis and Acute Ischemic Stroke Among Patients With Multiple Sclerosis and United States: A 10 Year National Estimate

Background: Several studies reported increased incidence of acute ischemic stroke (AIS) among patients with multiple sclerosis (MS) but there is paucity of data for utilization of intravascular thrombolysis (IVT) and its outcomes in this population. This study aimed to evaluate trends in utilization of IVT and its outcomes among MS patients. Methods: Nationwide Inpatient Sample (NIS) from 2005 to 2014 was utilized to identify patients with MS using ICD CM code 340 in any diagnostic field and AIS with appropriate diagnostic codes in primary field. IVT utilization was identified by ICD9 procedure code 99.10 in any procedural field. Differences between categorical variables were tested using the chi-square test and continuous variables using the Student t-test. Results: We identified 11,881 patients with ischemic stroke among MS patients, of which 638 (5.4%) received IVT during our study period (86.4% with age≥ 50years; 68.4% Female). IVT study compared to non-IVT group associated with more comorbid conditions (CCI ≥2 in 70.1 % vs 41.4%). Hospitals in the Southern states constitute the highest percentage of IVT hospitalizations in patients with MS (33.7%), followed by West (27%), Midwest (23.1%), and Northeast (16.3%). MS patients that received thrombolysis were more likely to be at a teaching hospital (59.4%) (p &lt;0.0001). Overall in-hospital mortality associated with IVT hospitalizations was 4.7% vs 2.8% in non IVT group and was associated with longer mean length of stay (6 days vs 5 days, p=0.01). Hospitalizations for AIS among MS patients increased from 0.7% in 2005 to 1.1% in 2014. A similar upward trend was seen in IVT use in this population (from 0.4% in 2005 to 9.3% in 2014, ptrend &lt;0.0001). Conclusion: 1 out of 20 MS patients with AIS received thrombolysis. IVT was more likely to be administered at a teaching hospital during our study period. There were significant upward trend in number of MS patients receiving thrombolysis. Patients with MS that received thrombolysis for AIS had higher mortality. It is important to note however that this group was older and had more comorbid conditions.

Abstract WP433: Effect of Race on Rates of Patent Foramen Ovale Closure during Acute ischemic Stroke Hospitalization in the United States

Background: Published data indicate that African American stroke patients are significantly less likely than their non-Hispanic White counterparts to receive therapeutic procedures in acute ischemic stroke (AIS). Little is known about frequency of PFO closure for secondary stroke prevention by race among patients with cryptogenic stroke. Objective: To investigate trends in PFO closure among hospitalized patients in the U.S., with an emphasis on treatment by race. Methods: The Nationwide Inpatient Sample was queried from 2006 to 2014 for all patients older than 18-years of age with a primary diagnosis of AIS who had procedure codes for PFO closure excluding congenital heart disease. We utilized multivariable logistic regression analyses to study the independent association between race and trends in PFO closure. Results: A population of patients with AIS (n=1028565), excluding congenital heart disease, was analyzed. The queried was divided by PFO closure (n=384) and no PFO closure (n=1028181). Demographic variables included age, gender (male or female) race (White, African American, Hispanic, others) and payer status (Medicare, Medicaid, private, other). In multivariable logistic regression, the odds to have a PFO closure was greatest in the 18-45 age group [age 45-65 (Odds Ratio [OR]: 0.27, 95% CI: 0.20-0.35); age 65-84 (OR: 0.11, 95% CI: 0.81-0.15); age ≥85 (OR: 0.02, 95% CI: 0.01-0.05)], no difference among genders was found (OR: 1.14, 95% CI: 0.93-1.40). African Americans were less likely have PFO closure (OR: 0.51, 95%, CI: 0.35-0.74) when compared to Whites. Private insurance (OR: 1.5, 95% CI: 1.16-2.16); urban teaching hospitals (OR: 3.0, 95% CI: 1.35-6.83); higher median household income for patient’s ZIP code (OR: 2.14, 95% CI: 1.46-3.11); higher Charlson’s Comorbidity Index (OR: 0.78, 95% CI: 0.68-0.90) and admission in 2011-2014 (OR: 0.49, 95% CI: 0.31-0.78) were found to increase the likelihood of having a percutaneous PFO closure after an AIS. Conclusions: Over the last decade in the U.S., being African American was associated with a significantly lower likelihood of receiving percutaneous PFO closure. Now that the beneficial role of PFO closure for cryptogenic stroke is established, this racial disparity needs to be monitored and bridged.

Abstract WP434: Effect of Race on Rates of Hemicraniectomy During Acute Ischemic Stroke Hospitalization in the United States

Background: surgical decompressive techniques have shown a significant reduction in mortality in acute ischemic stroke (AIS) compared to medical treatment. Limitations in acute stroke therapies have been described among Hispanic and African American populations compared to other races. Objective: To investigate trends in hemicraniectomy among hospitalized patients in the United States, with emphasis on treatment by race. Methods: The Nationwide Inpatient Sample was queried from 2006 to 2015 for all patients older than 18-years of age with a primary diagnosis of AIS who had procedure codes for craniotomy excluding posterior fossa territory infarctions. Frequency of hemicraniectomy in patients with AIS hospitalization was determined. We utilized multivariable logistic regression analyses to study the independent association between race and trends in hemicraniectomy. Results: A population of patients with AIS (n=715649) was analyzed. The queried was divided by hemicraniectomy (n=1514) and no hemicraniectomy (n=714135). Demographic variables included age, gender (male or female), race (White, African American, Hispanic, others) and payer status (Medicare, Medicaid, private, other). In multivariable analysis, adjusted for potential confounders the odds to have a hemicraniectomy was greatest in the 18-44 age group [age 45-64 (Odds Ratio [OR]: 0.49, 95% CI: 0.42-0.58); age 65-84 (OR: 0.16, 95% CI: 0.13-0.20); age ≥85 (OR: 0.007, 95% CI: 0.003-0.01)]. Medicare insurance [Medicaid (OR: 1.5, 95% CI: 1.2-1.9); Private insurance (OR: 1.7, 95% CI: 1.43-2.03)]; urban teaching hospital (OR: 1.57, 95% CI: 3.63-12.05); prior administration of intravenous tPA (OR: 2.64, 95% CI: 2.21-3.16); being admitted after 2009 (2009-2011 OR: 1.68, 95% CI: 1.13-2.13; 2012-2014 OR: 1.81, 95% CI: 1.44-2.27) and coma status (OR: 15.8, 95% CI: 13.1-19.2) were found to increase the likelihood of having a hemicraniectomy after an AIS. The Hispanic population was more likely to have a hemicraniectomy when compared to White (OR: 1.28, 95% CI: 1.02-1.60). Conclusions: Over the last decade in the United States, being Hispanic was independently associated with an increased likelihood to have a hemicraniectomy.

Abstract WP380: Hospital-Level Variability in Diagnostic Testing and Ischemic Stroke Subtype Documentation

Objective: Documentation of ischemic stroke subtype has clinical and research implications. We aimed to assess hospital-level variability in subtype documentation and diagnostic testing patterns in the Get With The Guidelines (GWTG)-Stroke registry. Methods: We identified patients admitted with ischemic stroke to GWTG-Stroke participating hospitals between January 1, 2016 and September 30, 2017. Sites were instructed on use of the TOAST criteria for subtype documentation. We assessed hospital-level variability in TOAST subtype documentation and, among those with subtype documented, the performance of echocardiography, cerebrovascular imaging, and cardiac rhythm monitoring. Results: Among 607,563 patients with ischemic stroke from 1,906 sites, 348,715 (57.4%) had documented ischemic stroke subtype. Considerable hospital-level variability was observed in subtype documentation (Figure A). Patients with subtype documentation were more likely to be inter-facility transfers and treated at higher volume and academic centers, have complete medical history data, and have higher rates on achievement and quality measures. Carotid and intracranial vascular imaging (69.1% and 58.7%, respectively), echocardiography (74.3%), and cardiac rhythm monitoring (76.2%) were performed most frequently in cryptogenic stroke (CS) patients compared to other subtypes (Figure B; p&lt;0.001 for each comparison). Among CS patients, short-term cardiac rhythm monitoring (65.7%) was most common with only 6.1% undergoing extended surface cardiac rhythm monitoring and 4.4% receiving extended implantable cardiac rhythm monitoring. Conclusions: In a large contemporary nationwide dataset of acute ischemic stroke hospitalizations, we observed that stroke subtype is documented in 57.4% of records, raising an important opportunity for quality improvement. Furthermore, diagnostic testing patterns suggest incomplete evaluation is common, even among patients with CS.

Abstract TP408: Alcohol Withdrawal is Associated With Poorer Outcome in Ischemic Stroke

Objective: Prevalence of alcohol abuse (AA) in the United States (US) is on the increase. AA patients may develop alcohol withdrawal (AW) during hospitalization, but it remains unknown how AW influences acute ischemic stroke (AIS) outcome. Methods: All adult AIS admissions in the US from 2004–2014 were identified from the National Inpatient Sample (NIS) (weighted N=4,438,968). Multivariable-adjusted models were used to evaluate the association of AW with in-hospital medical complications, mortality, cost, and length-of-stay in patients with AIS. Results: During this period, 3.9% of all AIS admissions had comorbid codes for AA but prevalence differed significantly by age; 10.6% of AA patients, representing 0.4% of all AIS, developed AW. Prevalence of AA and AW in AIS increased by 45.2% and 40.0%, respectively, over time (p-value for trend &lt;0.001). AA patients were predominantly men (80.2%), white (65.9%), and in the 40–59-year (44.6%) and 60–79-year (45.6%) age groups. After multivariable adjustment, AIS patients with AW had &gt;50% increased odds of urinary tract infection, pneumonia, sepsis, gastrointestinal bleeding, deep venous thrombosis, and acute renal failure compared to those without AW. Patients with AW were also 32% more likely to die during their AIS hospitalization compared to those without AW (OR 1.32, 95% CI 1.11–1.58). AW was associated with 15-day increase in length-of-stay and $5,000 increase in hospitalization cost (p-values &lt;0.001). Conclusions: AW is associated with increased cost, longer hospitalizations, and higher odds of medical complications and in-hospital mortality following AIS. Proactive surveillance and management of AW may be important in improving outcomes in these patients.

Dyslipidaemia was correlated to the posterior circulation infarction in non-diabetic populations

BackgroundDiabetes mellitus (DM) was prone to happening in posterior circulation infarction (POCI) and DM also has the impact on the lipids, our study was to investigate the correlation between lipid compositions and POCI.MethodsData was collected from the patients with acute ischemic stroke (AIS) hospitalization in Affiliated Drum Tower Hospital of Nanjing University Medical School from October 2008 to May 2012. Lipids and other risk factors in the different populations were investigated in relation to occurrence of POCI based on the infarction location.ResultsSix hundred ten patients with AIS were included in this study, which had 428 with anterior circulation infarction (ACI) and 182 with POCI. Elevated Triglyceride (TG) and decreased High density lipoprotein cholesterol (HDL-C) were seen in the POCI of total populations and AIS without DM compared to the ACI, but not in the populations of AIS with DM, so did the elevated TG/HDL-C ratios. Also, the percent of low HDL-C level and high TG level were higher in POCI group than that in ACI group. Furthermore, single factors logistic regression demonstrated that TG, HDL-C and TG/HDL-C ratio were correlated to the POCI whatever in the total populations or AIS without DM, but this kind of trend just maintained in the populations of AIS without DM after adjusting by relative interference factors.ConclusionDyslipidaemia was prone to happening in POCI compared to ACI in the non-diabetic populations, which was correlated to the pathogenesis of POCI.

Effects of Barometric Pressure and Temperature on Acute Ischemic Stroke Hospitalization in Augusta, GA.

Several studies worldwide have demonstrated significant relationships between meteorological parameters and stroke events. However, authors often reported discordant effects of both barometric pressure and air temperature on stroke occurrence. The present study investigated whether there was an association between weather parameters (barometric pressure and temperature) and ischemic stroke hospitalization. The aim of the study was to find out whether daily barometric pressure may be used as a prognostic variable to evaluate the workload change of a neurological intensive care unit. We conducted a retrospective review study in which we collected the independent (barometric pressure and temperature) and dependent variables (stroke hospitalization) every 24h for the periods 10/1/2016-4/30/2017 at Augusta University Medical Center of Augusta, GA. We analyzed the data with zero-inflated Poisson model to assess the relationship between the barometric pressure, temperature, and daily stroke hospitalization. The results showed that there was a significantly correlation between daily barometric pressure variation and daily stroke hospitalization, especially on elder male patients (≥ 65). Stroke events were more likely to occur in the patients with risk factors than in those without risk factors when exposed to barometric pressure and temperature changes. Decreased barometric pressure and increased temperature were associated with increased daily stroke hospitalization. Furthermore, there was a potential delayed effect of increased stroke events after cold temperature exposure. Barometric pressure and temperature changes over the preceding 24h are associated with daily stroke hospitalization. These findings may enhance our understanding of relationship between stroke and weather and maybe used in the development of public health strategies to minimize the weather-related stroke risk.

Age-related differences in the rate and diagnosis of 30-day readmission after hospitalization for acute ischemic stroke.

Background Little is known about the association between age and readmission within 30 days after hospitalization for acute ischemic stroke. Aim To examine the age-related differences in rate and principal reason of 30-day readmissions in patients hospitalized for acute ischemic stroke. Methods In this retrospective, population-based cohort study using State Inpatient Databases from eight US states, we identified all adults hospitalized for acute ischemic stroke. We grouped the patients into four age categories: < 65, 65-74, 75-84, and ≥85 years. Outcomes were any-cause readmission within 30 days of discharge from the index hospitalization for acute ischemic stroke and the principal diagnosis of 30-day readmission. Results We identified 620,788 hospitalizations for acute ischemic stroke. The overall 30-day readmission rate was 16.6% with an increase with advanced age. Compared to patients aged <65 years, the readmission rate was significantly higher in age 65-74 years (OR 1.19; 95% CI 1.16-1.21), in age 75-84 years (OR 1.29; 95% CI 1.27-1.31), and in ≥ 85 years (OR 1.24; 95% CI 1.22-1.27; all P<0.001). There was heterogeneity in the age-readmission rate association between men and women (Pinteraction < 0.001). Overall, 45.8% of readmissions were assigned stroke-related conditions or rehabilitation care. Compared to younger adults, older adults were more likely to present with non-stroke-related conditions (46.1% in < 65 years, 50.6% in 65-74 years, 57.1% in 75-84 years, and 62.9% in ≥ 85 years; P<0.001). Conclusions Advanced age was associated with a higher 30-day readmission rate after acute ischemic stroke. Compared with younger adults, older adults were more likely to be readmitted for non-stroke-related conditions.

Administrative data underestimate acute ischemic stroke events and thrombolysis treatments: Data from a multicenter validation survey in Italy.

BackgroundInforming health systems and monitoring hospital performances using administrative data sets, mainly hospital discharge data coded according to International-Classification-Diseases-9edition-Clinical-Modifiers (ICD9-CM), is now commonplace in several countries, but the reliability of diagnostic coding of acute ischemic stroke in the routine practice is uncertain. This study aimed at estimating accuracy of ICD9-CM codes for the identification of acute ischemic stroke and the use of thrombolysis treatment comparing hospital discharge data with medical record review in all the six hospitals of the Florence Area, Italy, through 2015.MethodsWe reviewed the medical records of all the 3915 potential acute stroke events during 2015 across the six hospitals of the Florence Area, Italy. We then estimated sensitivity and Positive Predictive Value of ICD9-CM code-groups 433*1, 434*1 and thrombolysis code 99.10 against medical record review with clinical adjudication. For each false-positive case we obtained the actual diagnosis. For each false-negative case we obtained the primary and secondary ICD9-CM diagnoses.ResultsThe medical record review identified 1273 acute ischemic stroke events. The hospital discharge records identified 898 among those (true-positive cases),but missed 375 events (false-negative cases), and identified 104 events that were not eventually confirmed as acute ischemic events (false-positive cases). Code-group specific Positive Predictive Value was 85.7% (95%CI,74.6–93.3) for 433*1 and 89.9% (95%CI, 87.8–91.7) for 434*1 codes. Thrombolysis treatment, as identified by ICD9-CM code 99.10, was only documented in 6.0% of acute ischemic stroke events, but was 13.6% in medical record review.ConclusionsHospital discharge data were found to be fairly specific but insensitive in the reporting of acute ischemic stroke and thrombolysis, providing misleading indications about both quantity and quality of acute ischemic stroke hospital care. Efforts to improve coding accuracy should precede the use of hospital discharge data to measure hospital performances in acute ischemic stroke care.

Acute Ischemic Stroke Hospital Admissions, Treatment, and Outcomes in Poland in 2009-2013.

Ischemic stroke (IS) still constitutes a serious problem for public health worldwide. The data on its burden in Poland before 2009 is limited and came only from a few metropolitan areas. To assess temporal trends in the hospital admissions, treatment, and outcomes of IS in Poland in 2009-2013, to identify risk factors for IS mortality and to compare the results with other countries. The data from the Polish Stroke Registry were analyzed. The data concerned all subjects hospitalized due to IS (classified according to the ICD10 classification as I63.0-I63.9) as primary diagnosis in Poland in 2009-2013. Temporal trends in treatment and outcome were analyzed. Hospital admissions rates as well as case fatality and 12-month mortality rates were calculated. Altogether, 360,556 patients (47.5% of males) were hospitalized due to IS in Poland in 2009-2013. The median of age was 75 years, IQR 18 (Women 78, IQR 14 vs. Men 70, IQR 17; p < 0.001). The hospital admissions age-standardized annual rate for IS in Poland in 2013 was 8% lower than in 2009 (169 vs. 157/100,000; p for trend < 0.001). In-hospital case fatality has slightly decreased (from 13.6% in 2009 to 12.9% in 2013; p for trend < 0.001). One-year posthospital mortality rate has not changed (19.3% in 2009 and 2013). The percentage of IS subjects treated with intravenous thrombolysis was low but increased from 1.7% in 2009 to 6.3% in 2013 (p for trend <0.001). Since 2009, Poland has had national epidemiological data on the hospital admissions, treatment, and outcomes in IS. The data indicate a slow improvement of in-hospital survival and suggest the need for better stroke prevention and further dissemination of reperfusion therapy.

Cardiovascular outcomes associated with canagliflozin versus other non-gliflozin antidiabetic drugs: population based cohort study

ABSTRACTObjectiveTo evaluate the cardiovascular safety of canagliflozin, a sodium-glucose cotransporter 2 inhibitor for the treatment of type 2 diabetes mellitus, in direct comparisons with DPP-4 inhibitors (DPP-4i), GLP-1 receptor agonists...

Abstract TP36: Medical Specialty and Training of Physicians Performing Mechanical Thrombectomy for Acute Ischemic Stroke in the U.S

Introduction: We sought to determine the medical specialty and training of U.S. physicians who perform mechanical thrombectomy for stroke. Methods: We analyzed claims between 2009-2015 from a 5% nationally representative sample of Medicare beneficiaries ≥65 years of age. Validated ICD-9-CM diagnosis codes were used to identify hospitalizations for acute ischemic stroke. Mechanical thrombectomy was defined as a physician claim with CPT code 37184 and an accompanying diagnosis of cerebrovascular disease. Medical specialty was identified using the claim’s Medicare provider specialty code. We reviewed public online profiles to ascertain providers’ residency and fellowship training. Statistical analysis involved chi-square tests and kappa statistics. Results: During 77,774 stroke hospitalizations, we identified 555 thrombectomies, of which 341 (61.4%; 95% CI, 57.2-65.5%) were performed by radiologists, 110 (19.8%; 95% CI, 16.6-23.4%) by neurologists, 91 (16.4%; 95% CI, 13.4-19.7%) by neurosurgeons, and 13 (2.3%; 95% CI, 1.3-4.0%) by others such as cardiologists and vascular surgeons. Of the 555 procedures, 367 (66.1%; 95% CI, 62.0-70.1%) were performed by a physician who had completed a dedicated neurointerventional fellowship. There was excellent agreement (91.4%; kappa, 0.86) between Medicare specialty designations and the online profiles of the 350 physicians who performed these 555 procedures. The rate of mechanical thrombectomy rose from 0.62% (95% CI, 0.56-0.68%) before publication of the MR CLEAN trial to 1.45% (95% CI, 1.21-1.72%) after, but there was no significant change after its publication in the distribution of providers’ specialties or the proportion of procedures performed by those with neurointerventional fellowship training (Figure). Conclusions: Most mechanical thrombectomies for stroke in the U.S. are performed by radiologists, neurologists, and neurosurgeons with dedicated neurointerventional fellowship training.

Abstract TP146: Trend, Outcomes, and Predictors of Utilization of Speech Rehabilitation Therapy in Acute Ischemic Stroke Hospitalization

Background: At least one-fourth of all stroke survivors experience language impairments. Many recover within a few months after the stroke, but up to 60% still have language impairments more than six months after a stroke, known as chronic aphasia. We aimed to look the outcomes, cost, a length of stay (LOS), and predictors of utilization of speech rehabilitation therapy (SRT) in stroke patients. Methods: We performed a cross-sectional study using the Nationwide Inpatient Sample (NIS) (years 2003-2013) in adult hospitalizations for AIS who had undergone SRT. We performed weighted analyses using chi-square, Cochran-Armitage Trend-test, and t-test to find outcomes, trend, and cost and LOS respectively. Multivariate survey logistic regression was done to evaluate the predictors of utilization of SRT. Results: Amongst 4,566,282 AIS hospitalizations, 23,597 had SRT. There was a decrease in trend (0.9% in 2003 to 0.55% in 2013, p&lt;0.001). The mean LOS was longer by 2 days, the cost of hospitalization was higher by $11517, and outcomes were poor in AIS patients on SRT compared to those without (Table). The predictors for higher utilization in AIS patients on SRT included African American (aOR: 1.64; 95% CI: 1.48-1.82), Hispanic (aOR: 1.78; 95% CI: 1.52-2.09), Asian/pacific islander (aOR: 2.04; 95% CI: 1.56-2.67), urban teaching hospitals (aOR: 1.40; 95% CI: 1.23-1.60), depression (aOR: 1.16; 95% CI: 1.01-1.35), tPA treatment (aOR: 1.47; 95% CI: 1.20-1.81), alcohol (aOR: 1.33; 95% CI: 1.07-1.64), and atrial fibrillation (aOR: 1.17; 95% CI: 1.05-1.31). Significant predictors for lower utilization included emergency admission type, urban non-teaching hospital, medium bed-size hospitals, large bed-size hospitals, and private insurance. Conclusion: High cost and LOS might be responsible for declined utilization of SRT in private insurance payers but poor outcomes even after SRT need further research to evaluate the cost-effectiveness of therapy.

Abstract WP159: Predictors and Outcomes of Epilepsy and Seizure in Acute Ischemic Stroke Hospitalization

Background: Acute ischemic stroke (AIS) is the most commonly identified cause of acute seizures and secondary epilepsy in adults. There is a lack of large data base study regarding the predictors and outcome of epilepsy in post-AIS patients. Methods: We performed a retrospective analysis of the Nationwide Inpatient Sample (years 2003-2013) in adult hospitalizations for AIS with epilepsy to compare the outcomes (Mortality, Risk of Death and Loss of Function, discharge status) using ICD-9-CM codes. We performed weighted analyses using chi-square, t-test, and Cochran Armitage trend test. Multivariate survey logistic regression was done to evaluate post-AIS epilepsy outcomes and predictors. Results: Amongst 4,566,282 AIS hospitalizations, 271,519 (5.9%) had seizure or epilepsy. There was a decrease in trend (6.3% in 2003 to 5.9% in 2013; p&lt;0.001). The mean length of stay was longer for 2 days (p&lt;0.001) and cost of hospitalization was higher by $12,754 (p&lt;0.001) in post-AIS epilepsy patients compared to those without. They had significant higher mortality rates (9.1% vs 5.1%; aOR: 1.93; 95%CI: 1.84-2.01), adverse discharge event (65.2% vs 58.2%; aOR: 1.34; 95% CI: 1.31-1.38), loss of function (56.8% vs 37.8%; aOR: 2.29; 95%CI: 2.23-2.36), and risk of death (38.7% vs 22%; aOR: 2.35; 95%CI: 2.28-2.41) as compared to those without epilepsy. Predictors for post-AIS epilepsy were Afro-American (aOR: 1.42; 95%CI: 1.38-1.47), CNS disorders (aOR: 7.56; 95%CI: 6.91-8.28), AV malformation (aOR: 2.35; 95%CI: 1.81-3.06), drug abuse (aOR: 1.81; 95%CI: 1.14-2.87), alcohol (aOR: 1.36; 95%CI: 1.28-1.44), amyloidosis (aOR: 1.68; 95%CI: 1.13-2.49), AIDS (aOR:1.25; 95%CI:1.03-1.52), SLE (aOR: 1.52; 95%CI: 1.32-1.74), hemorrhagic transformation (aOR: 1.60; 95%CI: 1.46-1.75), hypercoagulable state (aOR: 1.38; 95%CI: 1.23-1.55), and H/O TIA (aOR: 1.24; 95%CI: 1.18-1.30). Treatment with aspirin (aOR: 0.89; 95%CI: 0.84-0.94), rt-PA (aOR: 0.71; 95%CI: 0.66-0.77), and mechanical thrombectomy (aOR: 0.68; 95%CI: 0.53-0.87) were significantly protective against post-AIS epilepsy. Conclusion: Early identification of risk factors and prompt management with antiepileptic prophylaxis in such patients help to improve the chance of survival amongst stroke patients.

Abstract TMP118: Outcomes of Previously Identified Transient Ischemic Attack Among Acute Ischemic Stroke Hospitalization and Predictors of Fatal Stroke

Background: Patients with transient ischemic attack (TIA) or minor stroke are at increased risk of recurrent stroke, and therefore require urgent evaluation and treatment since immediate intervention may substantially reduce the risk of recurrent stroke and improve the outcome. We hypothesized that AIS hospitalizations with previously identified/personal medical history (PMH) of TIA are associate with lower all cause in-patient mortality, likelihood of death and disability. Methods: We performed a population-based retrospective analysis of the Nationwide Inpatient Sample (NIS) (years 2007-2013) in adult hospitalizations for AIS to compare the outcomes [Death, APRDRG Risk Mortality (likelihood of dying), and APRDRG Severity (loss of function)] amongst TIA patients using ICD-9-CM codes. We performed weighted analyses using Chi-square and Jonckheere-Terpstra trend test. Multivariate survey logistic regression was done to evaluate the association of PHO TIA with poor outcomes and predictors of fatal stroke in PHO TIA patients. Results: Between years 2007 to 2013, total 3,082,973 patients with stroke were hospitalized. Of these admissions, 315,026(10.22%) patients also had PMH of TIA as a concurrent diagnosis. There was a substantial increase in rates of PMH TIA among stroke patients; 1.28% in 2007 to 13.34% in 2013 (p&lt;0.0001). On multivariate regression analysis, there was a statistically significant lower mortality (OR:0.8; 95%CI:0.75-0.85), Risk Mortality (OR:0.85; 95%CI:0.82-0.88), and Risk Severity (OR:0.87; 95%CI:0.84-0.89) in stroke patients with PMH TIA compared to those without PMH TIA or unidentified TIA. Independent predictors of fatal stroke in PMH of TIA patients included age &gt;80 (aOR:3.98; 95%CI:1.15-13.76), comorbid congestive heart failure (aOR:1.79; 95%CI:1.53-2.09), coagulopathies (aOR:1.47; 95%CI:1.06-2.04), hemorrhage transformation (aOR:4.65; 95%CI:3.49-6.19), and atrial fibrillation (aOR:1.77; 95%CI:1.54-2.03). Conclusion: We observed better outcomes amongst pre-identified TIA patients during stroke hospitalization than previously non-reported. That’s why risk stratification and secondary prevention play a very crucial role to improve outcomes of stroke by identifying and managing TIA.