Florida Hospitals Research Articles

Outcomes in laparoscopic cholecystectomy by single incision with SPIDER surgical system are comparable to conventional multiport technique: one surgeon's experience.

Single-incision laparoscopic cholecystectomy has emerged as an alternative to conventional multiport laparoscopic cholecystectomy (LC). Technical difficulty, prolonged surgical times and increased complication rates have been reported in single-incision laparoscopic surgery. One of the concerns is lack of triangulation of instruments. The SPIDER® surgical system is a single-incision laparoscopic device that utilizes flexible instruments with the purpose of achieving adequate triangulation. The purpose of this study is to compare the outcomes of SPIDER versus LC. A retrospective chart review of patients who underwent LC and SPIDER cholecystectomy by a single surgeon during a concurrent 44-month period at Baptist Health South Florida hospitals was performed focusing on demographics, indication for surgery, complications and incisional hernia rates. Exclusion criteria were concomitant surgery and hernia repair at the time of surgery. A total of 612 patients underwent minimally invasive cholecystectomy: 279 cases for SPIDER cholecystectomy and 333 for multiport LC. Baseline differences in patient characteristics between the SPIDER and LC groups were statistically significant. The SPIDER group had younger and healthier patients (lower ASA classification scores) with predominant diagnosis of cholelithiasis (69%) compared to the LC group which had more complex cases. Total complications rate for both SPIDER and LC were 0.4% (n=1) and 3% (n=10), respectively. Conversion to open cholecystectomy occurred in one patient from the LC group (0.3%). Conversion rate from SPIDER to additional ports or LC was performed in 5 cases (1.8%) with no conversions to open surgery. Hemoperitoneum was reported in 2 cases, one for each approach, requiring reoperation. Single-incision laparoscopic cholecystectomy with SPIDER is a safe and feasible technique with similar outcomes to multiport LC. However, statistical significant difference was reported in baseline characteristics of both groups. No incisional hernias were reported in this case series for either technique.

In-Hospital Outcomes and Costs Among Patients Hospitalized During a Return Visit to the Emergency Department.

Unscheduled short-term return visits to the emergency department (ED) are increasingly monitored as a hospital performance measure and have been proposed as a measure of the quality of emergency care. To examine in-hospital clinical outcomes and resource use among patients who are hospitalized during an unscheduled return visit to the ED. Retrospective analysis of adult ED visits to acute care hospitals in Florida and New York in 2013 using data from the Healthcare Cost and Utilization Project. Patients with index ED visits were identified and followed up for return visits to the ED within 7, 14, and 30 days. Hospital admission occurring during an initial visit to the ED vs during a return visit to the ED. In-hospital mortality, intensive care unit (ICU) admission, length of stay, and inpatient costs. Among the 9,036,483 index ED visits to 424 hospitals in the study sample, 1,758,359 patients were admitted to the hospital during the index ED visit. Of these patients, 149,214 (8.5%) had a return visit to the ED within 7 days of the index ED visit, 228,370 (13.0%) within 14 days, and 349,335 (19.9%) within 30 days, and 76,151 (51.0%), 122,040 (53.4%), and 190,768 (54.6%), respectively, were readmitted to the hospital. Among the 7,278,124 patients who were discharged during the index ED visit, 598,404 (8.2%) had a return visit to the ED within 7 days, 839,386 (11.5%) within 14 days, and 1,205,865 (16.6%) within 30 days. Of these patients, 86,012 (14.4%) were admitted to the hospital within 7 days, 121,587 (14.5%) within 14 days, and 173,279 (14.4%) within 30 days. The 86,012 patients discharged from the ED and admitted to the hospital during a return ED visit within 7 days had significantly lower rates of in-hospital mortality (1.85%) compared with the 1,609,145 patients who were admitted during the index ED visit without a return ED visit (2.48%) (odds ratio, 0.73 [95% CI, 0.69-0.78]), lower rates of ICU admission (23.3% vs 29.0%, respectively; odds ratio, 0.73 [95% CI, 0.71-0.76]), lower mean costs ($10,169 vs $10,799; difference, $629 [95% CI, $479-$781]), and longer lengths of stay (5.16 days vs 4.97 days; IRR, 1.04 [95% CI, 1.03-1.05]). Similar outcomes were observed for patients returning to the ED within 14 and 30 days of the index ED visit. In contrast, patients who returned to the ED after hospital discharge and were readmitted had higher rates of in-hospital mortality and ICU admission, longer lengths of stay, and higher costs during the repeat hospital admission compared with those admitted to the hospital during the index ED visit without a return ED visit. Compared with adult patients who were hospitalized during the index ED visit and did not have a return visit to the ED, patients who were initially discharged during an ED visit and admitted during a return visit to the ED had lower in-hospital mortality, ICU admission rates, and in-hospital costs and longer lengths of stay. These findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit.

Nurse staffing and the work environment linked to readmissions among older adults following elective total hip and knee replacement.

To examine the effect of nurse staffing and the work environment on 10- and 30-day unplanned readmissions for US Medicare patients following elective total hip and knee replacement. A cross-sectional analysis of secondary data. Acute care hospitals in California, Florida, New Jersey and Pennsylvania, during 2006. Medicare patients (n = 112 017) admitted to an acute care hospital for an elective total hip or knee replacement. The adjusted odds ratio (OR) of experiencing an unplanned readmission within 10 and 30 days of discharge following an elective total hip or knee replacement. Our sample included 112 017 Medicare patients in 495 hospitals. Nearly 6% of the patients were readmitted within 30 days; more than half of whom were rehospitalized within 10 days. Adjusted for patient and hospital characteristics, patients had 8% higher odds of 30-day readmission and 12% higher odds of 10-day readmission, for each additional patient per nurse. Patients cared for in the best work environments had 12% lower odds of 30-day readmission. Readmission outcomes following major joint replacement are associated with hospital nursing care. Attention to nurse work conditions may be central to improving readmissions in this postoperative Medicare population.

Abstract WP194: Stroke Risk and Mortality in Patients with Ventricular Assist Devices

Background: Ventricular assist devices (VADs) have revolutionized the management of end-stage heart failure. However, these devices are associated with many complications, including stroke. Hypothesis: We sought to determine the risk and risk factors for stroke after VAD placement and to assess the hypothesis that stroke is associated with increased mortality after VAD placement. Methods: From administrative claims data on all discharges from nonfederal acute care hospitals in California, Florida, and New York from 2005-2012, we used International Classification of Diseases, 9 th Revision, Clinical Modification ( ICD-9-CM ) code 37.66 to identify patients who underwent VAD placement. Patients were included regardless of whether they underwent VAD placement as destination therapy or as bridge to transplant. Ischemic and hemorrhagic strokes were identified by validated coding algorithms. Kaplan-Meier statistics were used to calculate cumulative rates. Cox proportional hazard analyses were used to identify risk factors for stroke in patients with VADs and to evaluate the association between stroke (modeled as a time-varying covariate) and mortality. Results: We had 3.0 (±1.7) years of follow-up data on 1,398 patients after implantation of a VAD. The mean age of the patients was 55.4 years (±13.2), and patients were predominantly male. A total of 227 strokes were identified: 147 ischemic and 79 hemorrhagic. The cumulative stroke rate was 24.3% (95% confidence interval [CI], 21.3-27.7%). After adjustment for age, race, insurance status, and comorbidities, women had a higher hazard of stroke than men (hazard ratio [HR], 1.7; 95% CI, 1.2-2.3), particularly hemorrhagic stroke (HR, 2.6; 95% CI, 1.5-4.3). Stroke was strongly associated with subsequent mortality (HR, 4.1; 95% CI, 3.3-5.1). Conclusion: Stroke is common in patients after VAD placement and is strongly associated with mortality in this vulnerable population. Women appear to be at higher stroke risk than men, particularly for hemorrhagic stroke.

A Severe Sepsis Mortality Prediction Model and Score for Use With Administrative Data.

Administrative data are used for research, quality improvement, and health policy in severe sepsis. However, there is not a sepsis-specific tool applicable to administrative data with which to adjust for illness severity. Our objective was to develop, internally validate, and externally validate a severe sepsis mortality prediction model and associated mortality prediction score. Retrospective cohort study using 2012 administrative data from five U.S. states. Three cohorts of patients with severe sepsis were created: 1) International Classification of Diseases, 9th Revision, Clinical Modification codes for severe sepsis/septic shock, 2) Martin approach, and 3) Angus approach. The model was developed and internally validated in International Classification of Diseases, 9th Revision, Clinical Modification, cohort and externally validated in other cohorts. Integer point values for each predictor variable were generated to create a sepsis severity score. Acute care, nonfederal hospitals in New York, Maryland, Florida, Michigan, and Washington. Patients in one of three severe sepsis cohorts: 1) explicitly coded (n = 108,448), 2) Martin cohort (n = 139,094), and 3) Angus cohort (n = 523,637) INTERVENTIONS: None. Maximum likelihood estimation logistic regression to develop a predictive model for in-hospital mortality. Model calibration and discrimination assessed via Hosmer-Lemeshow goodness-of-fit and C-statistics, respectively. Primary cohort subset into risk deciles and observed versus predicted mortality plotted. Goodness-of-fit demonstrated p value of more than 0.05 for each cohort demonstrating sound calibration. C-statistic ranged from low of 0.709 (sepsis severity score) to high of 0.838 (Angus cohort), suggesting good to excellent model discrimination. Comparison of observed versus expected mortality was robust although accuracy decreased in highest risk decile. Our sepsis severity model and score is a tool that provides reliable risk adjustment for administrative data.

Abstract 134: Postoperative Atrial Fibrillation and the Short-term Risk of Ischemic Stroke

Introduction: We have recently shown an association between new-onset postoperative atrial fibrillation (AF) and the long-term risk of ischemic stroke after noncardiac surgery. However, the degree of stroke risk with AF in the postoperative setting remains unclear. Hypothesis: New-onset postoperative AF is associated with an increased risk of ischemic stroke in the 30 days after surgery. Methods: Administrative claims data from all discharges at nonfederal acute care hospitals in California, New York, and Florida were used to identify patients who underwent inpatient surgery in 2007-2012. Our predictor variable was new-onset AF, defined using validated ICD-9-CM diagnosis and present-on-admission codes. Patients with prior stroke or AF were excluded. The outcome was postoperative stroke, defined as ischemic stroke occurring within 30 days of surgery. Cox proportional hazards analysis was used to examine the association between postoperative AF and stroke while adjusting for demographics and vascular risk factors. In sensitivity analyses, we limited the outcome to stroke occurring after discharge but within 30 days of surgery. Cardiac and noncardiac surgeries were analyzed separately. Results: Among 7,139,472 patients with inpatient surgery, 102,831 (1.44%) developed postoperative AF and 17,117 (0.24%) developed a postoperative stroke. After noncardiac surgery, the 30-day cumulative risk of stroke was significantly higher in those with postoperative AF (2.07%) than those without AF (0.18%). This difference was significant after adjustment for demographics and potential confounders (hazard ratio [HR], 4.3; 95% CI, 4.1-4.6). After cardiac surgery, postoperative AF was also associated with an increased cumulative risk of stroke (2.27%) compared to those without AF (1.17%), but the strength of association (HR, 1.8; 95% CI, 1.6-1.9) was less marked than in the setting of noncardiac surgery ( P value for interaction <0.001). Postoperative AF was associated with stroke occurring after discharge and within 30 days of noncardiac surgery (HR, 1.9; 95% CI, 1.6-2.3), but not cardiac surgery (HR, 1.1; 95% CI, 0.9-1.3). Conclusions: Postoperative AF is associated with an increased short-term risk of stroke after noncardiac surgery.

Abstract TP182: Risk of Acute Ischemic Stroke Increases During Severe Flares of Inflammatory Bowel Disease

Introduction: Flares of inflammatory bowel disease (IBD) have been associated with venous thromboembolism, and recent studies suggest an association between IBD and myocardial infarction. The association between IBD flares and cerebral thrombotic disease is less clear. We therefore sought to evaluate the risk of cerebral venous and arterial stroke during IBD flares. Hypothesis: IBD flares are associated with an increased risk of a cerebral thrombotic event. Methods: We used data on all admissions at nonfederal acute care hospitals in California, Florida, and New York to identify patients with a primary ICD-9-CM diagnosis code for ulcerative colitis or Crohn’s disease between 2005 and 2012. Patients with a documented abdominal surgery during the index hospitalization were excluded. An IBD flare was defined as a period of 120 days from the start of the index IBD-related hospitalization. Our outcomes were ischemic stroke and cerebral venous sinus thrombosis. We used a self-controlled case series design in which we compared the risk of a thrombotic event in the 120 days after hospitalization versus the risk during the 120 days prior to hospitalization. Results: We identified 31,993 patients with IBD, of whom 98 (0.31%) developed ischemic stroke. As compared with the control period preceding the index hospitalization, the risk of stroke was significantly elevated during the 120 days after IBD-related hospitalization (incidence rate ratio [IRR] 2.0; 95% confidence interval [CI] 1.3-3.0). In subgroup analyses, this elevated risk was apparent only in the 16,280 patients older than the median age of 44 years (IRR 1.9; 95% CI, 1.27-2.95), and not in the 15,713 patients younger than 44 years of age, among whom we identified only one stroke. We found only one patient with a documented venous sinus thrombosis and thus could not estimate the risk associated with an IBD flare. Conclusion: We found an association between IBD-related hospitalization and the risk of ischemic stroke in older patients. These results build on recent studies suggesting an association between IBD and the risk of arterial thrombotic events. Further research is needed to better define the association between IBD and cerebrovascular events, especially rare events such as cerebral sinus thrombosis.

Abstract TMP67: Sex Disparities in Atrial Fibrillation as a Predictor of Poor Discharge Disposition After Ischemic Stroke Hospitalization: The Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study

Background: It is unknown whether atrial fibrillation (AF) is responsible for increased morbidity and disability seen in women with ischemic stroke. We sought to determine whether patients with ischemic stroke and AF had poorer outcomes than ischemic stroke patients without AF and whether this effect is more pronounced among women. Methods: We analyzed data from the FL-PR CReSD Study, a large quality improvement registry of Florida (N=66) and Puerto Rico (N=9) hospitals based on the Get With The Guidelines-Stroke (GWTG-S) program. Discharge disposition was utilized as a surrogate marker for morbidity and disability, with discharge to home or rehabilitation in comparison to other discharge dispositions (skilled nursing facility, hospice or died). Multilevel generalized linear models were used to evaluate AF and sex disparities in discharge disposition adjusted for demographics, risk factors (hypertension, diabetes, heart failure, previous stroke/TIA), and NIHSS and CHADS2 scores. Results: We examined a total of 55,945 ischemic stroke patients, of whom 11,797 (21%) had AF at discharge. AF patients were older than non-AF patients (79.0±10.9 years vs. 68.7±14.4 years), had higher proportion of women (54% vs. 49%) and more severe strokes (mean NIHSS 10±9 vs. 7±7). Among AF patients, women were older (81±10 vs. 76±11 years) and had greater NIHSS (11±9 vs. 9±8) and CHADS2 scores (3.9±0.9 vs. 3.7±1.0) than men. Overall, AF patients were less likely discharged to home or rehabilitation than those without AF (54% vs. 71%, OR 0.93, 95% CI 0.89-0.98). There was a significant effect modification between AF and discharge disposition by sex. In stratified analyses by sex, AF was associated with less discharged to home or rehabilitation among women (OR 0.85, 95% CI 0.79-0.91), but not among men (OR 1.04, 95% CI 0.96-1.11). Conclusion: Women with AF were less likely discharged to home or rehabilitation facility after ischemic stroke. Baseline differences in age, stroke severity, risk factors, and comorbidities between men and women had little impact on the poorer outcome and discharge disposition after ischemic stroke in women. Further studies are warranted to identify the causes of sex-specific differences in stroke outcomes for patients with AF.

Does Hospital Investment in Quality Improvement Improve Quality? Evidence from a Panel Study of Florida Hospitals

For over a decade, and with renewed intensity since the passage of the Affordable Care Act, there has been heightened awareness and concern about the safety and quality of inpatient hospital care. In this paper, we estimate the impact of investment in quality improvement, as well as change in the policy environment, on patient safety (adverse) events in a 2004-2012 panel of hospitals in the state of Florida. We find hospital quality investment has favorable, but modest, effects on quality. On the other hand, policy change, which brings public attention to the issue, may have stronger effects. On average, we find a 10 percent increase in hospital quality investment leads to a 2 to 6 percent decrease in adverse events. In contrast, passage of the Patient Safety and Quality Improvement Act, in 2005, and the Centers for Medicare and Medicaid’s policy of withholding reimbursement, in 2008, had much larger effects (45 and 10 percent decreases in adverse events, respectively). Thus, reputation and professionalism may be more important than a “business case” for promoting health care quality. We also find evidence of spillover effects of quality investment from large research (“leading”) hospitals to less-resourced hospitals.

The When and Why of Abandonment: The Role of Organizational Differences in Medical Technology Lifecycles

Although the adoption of new technology has received significant attention in management research, investigations of abandonment have lagged. In this study, we examine differences in the rates of abandonment of medical technologies based on whether abandonment occurs in response to the emergence of a superior technology, or in light of new information questioning its efficacy. We link differences in responses to underlying differences in the mission and incentives of organizations. Examining coronary stents across three technological regime changes using a census of approximately 2 million patients admitted to Florida hospitals from 1995-2007, we show meaningful differences across three hospital types: for-profit, not-for-profit, and academic medical centers (AMCs), Results show that for-profit hospitals abandon the earlier generation in favor of a superior technology faster than not-for-profit hospitals, but this is not the case if the efficacy of the technology is questioned. Academic medical centers, however, have the highest rates of abandonment under both triggers. Importantly, we find that organizational factors dominate physician differences as explanatory factors for abandonment. Implications of these findings are two-fold. First, we identify the factors likely at play, i.e. the salience of norms of science and the corresponding trade-offs with economic benefits, when organizations make abandonment decisions. Second, our work underscores the importance of organizational mission, which dominates individual preferences in determining rates of abandonment.

Cardiothoracic surgical site phaeohyphomycosis caused by Bipolaris mould, multiple US states, 2008-2013: a clinical description.

Bipolaris mould surgical site infections (SSIs) are exceedingly rare. We describe 21 cases of Bipolaris SSIs in pediatric and adult cardiothoracic surgery patients at ten hospitals in Texas, Arkansas, and Florida during 2008-2013. Median case-patient age was 55 years (range: 3 days-82 years), and 19 (90%) were male. Ten (48%) had coronary artery bypass or valve surgery, and seven (33%) had heart transplantation. Fifteen (71%) had more than one cardiothoracic procedure (median: 3, range: 1-11). Thirteen (62%) case-patients (all 5 pediatric patients, and 8 (50%) of 16 adult patients) had delayed sternal closure (chest closed >1 day [median = 8 days; range: 2-22] following the initial cardiothoracic procedure). Thirteen (62%) had mediastinitis. Median time from initial surgery to positive Bipolaris culture was 20 days (range: 6-497). Sixteen (76%) case-patients died.

Association between Liver Disease and Intracranial Hemorrhage

Liver disease is common and associated with clinical and laboratory evidence of coagulopathy. The association between liver disease and intracranial hemorrhage (ICH) remains unclear. Our aim was to assess whether liver disease increases the risk of ICH. We performed a retrospective cohort study based on administrative claims data from California, Florida, and New York acute care hospitals from 2005 through 2011. Of a random 5% sample, we included patients discharged from the emergency department or hospital after a diagnosis of liver disease and compared them to patients without liver disease. Patients with cirrhotic liver disease were additionally analyzed separately. Kaplan-Meier survival statistics were used to calculate cumulative rates of incident ICH, and Cox proportional hazard analysis was used to adjust for demographic characteristics, vascular disease, and Elixhauser comorbidities. Multiple models tested the robustness of our results. Among 1,909,816 patients with a mean follow-up period of 4.1 (±1.8) years, the cumulative rate of ICH after a diagnosis of liver disease was 1.70% (95% confidence interval [CI], 1.55%-1.87%) compared to .40% (95% CI, .39%-.41%) in patients without liver disease (P <.001 by the log-rank test). Liver disease remained associated with an increased hazard of ICH after adjustment for demographic characteristics and vascular risk factors (hazard ratio [HR], 1.8; 95% CI, 1.6-2.0). This was attenuated in models additionally adjusted for general comorbidities (HR, 1.3; 95% CI, 1.2-1.5). There is a modest, independent association between liver disease and the risk of ICH.

Physician spending and subsequent risk of malpractice claims: observational study

Study question Is a higher use of resources by physicians associated with a reduced risk of malpractice claims?Methods Using data on nearly all admissions to acute care hospitals in Florida...

Association of Rehabilitation Intensity for Stroke and Risk of Hospital Readmission.

Little is known about the use of rehabilitation in the acute care setting and its impact on hospital readmissions. The objective of this study was to examine the association between the intensity of rehabilitation services received during the acute care stay for stroke and the risk of 30-day and 90-day hospital readmission. A retrospective cohort analysis of all acute care hospitals in Arkansas and Florida was conducted. Patients (N=64,065) who were admitted for an incident stroke in 2009 or 2010 were included. Rehabilitation intensity was categorized as none, low, medium-low, medium-high, or high based on the sum and distribution of physical therapy, occupational therapy, and speech therapy charges within each hospital. Cox proportional hazards regression was used to estimate hazard ratios, controlling for demographic characteristics, illness severity, comorbidities, hospital variables, and state. Relative to participants who received the lowest intensity therapy, those who received higher-intensity therapy had a decreased risk of 30-day readmission. The risk was lowest for the highest-intensity group (hazard ratio=0.86; 95% confidence interval=0.79, 0.93). Individuals who received no therapy were at an increased risk of hospital readmission relative to those who received low-intensity therapy (hazard ratio=1.30; 95% confidence interval=1.22, 1.40). The findings were similar, but with smaller effects, for 90-day readmission. Furthermore, patients who received higher-intensity therapy had more comorbidities and greater illness severity relative to those who received lower-intensity therapy. The results of the study are limited in scope and generalizability. Also, the study may not have adequately accounted for all potentially important covariates. Receipt of and intensity of rehabilitation therapy in the acute care of stroke is associated with a decreased risk of hospital readmission.

Routine diversion of patients with STEMI to high-volume PCI centres: modelling the financial impact on referral hospitals

ObjectiveTo quantify possible revenue losses from proposed ST-elevation myocardial infarction (STEMI) patient diversion policies for small hospitals that lack high-volume percutaneous coronary intervention (PCI) capability status (ie, ‘STEMI referral hospitals’).BackgroundNegative...

Has competition increased hospital technical efficiency?

Hospital competition and managed care have affected the hospital industry in various ways including technical efficiency. Hospital efficiency has become an important topic, and it is important to properly measure hospital efficiency in order to evaluate the impact of policies on the hospital industry. The primary independent variable is hospital competition. By using the 2001-2004 inpatient discharge data from Florida, we calculate the degree of hospital competition in Florida for 4 years. Hospital efficiency scores are developed using the Data Envelopment Analysis and by using the selected input and output variables from the American Hospital Association's Annual Survey of Hospitals for those acute care general hospitals in Florida. By using the hospital efficiency score as a dependent variable, we analyze the effects of hospital competition on hospital efficiency from 2001 to 2004 and find that when a hospital was located in a less competitive market in 2003, its technical efficiency score was lower than those in a more competitive market.

Procedure-specific surgical site infection incidence varies widely within certain National Healthcare Safety Network surgery groups

The National Healthcare Safety Network (NHSN) classifies surgical procedures into 40 categories. The objective of this study was to determine surgical site infection (SSI) incidence for clinically defined subgroups within 5 heterogeneous NHSN surgery categories. This is a retrospective cohort study using the longitudinal State Inpatient Database. We identified 5 groups of surgical procedures (amputation; bile duct, liver or pancreas [BILI]; breast; colon; and hernia) using ICD-9-CM procedure codes in community hospitals in California, Florida, and New York from January 2009-September 2011 in persons aged ≥18 years. Each of these 5 categories was classified to more specific surgical procedures within the group. The 90-day SSI rates were calculated using ICD-9-CM diagnosis codes. There were 62,901 amputation surgeries, 33,358 BILI surgeries, 72,058 breast surgeries, 125,689 colon surgeries, and 85,745 hernia surgeries in 349,298 people. The 90-day SSI rates varied significantly within each of the 5 subgroups. Within the BILI category, bile duct, pancreas, and laparoscopic liver procedures had SSI rates of 7.2%, 17.2%, and 2.2%, respectively (P < .0001 for each) compared with open liver procedures (11.1% SSI). The 90-day SSI rates varied widely within certain NHSN categories. Risk adjustment for specific surgery type is needed to make valid comparisons between hospitals.

Abstract 188: Safety of Stroke Thrombolysis During Pregnancy: A Population-Based Analysis

Background: Use of tissue plasminogen activator (TPA) during pregnancy is controversial given potential risks of placental and fetal complications. Since knowledge on this topic is limited, we assessed rates of TPA use during pregnancy and the associated patient characteristics and outcomes in a population-based sample of patients. Methods: We used administrative claims data on all discharges from nonfederal emergency departments and acute care hospitals in California, Florida, and New York between 2005 and 2012. Pregnancy was defined as the 40 weeks prior to delivery or abortive outcome. Using a validated ICD-9-CM diagnosis code algorithm, we identified cases of ischemic stroke, as well as cases of intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) since these may represent hemorrhagic transformation of an infarct. We included only the first recorded stroke to focus on incident cases. TPA use was identified by ICD-9-CM procedure code 99.10, which has been validated as 98% specific in this population. Comparisons between groups were made using Fisher’s exact test and t-test or rank-sum test as appropriate. Results: Among 428,564 women with stroke, 599 cases occurred during pregnancy. The rate of TPA use for stroke was significantly lower during pregnancy (1.2%; 95% CI, 0.4-2.4%) than otherwise (3.5%; 95% CI, 3.4-3.6%; P = 0.001). Among pregnant stroke patients, we found few notable differences in the baseline characteristics of the 7 who received TPA versus the 592 who did not: those receiving TPA had higher rates of heart failure (28.6% versus 2.2%; P = 0.01) and pneumonia (14.3% versus 1.2%; P = 0.09) and lower rates of of pre-eclampsia (0.0% versus 29.1%; P = 0.09). There were no notable differences between pregnant stroke patients who did or did not receive TPA in terms of length of hospital stay, discharge disposition, and in-hospital mortality rate. However, we noted a significantly higher rate of abortive pregnancy outcomes during stroke hospitalization in those who received TPA than those who did not (28.6% versus 4.6%; P = 0.04). Conclusion: We found a significantly higher rate of abortive pregnancy outcomes in patients who received TPA. This suggests the need for caution and further research regarding TPA use for stroke in pregnancy.

Abstract W P283: Race-Ethnic Stroke Disparities in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities Study - The NINDS Stroke Prevention Intervention Research Program

Background: Race-ethnic disparities in stroke care can contribute to inequality in stroke outcomes. We sought to determine the disparities in stroke performance metrics by race-ethnicity in a voluntary stroke registry of Florida and Puerto Rico Get With The Guidelines-Stroke (GWTG-S) data. Methods: Sixty-three sites who had enrolled in the FL-PR Stroke Registry (54 FL; 9 PR) recorded 38,684 ischemic stroke cases from 2010 to 2013. Generalized linear regression models were used to evaluate race-ethnic differences in 7 pre-defined acute stroke performance measures and defect-free care (IV tPA treatment, in-hospital antithrombotic therapy, DVT prophylaxis, antithrombotic therapy at discharge, anticoagulation therapy, statin medication at discharge, and smoking cessation counseling), adjusting for age and region (FL vs. PR). Results: Of acute ischemic stroke cases, 63% were non-Hispanic White (NHW), 18% NH-Black (NHB), and 17% Hispanic. The mean age was 71±14 years. NHW were older (73±14), followed by Hispanics (70±14), and NHB (63±14); p&lt;0.0001. Defect-free care was better among NHB (78%) and NHW (76%) than in Hispanics (68%), p&lt;0.0001. Defect-free care improved over time and the race-ethnic disparity decreased (2010: NHW 61%, NHB 64%, Hispanic 46%, p&lt;0.0001; 2013: 91%, 91%, 86%, p=0.47 respectively). NHW were most likely to receive IV tPA treatment (arrived by 2 hours and treated by 3 hours; 88%) and early antithrombotic treatment (96%). Hispanics were least likely to receive DVT prophylaxis (76%), anticoagulation (92%), statins (89%), and smoking cessation counseling (93%). Conclusions: Race-ethnic disparities in acute stroke care are evident yet decreasing, coinciding with improvements in quality of care over time in Florida and Puerto Rico hospitals participating in GWTG-S. Special stroke quality improvement programs to target areas where performance is less than expected and minimize race-ethnic disparities are necessary to improve stroke care for all Americans.

Abstract T P261: Stroke Care Improvement Trends in Puerto Rico Hospitals Participating in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study - the NINDS Stroke Prevention Intervention Research Program

Background: Racial and ethnic disparities in stroke care are known to contribute to inequality in stroke outcomes. The goal of the FL-PR CReSD Study is to assess and evaluate Get With The Guidelines-Stroke (GWTG-S) quality improvement data collected among Florida and Puerto Rico hospitals to evaluate for race-ethnic, sex, and regional disparities in stroke performance metrics. We sought to analyze the temporal trends in stroke performance metrics among the 9 hospitals located in Puerto Rico from 2010 to 2013. Methods: Age-adjusted temporal trends were evaluated in the following GWTG-S pre-defined performance measures (IV tPA treatment within 3 hours among eligible patients arriving in 2 hours, in-hospital antithrombotic therapy, DVT prophylaxis, antithrombotic therapy at discharge, anticoagulation therapy, statin medication at discharge, and smoking cessation counseling) and defect-free care (compliance with all 7 performance measures). Results: The mean age of 3,094 registered stroke cases was 69.5 ± 14.0 years, 50% were men, and 2,184 (71%) were diagnosed as ischemic strokes. Defect-free care occurred in 60% of ischemic stroke patients. Lower performance metrics were found for IV tPA treatment (78%), DVT prophylaxis (64%), and statin medication at discharge (83%). An additional IV tPA measure of treatment by 4.5 hours when arriving by 3.5 hours was observed in 65% of patients. The performance metrics that significantly improved over time from 2010 to 2013 included: IV tPA treatment within 3 hours (64% to 87%, p=0.04), DVT prophylaxis (33% to 87%, p&lt;0.0001), statin medication at discharge (78% to 87%, p=0.01), and defect-free care (37% to 79%, p&lt;0.0001). Conclusions: In only four years, Puerto Rico hospitals participating in GWTG-S showed significant improvement across all pre-defined acute stroke performance measures. Wider implementation of quality improvement programs like GWTG-S among the 3.7 million inhabitants of Puerto Rico could further improve acute stroke care.