Improve Stroke Care Research Articles

Stroke Learning Health Systems: A Topical Narrative Review With Case Examples.

To our knowledge, the adoption of Learning Health System (LHS) concepts or approaches for improving stroke care, patient outcomes, and value have not previously been summarized. This topical review provides a summary of the published evidence about LHSs applied to stroke, and case examples applied to different aspects of stroke care from high and low-to-middle income countries. Our attempt to systematically identify the relevant literature and obtain real-world examples demonstrated the dissemination gaps, the lack of learning and action for many of the related LHS concepts across the continuum of care but also elucidated the opportunity for continued dialogue on how to study and scale LHS advances. In the field of stroke, we found only a few published examples of LHSs and health systems globally implementing some selected LHS concepts, but the term is not common. A major barrier to identifying relevant LHS examples in stroke may be the lack of an agreed taxonomy or terminology for classification. We acknowledge that health service delivery settings that leverage many of the LHS concepts do so operationally and the lessons learned are not shared in peer-reviewed literature. It is likely that this topical review will further stimulate the stroke community to disseminate related activities and use keywords such as learning health system so that the evidence base can be more readily identified.

Abstract 10248: Incidence and Case-Fatality Rate of Stroke in Argentina: The EstEPA Population Study

Introduction: Stroke epidemiology varies among different populations. The burden of stroke is high in low- and middle-income countries. Reliable population data is needed to assess the impact of stroke and to develop policies aimed to improve stroke care in our region. Objectives: EstEPA is a population-based project assessing prevalence, incidence, mortality and burden of stroke in General Villegas, Buenos Aires, Argentina (pop=30,864 inhabitants). We determined incidence of stroke (first-ever and recurrent stroke) and stroke case-fatality rate from 2017 to 2020. Methods: First-ever strokes, recurrent strokes and transient ischemic attacks were ascertained and case-fatality rate was obtained. Diagnoses were based on standard AHA/WHO definitions. Study population included all persons residing in General Villegas in the three-year period. Hospitals, households, nursing homes, death certificates and several overlapping sources were surveyed. Results: We assessed 92,592 person-years. There were 155 cerebrovascular events, of which 115 were first-ever strokes (74%), 21 recurrent strokes (13·5%) and 19 transient ischemic attacks (12·5%). The annual crude incidence rate of first-ever strokes was 124·2 per 100,000 person-years, while it was 109·7 per 100,000 (95% CI 89·7-129·8), 72·4 per 100,000 (95% CI 47·8-97·0) and 86·9 per 100,000 (95% CI 58·5-115·2) when standardized by the Argentine population, Segi's World population and WHO World population, respectively. The crude incidence rate according to the different subtypes of stroke was 93·4 per 100,000 person-years for ischemic stroke, 18·4 per 100,000 person-years for hemorrhagic stroke and 10·8 per 100,000 person-years for subarachnoid hemorrhage. Incidence increased after age 70. Case fatality rate at 30 days of first-ever strokes was 19·4%. Conclusions: In this first population-based comprehensive stroke epidemiological study in Argentina, first-ever stroke incidence in an urban population was 124·2 per 100,000 person-years. This is lower than the incidence in other countries in the region. It is similar to reported incidence in Western developed countries. Stroke case-fatality rate was comparable to other population-based Latin-American studies and most developed countries.

Prehospital stroke care in Africa: The reality and potential solutions.

Prehospital stroke care in Africa: The reality and potential solutions.

Stroke services in the Middle East and adjacent region: A survey of 34 hospital-based stroke services.

Acute stroke care is complex and requires multidisciplinary networking. There are insufficient data on stroke care in the Middle East and adjacent regions in Asia and Africa. Evaluate the state of readiness of stroke programs in the Middle East North Africa and surrounding regions (MENA+) to treat acute stroke. Online questionnaire survey on the evaluation of stroke care across hospitals of MENA+ region between April 2021 and January 2022. The survey was completed by 34/50 (68%) hospitals. The median population serviced by participating hospitals was 2 million. The median admission of patients with stroke/year was 600 (250-1,100). The median length of stay at the stroke units was 5 days. 34/34 (100%) of these hospitals have 24/7 CT head available. 17/34 (50%) have emergency guidelines for prehospital acute stroke care. Mechanical thrombectomy with/without IVT was available in 24/34 (70.6%). 51% was the median (IQR; 15-75%) of patients treated with IVT within 60 min from arrival. Thirty-five minutes were the median time to reverse warfarin-associated ICH. This is the first large study on the availability of resources for the management of acute stroke in the MENA+ region. We noted the disparity in stroke care between high-income and low-income countries. Concerted efforts are required to improve stroke care in low-income countries. Accreditation of stroke programs in the region will be helpful.

Variation in stroke care at the hospital level: A cross-sectional multicenter study.

IntroductionStroke is one of the leading causes of mortality and disability. Improving patient outcomes can be achieved by improving stroke care and adherence to guidelines. Since wide variation in adherence rates for stroke guidelines still exists, we aimed to describe and compare stroke care variability within Belgian hospitals.Materials and methodsAn observational, multicenter study was performed in 29 Belgian hospitals. We retrospectively collected patient characteristics, quality indicators, and time metrics from the last 30 consecutive patients per hospital, diagnosed with ischemic stroke in 2019 with structured questionnaires. Mean adherence ratios (%) ± SD (minimum – maximum) were calculated.ResultsWe analyzed 870 patient records from 29 hospitals. Results showed large inter- and intrahospitals variations in adherence for various indicators. Almost all the patients received brain imaging (99.7%) followed by admission at a stroke unit in 82.9% of patients. Of patients not receiving thrombolysis, 92.5% of patients were started on antithrombotic drugs. Indicators with moderate median adherence but large interhospital variability were glycemia monitoring [82.3 ± 16.7% (26.7–100.0%)], performing clinical neurological examination and documentation of stroke severity [63.1 ± 36.8% (0–100%)], and screening for activities of daily living [51.1 ± 40.3% (0.0–100.0%)]. Other indicators lacked adequate adherence: swallowing function screening [37.0 ± 30.4% (0.0–93.3%)], depression screening [20.2 ± 35.8% (0.0–100%)], and timely body temperature measurement [15.1 ± 17.0% (0.0–60%)].ConclusionWe identified high adherence to guidelines for some indicators, but lower rates with large interhospital variability for other recommendations also based on robust evidence. Improvement strategies should be implemented to improve the latter.

The neurovascular unit and systemic biology in stroke - implications for translation and treatment.

Ischaemic stroke is a leading cause of disability and death for which no acute treatments exist beyond recanalization. The development of novel therapies has been repeatedly hindered by translational failures that have changed the way we think about tissue damage after stroke. What was initially a neuron-centric view has been replaced with the concept of the neurovascular unit (NVU), which encompasses neuronal, glial and vascular compartments, and the biphasic nature of neural-glial-vascular signalling. However, it is now clear that the brain is not the private niche it was traditionally thought to be and that the NVU interacts bidirectionally with systemic biology, such as systemic metabolism, the peripheral immune system and the gut microbiota. Furthermore, these interactions are profoundly modified by internal and external factors, such as ageing, temperature and day-night cycles. In this Review, we propose an extension of the concept of the NVU to include its dynamic interactions with systemic biology. We anticipate that this integrated view will lead to the identification of novel mechanisms of stroke pathophysiology, potentially explain previous translational failures, and improve stroke care by identifying new biomarkers of and treatment targets in stroke.

The quality disparity of stroke care over time: An analysis based on the national dataset from 2011 to 2017.

Adherence to evidence-based hospital stroke care is variable and may change over time. It is important to determine which process measures are associated with variation in outcome. In a large dataset, we analyzed the association between process and outcome and the fluctuations of indicators over time, and identified quality indicators (QIs) that should be prioritized for improving the quality of stroke care. We analyzed data from 123,259 patients diagnosed with acute ischemic stroke (AIS) who were treated at 109 large tertiary hospitals in China between January 2011 and May 2017. In total, 12 stroke treatment indicators were selected to calculate the hospital process composite performance (HPCP). Hospitals were divided into subgroups according to the time trend of HPCP estimated by the Group-Based Model. We analyzed the influence of hospital subgroups on the patient outcomes using a multi-level model and explored the QIs that led to variation. The HPCP trends for stroke indicators of 109 hospitals over 7 years were divided into two groups (Group 1, low-HPCP; Group 2, high-HPCP). After adjusting for patient age, medical insurance, comorbidities, patterns of admission, and NIHSS-scores, patients in the high-HPCP group presented higher rate of independence and longer length of stay compared to the low-HPCP group. The multi-level model showed that there was a statistically significant difference in the utilization rate between the two groups, with most marked differences seen in emergency assessment and function evaluation indicators. Variation in the quality of stroke care exists across hospitals, and better adherence to guideline-based care is associated with improved outcomes. We found that QIs related to emergency examination and functional assessment were the main factors differing between good and poor adherers to stroke indicators, suggesting that quality improvement in stroke care could prioritize these QIs.

Casein Kinase 2 Signaling in White Matter Stroke.

The growth of the aging population, together with improved stroke care, has resulted in an increase in stroke survivors and a rise in recurrent events. Axonal injury and white matter (WM) dysfunction are responsible for much of the disability observed after stroke. The mechanisms of WM injury are distinct compared to gray matter and change with age. Therefore, an ideal stroke therapeutic must restore neuronal and axonal function when applied before or after a stroke, and it must also protect across age groups. Casein kinase 2 (CK2), is expressed in the brain, including WM, and is regulated during the development and numerous disease conditions such as cancer and ischemia. CK2 activation in WM mediates ischemic injury by activating the Cdk5 and AKT/GSK3β signaling pathways. Consequently, CK2 inhibition using the small molecule inhibitor CX-4945 (Silmitasertib) correlates with preservation of oligodendrocytes, conservation of axon structure, and axonal mitochondria, leading to improved functional recovery. Remarkably, CK2 inhibition promotes WM function when applied after ischemic injury by specifically regulating the AKT/GSK3β pathways. The blockade of the active conformation of AKT confers post-ischemic protection to young and old WM by preserving mitochondria, implying AKT as a common therapeutic target across age groups. Using a NanoString nCounter miRNA expression profiling, comparative analyses of ischemic WM with or without CX-4945 treatment reveal that miRNAs are expressed at high levels in WM after ischemia, and CX-4945 differentially regulates some of these miRNAs. Therefore, we propose that miRNA regulation may be one of the protective actions of CX-4945 against WM ischemic injury. Silmitasertib is FDA approved and currently in use for cancer and Covid patients; therefore, it is plausible to repurpose CK2 inhibitors for stroke patients.

Effectiveness of quality improvement collaboratives in improving clinical processes and patient outcomes in stroke care.

Stroke remains one of the leading causes of death worldwide. In order to tackle the negative impacts of stroke, a high standard of clinical practice and a commitment to continuous quality improvement is needed across the stroke care pathway. One approach to quality improvement is the formation and implementation of quality improvement collaboratives (QIC's). However, there are several barriers to the implementation of a QIC for stroke care which may impact on their success. This article critically appraises a systematic review which assessed the effectiveness of QIC's for driving improvements in stroke care and explored the barriers to implementing a QIC's to improve care.

P.051 Stroke Care and Neurological Emergency Response Simulation (SCaNERS): High-fidelity acute stroke simulation increases learner confidence in providing acute stroke care

Background: Resident physicians often observe stroke alerts before managing them alone, which exposes patients to potential harm from trainees’ lack of experience. Simulation training offers a low-risk environment for skill acquisition. This project assessed learners’ confidence in leading stroke codes before and after completing a stroke simulation training program during neurology rotations at the University of Saskatchewan. Methods: High-fidelity simulation cases were developed encompassing several diagnostic and therapeutic goals of acute stroke care. Standardized patients were trained for increased fidelity. Standardized debriefing was given after each session. Pre- and post-simulation surveys captured learner confidence and cognitive load. Results: Pilot data reveal learners’ confidence and comfort in providing acute stroke care, including thrombolysis treatment decisions, significantly increases after simulation training (n=8; p=0.0006-0.01). They also felt more prepared to conduct future acute stroke care (p=0.009). Skills not directly addressed in simulation did not show significant improvement (p=0.09-1.89). Learners consistently rated the session as requiring high mental effort. Conclusions: Implementation of high-fidelity simulation training leads to significant improvement in learner confidence. Future cases will capture additional objectives and ensure acceptable cognitive load. Ongoing data collection to explore residents’ experiences and knowledge improvement in stroke care and assess local reductions in treatment delays is underway.

Ambiguities in blood pressure management in acute ischaemic stroke.

Blood pressure management in acute ischaemic stroke is crucial. Here we highlight uncertainties surrounding haemodynamic management in acute ischaemic stroke on the basis of current guidelines and the data available from recent studies. This review provides practical treatment options and suggestions for future research. The U-shaped relationship between baseline blood pressure value and patients' functional outcome or death is well established. Nonetheless, there is scant evidence for the benefits of early pharmacological intervention. Current guidelines differentiate blood pressure targets on the basis of implemented reperfusion treatment and allow blood pressure reduction in certain clinical situations. However, there is a substantial lack of evidence to guide management during acute stroke. Taking into account several aspects of blood pressure management can improve stroke care, although they are not included in current guidelines. To make an optimal decision as to whether to intervene regarding blood pressure, it is important to consider dehydration, recanalisation status, blood pressure variability, and autoregulation state as measured by novel imaging techniques. Further trials considering patient-specific factors with the use of continuous monitoring of blood pressure, as well as neurovascular imaging, are needed to resolve the current ambiguities.

Pre-Hospital and In-Hospital Delay in Acute Ischemic Stroke Patients in Indonesia: A Multi-center Study

Introduction: Little is known regarding pre-hospital and in-hospital delays in acute ischemic stroke (AIS) patients in Indonesia. This study aimed to evaluate the nature of these delays and identify factors causing pre-hospital delays among AIS patients in Indonesia. Methods: This was a prospective, observational study conducted among adult AIS patients in 3 hospitals in Surabaya during March–August 2019. Baseline characteristics along with time intervals both pre- and post-arrival of patients to the study sites were collected and analysed. Multiple logistic regression analyses with a stepwise forward model were performed to evaluate the factors contributing to the pre-hospital delay. Results: A total of 126 patients were recruited in this study. Mean age ± S.D. was 58.56 ± 10.71 years old. The mean ± S.D. time of pre-hospital delay and mean ± S.D. time to computerized tomography scan were 1,004±1,116.09 and 189±166.44 minutes, respectively. Only 18 out of 126 patients (14.29%) presented to the hospitals within 4.5-hour of intravenous thrombolysis (IVT) time window. However, only 3 patients (2.38%) ultimately received IVT. Wake-up stroke (OR=17.865; p=0.019), unawareness of the gravity of symptoms (OR=11.025; p=0.007), unawareness of stroke symptoms (OR=7.880; p=0.003) and referral patient (OR=7.819; p=0.008) were significantly associated with pre-hospital delay. Conclusion: Pre-hospital delay of AIS was very common and represented a challenging problem to improve stroke care in Indonesia. Wake-up stroke along with lack of patient understanding in recognizing stroke symptoms and ineffective referral system were the most prominent risk factors for pre-hospital delay in Indonesian AIS patients.

20 years of improvement in stroke care: the rewards from finally funding more research

Substantial improvements have taken place in the outcomes of patients with cerebrovascular disease since the beginning of the 21st century. These improvements are mainly due to the rapid translation of clinical research findings into service provision, including the roll-out of urgent assessment and treatment of patients with suspected transient ischaemic attack or minor stroke, and the swift provision of thrombectomy for those with major ischaemic stroke.

The impact of a comprehensive national policy on improving acute stroke patient care in Lithuania.

Introduction:Reperfusion therapy (RT) is a mainstay treatment for acute ischemic stroke (AIS). We aimed to evaluate the impact of a comprehensive national policy (CNP) to improve access to RT for AIS patients across Lithuania.Patients and methods:Aggregated anonymized data on AIS cases treated in Lithuanian hospitals between 2006 and 2019 were retrospectively obtained from the Institute of Hygiene and the Stroke Integrated Care Management Committee. Through an interrupted time series analysis, we examined the trends in AIS hospital admissions, RT, and in-hospital case fatality rates prior to the enactment of CNP in 2014, changes immediately after the intervention, and differences in trends between the pre- and post-intervention periods. Mean yearly door-to-needle times were calculated post-intervention.Results:114,436 cases were treated for AIS in Lithuanian hospitals before, and 65,084 after the government intervention. We observed a significant decreasing post-intervention trend change in AIS hospital admission rate per 100,000 population (regression coefficient ± standard error: β = –16.47 ± 3.95, p = 0.002) and an increasing trend change in the proportion of AIS patients who received reperfusion treatment: intravenous thrombolysis (β = 1.42 ± 0.96, p < 0.001) and endovascular therapy (β = 0.85 ± 0.05, p < 0.001). The proportion of patients treated in stroke centers increased immediately after the intervention (β = 4.95 ± 1.14, p = 0.001), but the long-term post-intervention trend did not change. In addition, there was a significant decreasing trend in all cause in-hospital case fatality rate within primary and comprehensive stroke centers after the intervention (β = –0.60 ± 0.18, p = 0.008) despite its prompt initial immediate increase (β = 1.68 ± 0.73, p = 0.043). The mean countrywide door-to-needle time decreased from 68 min in 2014 to 43 min in 2019.Conclusion:The comprehensive national stroke patient care policy could be associated with an immediate increase in stroke center treatment rate, increased access to RT, and improved stroke care performance measures.

Rationale and design of a stepped wedge cluster randomised trial to improve acute reperfusion treatment quality for stroke: IMPROVE stroke care in China

BackgroundReperfusion therapy is the most effective treatment for acute ischaemic stroke (AIS) but remains underutilised in China. There is an urgent need to develop tailored strategies to increase adherence to...

A Review of Strategies to Improve Stroke Care Services in Low and Middle-Income Countries: The Innovative Experience of LGH Stroke Programme

This manuscript aims to outline how pre-existing resources can be used for stroke care and how public and government awareness can be raised (influencer model).&#x0D; We likewise portray the achievement of the LGH stroke program as an example of advancement. In LGH, reperfusion treatment has begun in recent years and this paper portrays the one of a kind experience in Pakistan. The aim of this study is to do a comparative analysis between Pakistan, Thailand and Egypt and their approaches to stroke care management and treatment. These countries fall under similar economic standing (LMICs) but Egypt and Thailand have relatively better healthcare systems for stroke management as compared to Pakistan. Hence, this paper&#x0D; looks into these differences and presents potential solutions to how stroke care management can be improved in Pakistan. Additionally, current stroke management in Pakistan is reviewed.

A Review of Strategies to Improve Stroke Care Services in Low and Middle-Income Countries: The Innovative Experience of LGH Stroke Programme

This manuscript aims to outline how pre-existing resources can be used for stroke care and how public and government awareness can be raised (influencer model).&#x0D; We likewise portray the achievement of the LGH stroke program as an example of advancement. In LGH, reperfusion treatment has begun in recent years and this paper portrays the one of a kind experience in Pakistan. The aim of this study is to do a comparative analysis between Pakistan, Thailand and Egypt and their approaches to stroke care management and treatment. These countries fall under similar economic standing (LMICs) but Egypt and Thailand have relatively better healthcare systems for stroke management as compared to Pakistan. Hence, this paper&#x0D; looks into these differences and presents potential solutions to how stroke care management can be improved in Pakistan. Additionally, current stroke management in Pakistan is reviewed.

Improved Stroke Care in a Primary Stroke Centre Using AI-Decision Support

Background: Patient selection for reperfusion therapies requires significant expertise in neuroimaging. Increasingly, machine learning-based analysis is used for faster and standardized patient selection. However, there is little information on how such software influences real-world patient management. Aims: We evaluated changes in thrombolysis and thrombectomy delivery following implementation of automated analysis at a high volume primary stroke centre. Methods: We retrospectively collected data on consecutive stroke patients admitted to a large university stroke centre from two identical 7-month periods in 2017 and 2018 between which the e-Stroke Suite (Brainomix, Oxford, UK) was implemented to analyse non-contrast CT and CT angiography results. Delivery of stroke care was otherwise unchanged. Patients were transferred to a hub for thrombectomy. We collected the number of patients receiving intravenous thrombolysis and/or thrombectomy, the time to treatment; and outcome at 90 days for thrombectomy. Results: 399 patients from 2017 and 398 from 2018 were included in the study. From 2017 to 2018, thrombolysis rates increased from 11.5% to 18.1% with a similar trend for thrombectomy (2.8–4.8%). There was a trend towards shorter door-to-needle times (44–42 min) and CT-to-groin puncture times (174–145 min). There was a non-significant trend towards improved outcomes with thrombectomy. Qualitatively, physician feedback suggested that e-Stroke Suite increased decision-making confidence and improved patient flow. Conclusions: Use of artificial intelligence decision support in a hyperacute stroke pathway facilitates decision-making and can improve rate and time of reperfusion therapies in a hub-and-spoke system of care.

Abstract TP47: Emergency Medical Services Time Intervals For Suspected Stroke Patients In The United States

Introduction: Prehospital recognition and rapid transport of stroke patients by emergency medical services (EMS) is critical to optimize access to time-sensitive care. We aimed to describe EMS time intervals for suspected stroke patients in the U.S. and to quantify variation in EMS time intervals by geographic location and urbanicity. Methods: We conducted a cross-sectional evaluation of EMS 9-1-1 activations (i.e., calls for service) included in the 2018 and 2019 National EMS Information System. We included ground and air EMS activations for a scene response where a patient aged ≥18 years old with suspected stroke (EMS impression of I60-I63 or G45) was treated and transported by EMS. Time intervals for dispatch, response, scene, transport, and total prehospital time were calculated, stratified by ground and air transport type. Results: A total of 415,342 activations for suspected stroke were included, of which 98% were a ground transport. The overall median total prehospital time for ground transports was 35 minutes (IQR 27-45, 90 th percentile 58; Table). Median total prehospital time for air transports was substantially longer at 56 minutes (IQR 43-70, 90 th percentile 86). Times varied by census division and urbanicity with the shortest median total prehospital time of ground transports in the East North Central division (31 min, IQR 25-40) and urban areas (34 min, IQR 27-43) and longest times in the East South Central (39 min, IQR 30-52), rural (40 min, IQR 28-56), and frontier (44 min, IQR 29-63) areas. Conclusions: With ongoing focus on optimizing time-to-treatment for acute stroke interventions, prehospital transport can be targeted for quality improvement. While some variation is expected due to geographical constraints, we found substantial variation in prehospital transport times for suspected stroke that may present opportunities for future improvement. These findings may inform health services research and policy efforts to improve stroke care access.

Between-Center Variation in Outcome After Endovascular Treatment of Acute Stroke: Analysis of Two Nationwide Registries.

Insight in differences in patient outcomes between endovascular thrombectomy (EVT) centers can help to improve stroke care. We assessed between-center variation in functional outcome of patients with acute ischemic stroke who were treated with EVT. We analyzed to what extent this variation may be explained by modifiable center characteristics. We used nationwide registry data of patients with stroke treated with EVT in the Netherlands and in the Czech Republic. Primary outcome was modified Rankin Scale score at 90 days as an indicator of disability. We used multilevel ordinal logistic regression to quantify the between-center variation in outcomes and the impact of patient and center characteristics. Between-center variation was expressed as the relative difference in odds of a more favorable modified Rankin Scale score between a relatively better performing center (75th percentile) and a relatively worse performing center (25th percentile). We included a total of 4518 patients treated in 33 centers. Adjusted for patient characteristics, the odds of a more favorable outcome in a center at the 75th percentile of the outcome distribution were 1.46 times higher (95% CI, 1.31-1.70) than the odds in a center at the 25th percentile. Adjustment for center characteristics, including the median time between stroke onset and reperfusion per center, decreased this relative difference in odds to 1.30 (95% CI, 1.18-1.50, P=0.01). This translates into an absolute difference in likelihood of good functional outcome of 8% after adjustment for patient characteristics and to 5% after further adjustment for modifiable center characteristics. The considerable between-center variation in patient outcomes after EVT for acute ischemic stroke could be largely explained by center-specific characteristics, such as time to reperfusion. Improvement of these parameters may likely result in a decrease in center-specific differences, and an overall improvement in outcome of patients with acute ischemic stroke.