Quality Of Stroke Care Research Articles

Care Quality and Outcomes of Ischemic Stroke in Patients With Premorbid Dementia: Get With The Guidelines-Stroke Registry.

Patients with premorbid dementia have been generally excluded from trials of stroke therapies, and their dementia diagnosis may affect the care received. There are few data on the quality of stroke care and outcomes in these patients. We compared the quality of care and outcomes for acute ischemic stroke patients with versus without premorbid dementia using national data from the Get With The Guidelines-Stroke registry between July 1, 2020, and December 31, 2021. Process outcomes included receiving intravenous thrombolysis, endovascular thrombectomy, and additional national quality measures. Clinical outcomes included ambulatory status at discharge, discharge destination, and mortality. The analyses were adjusted for patient and hospital characteristics. Among 609 350 patients with acute ischemic stroke, 29 751 of 546 407 (5.4%) had documented prestroke dementia (median age, 84 [interquartile range, 78-89]; 62.8% female). Patients with versus without premorbid dementia were more likely to arrive via emergency medical services (70.5% versus 46.8%) and had more severe strokes (median National Institutes of Health Stroke Scale score, 7 [interquartile range, 3-15] versus 3 [interquartile range, 1-8]). They were less likely to be admitted to a comprehensive stroke center (17.9% versus 22.7%; P<0.0001), to receive intravenous thrombolysis (9.6% versus 11.1%; adjusted odds ratio [aOR], 0.91 [95% CI, 0.87-0.95]) or endovascular thrombectomy (4.5% versus 7.4%; aOR, 0.62 [95% CI, 0.56-0.68]), attain each of the Get With The Guidelines-Stroke Achievement Measures and Quality Measures, or attain defect-free stroke care (92.0% versus 95.0%; aOR, 0.75 [95% CI, 0.71-0.78]). Patients with premorbid dementia had longer door-to-needle times (adjusted difference, 3.17 minutes [95% CI, 1.34-5.01]), lower odds of being discharged home (43.8% versus 60.1%; aOR, 0.96 [95% CI, 0.93-1.00]), and higher odds of being nonambulatory at discharge (25.8% versus 9.3%; aOR, 1.62 [95% CI, 1.54-1.69]), and of in-hospital mortality or hospice admission (23.3% versus 8.6%; aOR, 1.38 [95% CI, 1.32-1.43]). Symptomatic intracranial hemorrhage after intravenous thrombolysis/endovascular thrombectomy did not differ (5.3% versus 3.7%; aOR, 1.13 [95% CI, 0.97-1.31]). Patients with premorbid dementia experienced slightly poorer quality of stroke care across multiple measures, were less likely to receive acute stroke interventions, and had worse poststroke outcomes than patients without dementia in a large nationwide registry. Our findings underscore the need for concerted efforts to further improve care quality and outcomes in this population.

Maximising the Quality of Stroke Care: Reporting of Data Collection Methods and Resourcing in National Stroke Registries: A Systematic Review.

Stroke registries are tools for improving care and advancing research. We aim to describe the methodology and resourcing of existing national stroke registries. We conducted a systematic search of the published, peer-reviewed literature and grey literature examining descriptions of data collection methods and resourcing of national stroke registries published from 2012 to 2023. The systematic review was registered in PROSPERO (CRD42023393841). 101 records relating to 21 registries in 19 countries were identified. They universally employed web-based platforms for data collection. The principal profession of data collectors was nursing. All included the acute phase of care, 28% (6) registered the pre-hospital (ambulance) phase and 14% (3) included rehabilitation. 80% (17) collected outcome data. The registries varied in their approach to outcome data collection; in 9 registries it was collected by hospitals, in 2 it was collected by the registry, and 7 had linkage to national administrative databases allowing follow-up of a limited number of end points. Coverage of the total number of strokes varies from 6 to 95%. Despite widespread use of Electronic Health Records (EHRs) the ability to automatically populate variables remained limited. Governance and management structures are diverse, making it challenging to compare their resourcing. Data collection for clinical registries requires time and necessary skills and imposes a significant administrative burden on the professionals entering data. We highlight the role of clinical registries as powerful instruments for quality improvement. Future work should involve creating a central repository of stroke registries to enable the development of new registries and facilitate international collaboration.

Analyzing stroke burden and risk factors in India using data from the Global Burden of Disease Study.

Stroke remains a critical global health issue, significantly impacting India with substantial contributions to mortality and disability. This study comprehensively analyses stroke incidence, mortality, and disability-adjusted life years (DALYs) across India from 1990 to 2021, using the latest Global Burden of Disease (GBD) 2021 data. We evaluate how Universal Health Coverage (UHC), health expenditure, human development index (HDI), and gross national income (GNI) influence stroke outcomes. Our findings reveal significant regional disparities, with higher stroke rates in urban areas and states like Goa and Kerala. Higher health expenditure and HDI are linked to lower stroke rates, while higher GNI per capita correlates with increased stroke incidence, likely due to lifestyle changes. Risk factors include air pollution, tobacco use, dietary risks, and high blood pressure. Air pollution notably impacts stroke mortality in Bihar and Jharkhand, while tobacco use is a major risk factor in Mizoram and Manipur. Dietary risks and hypertension are prevalent in Maharashtra and Jammu & Kashmir. The study highlights the need for targeted public health strategies addressing regional disparities and socioeconomic factors. Policymakers should focus on lifestyle modification programs, public awareness campaigns, and enhanced access to quality stroke care to reduce stroke-related morbidity and mortality effectively.

Anticoagulation Patterns in Ischemic Stroke Patients with Atrial Fibrillation in Developing Country: Insights from the Stroke Registry in Vietnam.

(1) Background: Atrial fibrillation (AF) poses a growing cardiovascular challenge globally, with significant implications in Vietnam. This study aimed to investigate the impact of AF on ischemic stroke/transient ischemic attack (TIA) and clinical outcomes, as well as the utilization of oral anticoagulation (OAC) therapy in Vietnam. (2) Methods: Data from the Registry of Stroke Care Quality (RES-Q) across 66 hospitals in Vietnam between 2017 and 2023 were utilized. Patients diagnosed with ischemic stroke or TIA were included, and clinical characteristics, pre- and post-hospitalization medication, and hospitalized outcomes were examined. (3) Results: Of 94,144 patients, 15.1% had AF. Patients with AF were older and had a higher prevalence of heart failure and more severe strokes. AF was associated with increased mortality during hospitalization and a poorer prognosis. In AF patients, anticoagulation therapy utilization increased from 15.8% pre-hospitalization to 82.4% at discharge, with a preference for direct oral anticoagulants. (4) Conclusions: AF significantly impacts ischemic stroke/TIA outcomes in Vietnam. Pre-hospitalization and anticoagulation therapy utilization were low but improved at discharge. These findings emphasize the need for improved AF management and stroke prevention strategies in developing countries.

'SNOMEDizing' Questionnaires for Standardizing Stroke Registry Data.

International interoperability of healthcare and research data requires a commitment to standards. To this end, SNOMED CT was evaluated for representing questionnaire items of the European Registry of Stroke Care Quality using a complex annotation protocol. The agreement between validators and annotators was 72.4%. At least 64% of the information could be represented by using SNOMED CT only, including complex post-coordinations. 9% of the information would require an information model, and 14% the addition of new content to SNOMED CT. Next steps will be the creation of an annotation guideline for questionnaires, a specific reference set, and the combination of both with an information model such as HL7 FHIR.

Towards improving stroke services in Africa: Results from the Africa-UK Stroke Partnership [AUKSP] surveys

BackgroundThe African Stroke Organization (ASO) in partnership with the University of Central Lancashire's Stroke Research Team launched the Africa-UK Stroke Partnership (AUKSP). AUKSP undertook two (stroke expert and hospital Stroke Unit (SU)) on-line surveys mapping existing capacity and capability to deliver African stroke care. MethodsAn on-line expert survey tool was sent to 139 stroke experts in 54 African countries October 2021-March 2022 and the hospital SU survey to 120 hospital SUs (identified from the expert survey) June-October 2022. Both survey tools were prepared according to the World Stroke Organisation's Roadmap for Delivering Quality Stroke Care. Completed responses were exported from Qualtrics into Microsoft excel and were analysed descriptively. ResultsForty-five expert responses and 62 hospital SU responses were analysed, representing 54(87%) public hospitals, 7(11%) private and 1(2%) charitable organization. In both surveys, three main priorities for improvement of stroke services were: a rapid and prompt stroke diagnosis; effective primary and secondary stroke prevention, and acute stroke management. Survey findings suggest that there is a low presence of national stroke surveillance systems and registries, and heterogeneity in availability of diagnostic services, SUs, endovascular treatments, and rehabilitation. ConclusionSignificant gaps exist in Africa's capacity and capability to deliver essential elements of effective and quality stroke care. Tackling these challenges requires urgent and sustained multi-stakeholder action including: government, administrators, policy makers and other partners. Our survey findings highlight key priority areas for multi-stakeholder engagement and crafting of a pragmatic, prioritized and context-sensitive African Stroke Action Plan.

Regional variation in access to and quality of acute stroke care: results of Germany’s Health System Performance Assessment pilot, 2014–2020

BackgroundHealth System Performance Assessments (HSPA) and analyses of unwarranted regional variation in health care both aim at identifying strengths and weaknesses of health systems to improve care. Applying HSPA’s conceptual approach of interrelated health system dimensions (e.g., access, quality) to regional levels might help to better understand variation in care to reduce inequity and improve performance.MethodsWe use four indicators identified and analysed in a pilot study for a German HSPA to assess variation in access to and quality of acute stroke care between Germany’s 16 federal states and urban vs. rural regions from 2014 to 2020. Stroke unit (SU) density, share of the population reaching a SU within 30 min by car, share of inpatient stroke cases treated in a hospital with a SU, and inpatient mortality were computed based on hospital quality reports and discharge data covering all acute care hospitals. Inpatient mortality was adjusted for age, sex, stroke type, and comorbidities.ResultsAbout 500 SU were identified, i.e., 2.0 per 1,000 inpatient stroke cases. Almost 95% of Germans could reach a SU hospital within 30 min (rural: 90%; urban: 99%; > 88% in all states but one). The share of inpatient stroke cases treated in a SU hospital increased to 93% with a decreasing span between rural (92%) and urban (95%) regions and between states (74–98%). Inpatient mortality stagnated around 8.5% and increased to 9.0% in 2020 (rural: 8.7%; urban: 9.2%; states: 7.0–9.7%, one outlier of 13.3%).ConclusionsThe results especially revealed varying performance patterns in access to and quality of acute stroke care between the federal states, indicating different areas for improvement which might be addressed by more targeted policy measures in the future.

Assessing regional disparities and vulnerability in stroke care across Gyeonggi Province: A focus on hospital service areas

BackgroundThis study aims to illuminate regional disparities and identify vulnerable areas in stroke care across Gyeonggi Province's hospital service areas. MethodsUsing data from the Korea National Cardio-cerebrovascular Disease Management Commission, we included 4,427 acute stroke patients admitted in 2018 to hospitals within Gyeonggi Province. Our evaluation focused on: 1) stroke care quality indicators, including rates of defect-free care, intravenous thrombolysis (IVT), endovascular thrombectomy (EVT), and acute reperfusion therapy (either IVT or EVT); 2) intra-regional treatment rates; and 3) one-year mortality across the province and its 12 hospital service areas. These were compared both with national averages and inter-regionally. Vulnerable areas were pinpointed by evaluating the number of quality indicators falling below the national average and through visual distribution mapping, categorizing each indicator into higher (ranks 1-4), middle (ranks 5-8), and lower (ranks 9-12) tiers. ResultsDespite fewer qualified stroke centers and specialists, Gyeonggi Province exhibited higher defect-free care rates (84.6 % vs. 80.7 %), intra-regional treatment rates (57.8 % vs. 51.0 %), and marginally lower one-year mortality (16.2 % vs. 17.3 %) compared to national averages. Notable regional disparities were observed; the highest-performing areas for defect-free care and acute reperfusion therapy exceeded the lowest by 1.4 and 3.3 times, respectively. Nine out of twelve areas fell below the national average for EVT rates, seven for IVT and reperfusion therapy rates, and five for intra-regional treatment rates. Pyeongtaek, with all stroke care quality indicators below the national average coupled with the highest one-year mortality, emerges as a critical area needing improvement in acute stroke care. ConclusionThis study not only exposes the regional disparities in stroke care within Gyeonggi Province's hospital service areas but also identifies areas most vulnerable. Consequently, a customized support strategy for these areas is imperative.

Quality of early stroke care and long-term mortality in patients with acute stroke: A nationwide follow-up study.

High quality of early stroke care is essential for optimizing the chance of a good patient outcome. The quality of care may be monitored by process performance measures (PPMs) and previous studies have found an association between fulfilment of PPMs and short-term mortality. However, the association with long-term mortality remains to be determined. We aimed to evaluate the association between fulfilment of PPMs and long-term mortality for patients with acute stroke in Denmark. We used data from Danish health care registers between 2008 and 2020 to identify all patients admitted with incident stroke (haemorrhagic (ICH) or ischaemic stroke). The quality of early stroke care was assessed using 10 PPMs. Mortality was compared using Cox proportional hazard ratios, risk ratios computed using Poisson regression, and standardized relative survival. We included 102,742 patients; 9804 cases of ICH, 88,591 cases of ischaemic stroke, and 4347 cases of unspecified strokes. The cumulative 10-year mortality risk was 56.8%. Fulfilment of the individual PPMs was associated with adjusted hazard rate ratios of death between 0.76 and 0.96. Patients with 100% fulfilment of all PPMs had a lower 10-year post-stroke mortality (adjusted risk ratio 0.90) compared to the patients with 0%-49% fulfilment and a standardized relative survival of 81.3%, compared to the general population. High quality of early stroke care was associated with lower long-term mortality following both ICH and ischaemic stroke, which emphasizes the importance of continued attention on the ability of stroke care providers to deliver high quality of early care.

Artificial intelligence to enhance prehospital stroke diagnosis and triage: a perspective.

As health systems organize to deliver the highest quality stroke care to their patients, there is increasing emphasis being placed on prehospital stroke recognition, accurate diagnosis, and efficient triage to improve outcomes after stroke. Emergency medical services (EMS) personnel currently rely heavily on dispatch accuracy, stroke screening tools, bypass protocols and prehospital notification to care for patients with suspected stroke, but novel tools including mobile stroke units and telemedicine-enabled ambulances are already changing the landscape of prehospital stroke care. Herein, the authors provide our perspective on the current state of prehospital stroke diagnosis and triage including several of these emerging trends. Then, we provide commentary to highlight potential artificial intelligence (AI) applications to improve stroke detection, improve accurate and timely dispatch, enhance EMS training and performance, and develop novel stroke diagnostic tools for prehospital use.

COVID-19 Pandemic and Stroke Care in Patients with Dementia Compared to Other Stroke Patients

ObjectivesThe primary objective of this study was to examine the impact of the COVID-19 pandemic on the quality of stroke care for patients with preexisting dementia, compared with patients who had only stroke. The secondary aim was to investigate how the quality of stroke care changed during the pandemic and post-pandemic periods compared with the pre-pandemic period in patients with preexisting dementia. DesignA registry-based, nationwide cohort study in Sweden. Setting and ParticipantsWe included patients with a first stroke between 2019 and 2022, both with and without dementia. The study periods were defined as follows: pre-pandemic (January 1, 2019, to February 29, 2020), COVID-19 pandemic (March 1, 2020, to February 24, 2022), and post-COVID-19 pandemic period (February 25, 2022, to September 19, 2022). The outcomes examined were the following quality indicators of stroke care, suggested by the national guideline of stroke care in Sweden: stroke admission site, performance of swallowing assessment, reperfusion treatment, assessment for rehabilitation, and early supported discharge. MethodsThe associations were studied through group comparisons and binary logistic regressions. ResultsOf the 21,795 patients with strokes, 1357 had documented preexisting dementia, and 20,438 had stroke without a dementia diagnosis. Throughout all study periods, a significantly lower proportion of patients with stroke with preexisting dementia, compared with stroke-only patients, received reperfusion treatment, assessments for rehabilitation, and early supported discharge from stroke units. In the subgroup of stroke patients with preexisting dementia, no significant associations were found regarding the quality indicators of stroke care before, during, and after the pandemic. Conclusions and ImplicationsDisparities in quality of stroke care were observed between stroke patients with preexisting dementia and those with only stroke during the COVID-19 pandemic. However, there were no statistically significant differences in stroke care for patients with dementia across the pandemic.

External quality monitoring facilitates improvement in already well-performing stroke units: insights from RES-Q Poland.

The Registry of Stroke Care Quality (RES-Q) is used in Poland for quality monitoring by numerous hospitals participating in the Angels Initiative. Our aim was to assess the degree of improvement in highly stroke-oriented centres that report cases to the RES-Q each year. This retrospective analysis included Polish stroke units that from January 2017 to December 2020 contributed to the RES-Q at least 25 patients annually. Seventeen out of 180 Polish stroke units reported patients each year (2017, n = 1,691; 2018, n = 2,986; 2019, n = 3,750; 2020, n = 3,975). The percentage of ischaemic stroke patients treated with alteplase remained stable (26%, 29%, 30% and 28%, respectively). The door-to-needle time progressively decreased, from a median 49 minutes to 32 minutes. The percentage of patients treated ≤ 60 minutes and ≤ 45 minutes significantly increased (from 68% to 86% and from 43% to 70%, respectively), with no change observed between 2019 and 2020. Despite a general improvement in dysphagia screening (81%, 91%, 98% and 99%), screening performed within the first 24h from admission became less frequent (78%, 76%, 69% and 65%). In-hospital mortality significantly increased (11%, 11%, 13% and 15%), while the proportion of patients discharged home remained stable. Quality-oriented projects facilitate the improvement of stroke care, even in centres demonstrating good baseline performance. Polish stroke units that consistently reported cases to the RES-Q demonstrated improvement in terms of door-to- -needle time and dysphagia screening. However, there is still a need to shorten the time to dysphagia screening, and carefully monitor stroke unit mortality following the COVID-19 pandemic.

Quality Indicators and Clinical Outcomes of Acute Stroke: Results from a Prospective Multicenter Registry in Greece (SUN4P)

Aim: The Stroke Units Necessity for Patients (SUN4P) project aims to provide essential data on stroke healthcare in Greece. Herein, we present results on established quality indicators and outcomes after first-ever stroke occurrences. Methods: This prospective multicenter study included consecutive patients admitted to nine hospitals across Greece in 2019–2021. Descriptive statistics were used to present patients’ characteristics, key performance measures and stroke outcomes. Results: Among 892 patients, 755 had ischemic stroke (IS) (mean age 75.6 ± 13.6, 48.7% males) and 137 had hemorrhagic stroke (HS) (mean age 75.8 ± 13.2, 57.7% males). Of those, 15.4% of IS and 8% of HS patients were treated in the acute stroke unit (ASU) and 20.7% and 33.8% were admitted to the intensive care unit (ICU) or high-dependency unit (HDU), respectively. A total of 35 (4.6%) out of 125 eligible patients received intravenous alteplase with a door-to needle time of 60 min (21–90). The time to first scan for IS patients was 60 min (31–105) with 53.2% undergoing a CT scan within 60 min post presentation. Furthermore, 94.4% were discharged on antiplatelets, 69.8% on lipid-lowering therapy and 61.6% on antihypertensives. Oral anticoagulants (OAC) were initiated in 73.2% of the 153 IS patients with atrial fibrillation (AF). Among the 687 IS patients who survived, 85.4% were discharged home, 12% were transferred to rehabilitation centers, 1.2% to nursing homes and 1.3% to another hospital. Conclusions: The SUN4P Registry is the first study to provide data from a prospectively collected cohort of consecutive patients from nine representative national hospitals. It represents an important step in the evaluation and improvement of the quality of acute stroke care in Greece.

Abstract TMP44: Widening Sex Disparity in Thrombolysis Amid Worsening Stroke Care Quality in Korea

Introduction: The difference in the use of intravenous thrombolysis (IVT) between females and males has been recognized. Nevertheless, there has been a lack of comprehensive investigation into the sex disparity in South Korea, where the stroke care system has experienced a government-initiated reform recently. Method: A prospective, multicenter, nationwide stroke registry (CRCS-K) was utilized to analyze acute stroke admissions during the years 2008 to 2022. IVT candidates were defined as patients with an NIHSS score of 4 or greater and who arrived at the hospital within 4.5 hours from the time last known well. The stroke care quality was measured by the 90th percentile of door-to-needle (DTN) time for IVT. The joinpoint regression model was applied to detect changes in trends of IVT utilization among the candidates. Results: A total of 96,855 admissions, of which 43% were female, were recorded during the period. IVT candidates were identified to be 15,732 (16%). The proportion of IVT among the candidates showed an increasing trend after 2008 (Phase 1), followed by a notable decline from 2013 to 2016 (Phase 2) and no significant change afterward (Phase 3, Panel A). During Phase 2, a significant decrease in IVT utilization was observed with an annual percent change (APC) of -5.40, with a greater downward trend in females (APC, -8.71) compared to males (APC, -1.99, Panel B). The 90th percentile of DTN time improved during Phase 1 (APC, -10.28), and worsened after the year 2013 (APC, 4.82, Panel C). IVT utilization was comparable between sexes in Phase 1 (adjusted OR [95% CI], 0.88 [0.76 - 1.03]), but a significant difference was noted in Phase 2 (0.77 [0.66 - 0.91]) and in Phase 3 (0.82 [0.30 - 0.91]), after the year 2013. Conclusion: A sex disparity in the use of IVT for ischemic stroke was documented in South Korea. In line with the deterioration in the hyperacute stroke care quality, the gender disparities in the utilization of IVT were also worsening.

Abstract WMP38: Access to Acute Stroke Care: Global Perspective From Registry of Stroke Care Quality (RES-Q)

Introduction: Disparities in access to acute stroke care represents a major global challenge. Addressing such challenges requires a comprehensive understanding of the variations in stroke care quality between nations. Methods: We used data from the global Registry of Stroke Care Quality (RES-Q). RES-Q is web-based quality monitoring platform for the management of stroke care. Key quality metrics on patients with acute ischemic stroke admitted in 2022 were calculated: patients percentage arriving by Emergency Medical Services (EMS); patients percentage admitted to the Stroke Unit/Intensive Care Unit (ICU); Door-to-Imaging Time (DIT), Door-to-Needle Time (DNT) for intravenous thrombolysis. Results: Of 153 181 patients across 912 hospitals in 67 countries enrolled in the register, 125 390 had acute ischemic stroke. After excluding secondary transfers (n=26 648), missing or erroneous data (n=45 526), and countries with &lt;200 cases (n=1 410), a total of 51,806 patients from 696 hospitals and in 30 countries were analyzed. The percentage of patients arriving at healthcare facilities by EMS varied from 3% to 98% (median 51%; IQR 26-87) and admitted to the Stroke Units/ICUs from 25% to 99% (median 78%; IQR 47-89). The median DIT was 32; IQR 21-39, with range 10-60 minutes. The median DNT was 44; IQR 31-52, with range 20-71 minutes. Median DNT of patients admitted directly to the CT scanner was 24 minutes (IQR 15-38), and, if admitted to the emergency department, DNT was 39 minutes (IQR 25-55). Data by quartiles (best is blue, worst is red) from each country are presented in a detailed Table below. Conclusion: Our study underscores the critical role of the global registry in enabling cross-national comparative analyses of acute stroke care quality. The findings highlight disparities and variations in critical aspects of acute stroke care, paving the way for targeted interventions, policy reforms, and enhanced collaboration among stakeholders to improve stroke care globally.

Abstract WMP43: Disparities in Large Vessel Occlusion Stroke Imaging and Endovascular Treatment Metrics, and Procedural Exclusions in the Global Registry of Stroke Care Quality (Res-Q)

Introduction: Global access to mechanical thrombectomy for large vessel occlusion (LVO) stroke is low and disparate between regions. Comparative global data on time metrics for imaging and endovascular treatment (EVT) performance, as well as the reasons for excluding EVT, are lacking. Methods: This is a cross-sectional study using quality metrics from the Res-Q registry on patients presenting directly to the hospital with acute ischemic stroke from January 1, 2022, to December 31, 2022, in countries with 200 or more cases. We used descriptive statistical methods to study the time metrics of interest including door to imaging and door to puncture. Additionally, reasons for not performing thrombectomy in patients with LVO were collected (Table 1). Results: Among the 153,181 patients from 912 hospitals across 67 countries enrolled in the Res-Q registry, 125,390 had an acute ischemic stroke. After excluding secondary transfers (n=26,648), patients with missing or erroneous data (n=42,232), and countries with less than 200 cases (n=1,626), data from a total of 54,884 patients from 631 hospitals across 30 countries were analyzed. CT angiography (CTA) was performed in 24,215 (44.1%) patients and EVT was done in 3,649 (6.6%) patients. For patients who had simultaneous CT+CTA, the median door-to-CTA time was 27.5 min (IQR 22.5-33.9) and the median door-to-puncture time was 98.5 (IQR 79.8-129.3) minutes. The most prevalent specific reason for excluding EVT in patients with LVO on CTA/MRA was the presentation in the late time window (42.0%). Only 11 (36.7%) countries achieved a median door-to-puncture time within 90 minutes (Table 1). Conclusions: The performance of acute imaging for LVO detection and time metrics for EVT appear to be disparate between countries and warrant further study. Additional data from global stroke care quality registries are needed to set benchmarks, compare regional stroke systems of care, and identify gaps to mobilize resources appropriately.

Abstract WP77: Changes in Acute Stroke Management and Outcomes in Korea Between 2013-2014 and 2018

Purpose: The quality of acute stroke care can be improved through the nationwide compulsory quality assessment. Acute stroke quality assessment (ASQA) covers most acute stroke patients treated in acute care hospitals in Korea. We evaluated the changes of acute stroke management and outcomes between 2013/2014 and 2018 in Korea. Methods: We compared the most recent available ASQA data from 2018 with the data from 2013/2014. Patients with ischemic stroke (IS), subarachnoid hemorrhage (SAH), and intracerebral hemorrhage (ICH), who were admitted via emergency rooms within 7 days of onset at hospitals treating 10 or more cases during the each 3-month (2013, 2014) and 6-month (2018) survey period were selected. We grouped 2013 and 2014 into one group and compared them with 2018. Results: A total of 19,599 acute stroke cases in 2013/2014 and 28,286 cases in 2018 were enrolled at 216 and 248 nationwide hospitals, respectively. Age of stroke patients increased slightly (67.1±13.5 vs 68.2±13.8, p &lt;0.001), and the proportion of stroke types slightly increased ICH and decreased SAH. The proportion of severe stroke was decreased. The number of hospitals equipped with stroke units increased. Mean bed size increased, but there was no difference in the number of stroke specialists by hospital. IVT and EVT were performed in 8.7% and 5.3% among IS patients in 2013/2014, respectively. In 2018, IVT rates decreased to 6.3% ( p &lt;0.001), and EVT rates increased to 9.8% ( p &lt;0.001). In particular, IVT rates significantly decreased from 1.3% to 0.2% in those over 80 years of age, and EVT rates increased from 0.7% to 2.4%. Decompressive surgery rates in ICH patients decreased slightly from 28.0% to 25.2% ( p =0.009). In SAH, clipping rates decreased from 34.7% to 24.3% ( p &lt;0.001), and coiling rates increased significantly from 39.8% to 53.0% ( p &lt;0.001). One-year mortality significantly decreased from 22.0% to 18.2% in all stroke patients ( p &lt;0.001). Mortality decreased at 1 month and 3 months, also, and decreased in all patients with IS, ICH, and SAH. Conclusions: This study showed that while stroke patients had improved outcomes from 2013/2104 to 2018 in Korea, there is still room for improvement, particularly in IVT rates.

Abstract WP93: Providing Stroke Reports to Emergency Medical Services (EMS) Agencies Improves Data Quality in Michigan's Statewide EMS Data Repository

Intro: The Michigan Stroke Program (MiSP) monitors statewide EMS stroke care performance and data quality. Starting in 2018, quarterly performance and outcome benchmark data were shared with EMS agency partners to support prehospital quality improvement (QI) for stroke patients. Objective: To improve EMS data quality and prehospital stroke care performance. Methods: This is a retrospective before and after study of the impact of tailored QI interventions to improve EMS compliance with three prehospital stroke quality metrics selected by MiSP EMS partners: (prehospital stroke scale documentation, last known well documentation, and prehospital notification). Five MiSP EMS partners participated in the intervention which consisted of provision of quarterly performance reports generated from linked data from Michigan’s EMS Information System and the Michigan Stroke Registry. The MiSP team reviewed agency performance with EMS leadership to select the target measures for intervention and then assisted in development of a QI plan to improve agency performance. Measure compliance was compared from three months prior to and six months after data quality solutions were implemented. Results: Through data sharing and communication with EMS agencies and EMS software data vendors, common themes were identified related to poor data quality beginning in January 2020. A sample of agencies and resolutions to address these issues are displayed in the Table. Compliance with the targeted metric improved significantly at each agency at three and six months following intervention. Conclusions: Analysis of EMS data and sharing performance data directly with EMS agency partners identified correctable data quality issues negatively impacting EMS quality measures. Correcting these issues led to dramatic and sustained improvement in EMS quality metric compliance. This approach may serve as a model for improving the accuracy of EMS performance data in state-level EMS registries.

Abstract WP92: Application of a Horizontal Communication Process in Combination With Artificial Intelligence (AI) to Improve Stroke Care in Patients With Large Vessel Occlusion (LVO)

Introduction: Timely acute stroke care in patients with large vessel occlusion (LVO) requires both early detection of LVO and efficient multidisciplinary communication. In this study, we aimed to evaluate the impact of using AI and a horizontal communication system within the RapidAI application platform on acute stroke quality metrics in patients with LVO. Methods: On April 2022, the RapidAI application was launched at our center, which allowed for use of AI as a screening measure for LVO detection with immediate notification to neurology, neuroradiology, and neuro-interventional teams. The various teams used instant messaging within the application to communicate clinical data, imaging findings and shared clinical decision making. In this single center study, we retrospectively evaluated stroke care quality metrics for 167 consecutive patients (mean age: 71.6, 49.1% male) who underwent mechanical thrombectomy (MT) from January 2021 to May 2023. Data were compiled from multiple resources including Get-With-The-Guidelines®, chart abstraction, and internal healthcare databases. The groups were compared using appropriate statistical tests and significance was determined using a two-sided alpha of 0.05. Results: 85 patients underwent MT before implementation of the new system, and 82 patients underwent MT after. Demographic features (age, sex, race), cerebrovascular risk factors (hypertension, diabetes, hyperlipidemia, smoking, BMI) and stroke severity were similar between the two groups (p&gt;0.05). Average door to groin puncture (pre: 97 minutes, post: 82 minutes, p=0.10) and discharge disposition (p=0.02) were significantly different between the two groups. In an adjusted analysis of door to groin puncture time, the difference between pre-RapidAI and post-RapidAI was an average reduction of 19 minutes trending towards significance (p = 0.06). Conclusion: Application of a horizontal communication platform in combination with RapidAI was associated with significant improvements in time to intervention in patients with LVO and a significant improvement in the number of patients discharged home.

Abstract TMP20: Mapping the Expansion of the Minnesota Stroke System of Care

Objectives: Stroke is the fifth leading cause of death in Minnesota (MN) and in the United States. The state of MN a has a unique geographical layout with many healthcare facilities located in rural areas. In 2013 legislation was passed authorizing the Minnesota Department of Health to designate hospitals as Acute Stroke Ready Hospitals, Primary Stroke Centers, and Comprehensive Stroke Centers. When a hospital joins the MN Stroke System they maintain vital infrastructure, expertise, and care processes to provide high quality stroke care in accordance with evidence-based guidelines. We used geographic information systems (GIS) methods to visualize the growth and expansion of the Minnesota Stroke System and quantify its reach to Minnesotans across the state over a 10-year period. Methods: Using the Network Analyst extension of ESRI ArcGIS Desktop 10.8.2, 30- and 60- minute drive time service areas were calculated around each designated hospital in 2013, 2017 and 2023. Census block groups were identified where the mean center of population fell within the 30-minute drive time areas and the populations of those block groups were summed. A percentage was calculated using the total Minnesota population as the denominator. Results: In 2013, only 66% of Minnesota’s population lived within 30 minutes of a designated stroke center and 80% lived within a 60-minute drive time. Stroke designated hospitals (19) were largely concentrated in metropolitan areas, leaving many rural Minnesotans without ready access to stroke centers. After the first cycle in 2017, or three-year period post statute, drive time status increased to 90% of the population living within 30 minutes of a designated stroke system hospital and 98% living within a 60- minute drive time. As of 2023, 94% of Minnesotans now live within a 30-minute drive of a designated Stroke System Hospital and 99% live within a 60-minute drive time. Conclusions: Stroke statute was the catalyst for improving stroke care access in MN. The voluntary system of care expanded rapidly from 19 initial hospitals to 119 over a 10-year period. This progress means more than 1.9 million additional Minnesotans now have better access to emergency stroke care.