Reduce Treatment Delays Research Articles

The accuracy of Johannesburg-based ambulance personnel in identifying stroke

Background. Stroke is a potentially life-threatening, time-dependent event that requires urgent management to reduce morbidity and mortality. It has been suggested that earlier recognition by ambulance personnel and transport to stroke centres may significantly reduce treatment delays. For this reason it is vitally important that ambulance personnel are able to accurately diagnose stroke. Methods. A series of vignettes were created that included images, video and audio displaying either signs or symptoms of stroke or those of another condition. Ambulance personnel were asked to review each vignette and state whether the patient described was suffering from a stroke or not. Further investigation was sought by requesting each individual to motivate their answer, mentioning upon what their diagnosis was based. Results. A total of 40 basic life support (BLS) and intermediate life support (ILS) personnel from different sites diagnosed 280 vignettes. BLS personnel were able to diagnose stroke with a sensitivity of 85.3% and a specificity of 89.9% (positive predictive value (PPV) 86.7%, negative predictive value (NPV) 88.8%), while ILS achieved a sensitivity of 98.2% and specificity of 94.0% (PPV 91.7%, NPV 98.8%). The combined sensitivity and specificity were 91.5% and 92.0%, respectively (PPV 89.2%, NPV 93.8%). In order to aid their diagnosis, only 5% of BLS and 18.34% of ILS utilised validated stroke screening tools. Conclusion. Despite not using validated screening tools, the ambulance personnel sampled in this study were able to identify stroke with high accuracy. Further studies should be considered to identify how these diagnoses were reached in order to identify training needs.

Protocolo de atención del ictus en Urgencias

Recanalization therapies restoring blood flow in acute stroke are more effective the sooner they are administered. The interventions aimed to reduce treatment delays are increasingly important in the last years. Emergency physicians should be prepared to suspect stroke symptoms at hospital arrival of patients and contact neurologist on call as soon as possible. Education of emergency medical service personnel and specific acute stroke treatment protocols could be useful to avoid in hospital-delays in these cases. We introduce a protocol focused on acute stroke treatment in emergency room to include the preliminary history, a rapid neurologic evaluation, test request (laboratory test and neuroimaging), specific criteria to recanalization therapies in ischemic stroke and specific hemorrhagic stroke treatment.

P09.13 Impact and cost-effectiveness of point-of-care testing for chlamydia: accounting for geographic variation in infection burden and testing rates, health service configuration, and implementation strategy

Introduction Point-of-care tests (PoCTs) for Chlamydia trachomatis potentially improve control by reducing transmission through reduced treatment delay, reduced loss to follow up, and greater convenience for patients leading to increased testing. However, with ~3–5 fold variation in rates of Chlamydia testing and diagnosis across geographic settings in England, in assessing cost-effectiveness the epidemiological context needs to be considered. Methods We developed a transmission-dynamic model to capture geographic variation in rates of testing and diagnosis using current technology to allow assessment of the impact of implementing PoCTs in different clinical services in different localities. The model incorporates heterogeneity in sexual partner change rates and is stratified by age and sex. It uses behavioural and prevalence data from the Natsal national survey, and Public Health England surveillance data on testing and diagnosis rates. Uncertainty in natural history and behavioural parameters is captured by Monte Carlo methods. Health service reconfiguration using PoCT is considered, including rates of PoCT introduction and reduction in presumptive treatment. Results The model captures observed geographic variation in rates of testing and diagnosis in females and males, which affects the impact and cost-effectiveness of PoCT introduction. In general, whilst PoCTs may reduce incidence by increasing diagnosis and treatment, if sensitivity is lower than conventional testing then there is potentially increased transmission from false-negative patients. The net effect depends upon characteristics of the particular PoCT. Conclusion PoCT sensitivity and specificity are key determinants of whether replacing conventional testing is likely to reduce or increase the incidence of infection. Importantly, if the convenience of PoCT increases testing rates then diagnoses might initially increase even though incidence falls; interpretation of surveillance data needs to account for this. This work is the foundation of a user-friendly web-based tool assessing the (cost-) effectiveness of introducing PoCTs in different local settings. Disclosure of interest statement CED, ESS, NG, EHE, RHJ, YC, CML, and PJW thank Innovate UK for funding. PJW thanks the UK Medical Research Council for Centre funding (grant MR/K010174/1), and also thanks the UK National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Modelling Methodology at Imperial College London in partnership with Public Health England (PHE) for funding (grant HPRU-2012–10080). The funding sources had no involvement in the study design or conduct; the collection, analysis and interpretation of data; the preparation, review or approval of the manuscript; or the decision to submit the manuscript for publication. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, the Department of Health, or Public Health England. CED was employed for part of the project by the National Chlamydia Screening Programme. The other authors declare no competing interests.

Association of socioeconomic status with treatment delays, disease activity, joint damage, and disability in rheumatoid arthritis.

To examine the association of socioeconomic status (SES) and delays in disease-modifying antirheumatic drug (DMARD) treatment with clinical measures in rheumatoid arthritis (RA) patients. RA patients were recruited from rheumatology practices. We assessed SES based on education, occupation, and income, and divided patients into tertiles. The time from RA symptom onset to DMARD initiation (DMARD lag) was determined by self-report of the 2 dates, and distance to the rheumatologist (Distance) was obtained from Google Maps. We examined disease activity, determined by the Disease Activity Score in 28 joints using the erythrocyte sedimentation rate (DAS28-ESR); joint damage, determined from hand radiographs by Sharp scores; and physical disability, determined by the modified Health Assessment Questionnaire (M-HAQ). We used linear regression models to examine the relationship between clinical measures and SES, Distance, and DMARD lag. We recruited 1,209 RA patients, 1,159 of whom had received DMARD treatment. Mean ± SD DMARD lag was 6.9 ± 9.0 years. On average, patients with lower SES waited 8.5 ± 10.2 years after onset of RA symptoms to begin DMARD treatment, compared to those in the middle and upper SES tertiles who waited 6.1 ± 7.9 years (P = 0.002) and 6.1 ± 8.6 years (P = 0.009), respectively. Each year of delayed treatment was associated with a DAS28-ESR increase of 0.02 (P ≤ 0.001), a Sharp score increase of 1.33 (P ≤ 0.001), and an M-HAQ score increase of 0.01 (P ≤ 0.001). Low SES was associated with delay in DMARD initiation, and both were independently associated with worse clinical measures in RA. Strategies to reduce treatment delay in low-SES RA patients are needed.

Use of the Theory of Planned Behaviour to assess factors influencing the identification of students at clinical high-risk for psychosis in 16+ Education.

BackgroundThe longer psychotic disorders are untreated the worse their prognosis. Increasing the awareness of early psychosis by professionals who come into regular contact with young people is one strategy that could reduce treatment delay. As teachers engage with students on a daily basis, their role could be exploited to increase awareness of the early signs of psychosis. This study employed the Theory of Planned Behaviour (TPB) to identify and measure factors that influence identification of students at high-risk (HR) of developing psychosis in 16+ educational institutions.MethodsAn elicitation phase revealed beliefs underlying teachers’ motivations to detect HR students and informed the construction of a preliminary 114-item questionnaire incorporating all constructs outlined in the TPB. To define the determinants of teachers’ intention to identify HR students, 75 teachers from secondary and further education institutions in 12 counties surrounding Cambridgeshire completed the questionnaire. A psychometric model of item response theory was used to identify redundant items and produce a reduced questionnaire that would be acceptable to teachers.ResultsThe final instrument comprised 73 items and showed acceptable reliability (α = 0.69-0.81) for all direct measures. Teacher’s confidence and control over identification of HR students was low. Although identification of HR students was considered worthwhile, teachers believed that their peers, students and particularly their managers might not approve. Path analysis revealed that direct measures of attitude and PBC significantly predicted intention, but subjective norm did not. PBC was the strongest predictor of intention. Collectively, the direct measures explained 37 % of the variance of intention to identify HR for psychosis.ConclusionsThis research demonstrated how the TPB can be used to identify and measure factors that influence identification of students at HR of developing psychosis in 16+ educational institutions and confirmed the feasibility, reliability and acceptability of a TPB-based questionnaire for teachers. Consideration of the key determinants of identification in schools will facilitate the design of successful educational intervention strategies with the potential to reduce treatment delays for HR students.

Disparities in Colorectal Cancer Treatment Delay Within Appalachia—The Role of For‐Profit Hospitals

Appalachian residents have a higher overall cancer burden than the rest of the United States because of the unique features of the region. Treatment delays vary widely within Appalachia, with colorectal cancer patients undergoing median treatment delays of 5 days in Kentucky compared to 9 days for patients in Pennsylvania, Ohio, and North Carolina combined. This study identified the source of this disparity in treatment delay using statistical decomposition techniques. This study used linked 2006 to 2008 cancer registry and Medicare claims data for the Appalachian counties of Kentucky, Pennsylvania, Ohio, and North Carolina to estimate a 2-part model of treatment delay. An Oaxaca Decomposition of the 2-part model revealed the contribution of the individual determinants to the disparity in delay between Kentucky counties and the remaining 3 states. The Oaxaca Decomposition revealed that the higher percentage of patients treated at for-profit facilities in Kentucky proved the key contributor to the observed disparity. In Kentucky, 22.3% patients began their treatment at a for-profit facility compared to 1.4% in the remaining states. Patients initiating treatment at for-profit facilities explained 79% of the observed difference in immediate treatment (<2 days after diagnosis) and 72% of Kentucky's advantage in log days to treatment. The unique role of for-profit facilities led to reduced treatment delay for colorectal cancer patients in Kentucky. However, it remains unknown whether for-profit hospitals' more rapid treatment converts to better health outcomes for colorectal cancer patients.

Abstract 213: Treatment Delays in Patients with ST-Elevation Myocardial Infarction Across All Hospitals Performing Primary Percutaneous Coronary Intervention in Quebec, Canada: Results of a Third Field Evaluation

Background: Our government-funded independent cardiology evaluation unit conducted a third systematic province-wide field evaluation of ST-elevation myocardial infarction (STEMI) in collaboration with an interdisciplinary committee of clinical experts. Primary percutaneous coronary intervention (PPCI) is the predominant reperfusion treatment for STEMI in Quebec and in 2 previous evaluations (2006-7; 2008-9), there were wide variations in treatment delays across the 13 PPCI hospitals. Initiatives to improve delays have included individualized hospital report cards, presentations and discussions of inter-regional analyses with clinicians and decision-makers and the province-wide implantation of an ambulance (prehospital) ECG program. Our objective was to describe the differences in STEMI processes of care over time that these initiatives may have produced. Methods: Medical charts of all patients with a final diagnosis of acute myocardial infarction who presented with characteristic symptoms to an emergency department (ED) during a 6-month period in 2013-2014 were reviewed. Trained medical record librarians collected data on clinical characteristics and time points of care. An automated algorithm was used to identify STEMI. All patients with STEMI who presented directly to the ED of one of the 13 PPCI centers (by ambulance or other means) and were treated with PPCI were included in this preliminary analysis. ECGs were reviewed at our core laboratory. Results: During the 6-month study period, 735 patients with STEMI presented directly to the ED of a PPCI hospital (including ambulance bypass of local non-PPCI hospitals) and were treated with PPCI. Center patient volume varied from 29 to 117. Over 80% (596/735) of the patients arrived by ambulance (up from 71% in 2009-9) and of these, 93% (552/596) had a prehospital ECG compared with 20% in 2008-9. The median ED door-in-door-out delay was 26 min (10-90th percentile: 8-72) compared with 49 min (17-126) in 2008-9 (p=0.001). The median door-to-device delay was 59 min (30-125), compared with 77 min (38-163) during 2008-9 (p=0.017), and varied from a median of 38 to 87 min across the 13 PPCI hospitals. For patients arriving by ambulance with documented first medical contact time, 48% (260/541) had a first medical contact-to-device time ≤ 90 min compared with 35% in 2008-9 (p=0.06). Conclusions: This third province-wide evaluation shows important improvements in Quebec’s system of STEMI care. Since 2008-9, ED door-in-door-out delay improved by 47% and door-to-device delay for direct admission PPCI improved by 23%. These improvements have occurred after local, regional and provincial efforts to monitor and reduce treatment delays and the implantation of a province-wide prehospital ECG program. However, the wide variation in delays across PPCI centers underlines the need for continued evaluation and improvement initiatives.

Tuberculosis control in South African gold mines: mathematical modeling of a trial of community-wide isoniazid preventive therapy.

A recent major cluster randomized trial of screening, active disease treatment, and mass isoniazid preventive therapy for 9 months during 2006–2011 among South African gold miners showed reduced individual-level tuberculosis incidence but no detectable population-level impact. We fitted a dynamic mathematical model to trial data and explored 1) factors contributing to the lack of population-level impact, 2) the best-achievable impact if all implementation characteristics were increased to the highest level achieved during the trial (“optimized intervention”), and 3) how tuberculosis might be better controlled with additional interventions (improving diagnostics, reducing treatment delay, providing isoniazid preventive therapy continuously to human immunodeficiency virus–positive people, or scaling up antiretroviral treatment coverage) individually and in combination. We found the following: 1) The model suggests that a small proportion of latent infections among human immunodeficiency virus–positive people were cured, which could have been a key factor explaining the lack of detectable population-level impact. 2) The optimized implementation increased impact by only 10%. 3) Implementing additional interventions individually and in combination led to up to 30% and 75% reductions, respectively, in tuberculosis incidence after 10 years. Tuberculosis control requires a combination prevention approach, including health systems strengthening to minimize treatment delay, improving diagnostics, increased antiretroviral treatment coverage, and effective preventive treatment regimens.

Abstract W P1: Reducing CT-To-Groin puncture Time for Endovascular Treatment of Acute ischemic Stroke: A High Volume Comprehensive Stroke Center Experience

BACKGROUND: One of the key variables that predict a good clinical outcome after endovascular stroke treatment is expeditious reperfusion. We describe a single center experience of process improvement to develop a streamlined Acute Stroke protocol in reducing CT-to-Groin Puncture (CTGP) time for endovascular stroke treatment (EVP) at Erlanger Medical Center. MATERIAL AND METHODS: All consecutive ischemic stroke patients who received EVP were retrospectively and prospectively registered in the stroke registry. A series of interventions to reduce treatment delays were implemented every year starting in 2012.Starting April 2013 provision for 24/7 in-house attending stroke neurologist presence was initiated. In-hospital delays were analyzed as annual mean/median CTGP time in minutes. RESULTS: A total of 176 patients were treated EVP between January 2011 to July 2014. The CTGP was reduced annually, from mean 275minutes (median118) in 2011, to 124 minutes (median104) in 2012, to 105 minutes (median99) in 2013 and 78minutes (median69) in 2014 (a 71% decrease in mean from 2011). There was a significant difference in the CTGP time before and after the initiation of 24/7 in-house attending Stroke neurologist presence. The in-hospital mortality, LOS (length of stay) and sICH (symptomatic ICH) were not adversely affected. Conclusion: With multiple institution specific interventions, it is possible to improve the treatment times for endovascular stroke treatment even at a high volume non-academic center. The 24/7 in-house stroke neurologist’s presence is feasible and can be justified by expeditious patient selection for endovascular stroke treatment. The next step will be to show the impact in improving clinical outcome after the successful reperfusion.

Abstract W P223: Systems wide Streamlining of Door to Recanalization Processes in Endovascular Stroke Therapy

Objective: Faster reperfusion leads to better outcome both in thrombolytic therapy and endovascular therapy in acute stroke. We analyzed the effect of interventions aimed to reduce treatment delays in our single-center prospective series. Methods: All consecutive ischemic stroke patients treated with endovascular therapy were prospectively registered from 4/20/12 to 7/29/14. We divided the patients into pre-intervention (4/20/12-10/8/13) and post-intervention (10/9/13-7/29/14) period. The main interventions included: awareness, continuous feedback and regular education of staff involved, EMS pre notification, protocolized immediate direct ED attending to stroke attending communication, direct IR activation by stroke team including for possible rather than certain intervention, direct patient transportation by EMS to CT scanner, direct transportation of patient from CT scanner to angiosuite, direct transport from outside hospital to angiosuite. Results: See table. There was no significant difference between the demographics, location of the occlusion, rate of IV tpa, or revascularization rate between the groups with the exception of better ASPECT in pre-intervention group (P=0.034). Compared to pre-intervetion, time delays were improved at virtually every step. Median door-to-puncture (D2P) improved from 105 minutes to 67 minutes post-intervention which was significant (p=0.006). Despite time to perfusion improvement, there was no significant difference in rate of 3 month good outcome which is most likely due to small sample size. Conclusions: This pilot study demonstrates that D2P times can be dramatically lowered with a few simple measures. Larger prospective studies will be necessary to determine whether these interventions will translate into improved clinical outcomes.

Why do farmworkers delay treatment after debilitating injuries? Thematic analysis explains if, when, and why farmworkers were treated for injuries.

Farmworkers who delay treatment after workplace injuries may increase injury severity and experience longer recovery times. To understand why farmworkers delay treatment we employed a mixed-methods analysis of 393 farmworker injury narratives from the National Agricultural Workers Survey (NAWS). First, open-ended injury narratives were coded for attitudes related to injury timing and delay. Next, narratives were compared against demographic survey attributes to assess contextual information and patterns linked to treatment timing. Four treatment timings were identified: immediate medical treatment (57.9%), delayed medical treatment (18.2%) self- administered treatment (14.9%), and no treatment at all (8.9%). Delay was primarily attributed to attitudes prioritizing work over pain, and when workers were able to work despite injury. However, immediate treatment was sought when workers were completely debilitated and unable to work, when a supervisor was notified, or when exposed to pesticides during injury. Timing choices varied by education, gender and migrant status. Training on timely treatment, including notification of supervisors, may help reduce treatment delay for farmworkers.

High levels of anomalous self-experience are associated with longer duration of untreated psychosis.

To investigate the relationship between anomalous self-experiences and duration of untreated psychosis in a sample of patients with first-episode schizophrenia spectrum disorders. Anomalous self-experiences were assessed by means of the Examination of Anomalous Self-Experience manual in 55 patients referred to their first adequate treatment for schizophrenia. Diagnoses, symptom severity, functioning and childhood trauma were assessed using the Structured Clinical Interview for the Positive and Negative Syndrome Scale, Premorbid Adjustment Scale, Social Functioning Scale and Childhood Trauma Questionnaire. Substance misuse was measured with the Drug Use Disorder Identification Test, and alcohol use was measured with the Alcohol Use Disorder Identification Test. Duration of untreated psychosis was measured in accordance with a standardized procedure. High levels of anomalous self-experiences are significantly associated with longer duration of untreated psychosis, an association which held after correcting for other variables associated with long duration of untreated psychosis. The field of early detection in psychosis is in need of additional clinical perspectives to make further progress. Improved understanding and assessment of anomalous self-experiences may help clinicians to detect these important phenomena and provide earlier help, and thus reduce treatment delay.

Cultural epidemiology of pandemic influenza in urban and rural Pune, India: a cross-sectional, mixed-methods study

ObjectiveTo identify and compare sociocultural features of pandemic influenza with reference to illness-related experience, meaning and behaviour in urban and rural areas of India.DesignCross-sectional, mixed-methods, cultural epidemiological survey with vignette-based...

Point-of-care testing versus standard practice for chlamydia: a new approach to assessing the public health effect of rapid testing and treatment at local level

BackgroundChlamydia trachomatis is the most commonly diagnosed bacterial sexually transmitted infection in Britain. Present standards specify treatment within 14 days of testing positive; point-of-care testing (POCT) can eliminate this delay and potentially reduce loss to follow-up; its greater convenience might increase testing. 90-min nucleic acid amplification tests are the best available POCTs for chlamydia, with alternatives under development. However, cost-effectiveness depends on cost-per-test, sensitivity and specificity, and the effect of POCT on transmission. MethodsWe developed a user-friendly web-based method, based on a transmission-dynamic model for chlamydia, to assess the epidemiological impact and cost-effectiveness of introducing POCT in different local settings. The model uses behavioural and prevalence data from the National Survey of Sexual Attitudes and Lifestyles, and Public Health England surveillance data; these data inform on local-level variation, which is represented by sampling parameter values from within their ranges of uncertainty and selecting parameter sets that reproduce local coverage and diagnosis rates. The user can select different local settings, and vary sensitivity and specificity for the tests, specify costs (fixed and unit costs, including staff time), and then assess the effect of introducing POCT in different clinical services by comparison with a situation with no POCT. In the model, presumptive treatment is represented, which we expect to be reduced with the introduction of POCT because test results would be rapidly available to guide treatment. FindingsChanges in numbers of infections and diagnoses occurring under different scenarios (including conventional testing) were estimated, with uncertainty ranges, allowing calculation of total costs, and cost per infection (and serious sequelae) averted, while accommodating the considerable variation in chlamydia testing coverage, positivity, and diagnosis rates. Potential changes in sexual behaviour between test and treatment could determine the relative contribution of increased treatment rates and reduced treatment delay to the reduction in prevalence as a consequence of POCT. InterpretationThe effect of POCT was dependent on both the test performance characteristics and the assumptions about the implementation of the test across local services. Exploration of many uncertainties surrounding chlamydia epidemiology and screening implementation is possible with this model. This method can complement local and national knowledge, and contribute to local-level management of chlamydia infection. FundingInnovate UK (Technology Strategy Board), UK Medical Research Council, and the National Institute for Health Research. The Electronic Self-Testing Instruments for Sexually Transmitted Infection (eSTI2) Consortium eSTI2 is Funded under the UKCRC Translational Infection Research (TIR) Initiative supported by the Medical Research Council (Grant Number G0901608) with contributions to the Grant from the Biotechnology and Biological Sciences Research Council, the National Institute for Health Research on behalf of the Department of Health, the Chief Scientist Office of the Scottish Government Health Directorates, and the Wellcome Trust

In vitro localisation of intracranial haematoma using electrical impedance tomography semi-array

Electrical Impedance Tomography is a non-invasive and portable method that has good potential as an alternative to the conventional modalities for early detection of intracranial haematomas in high risk patients. Early diagnosis can reduce treatment delays and most significantly can impact patient outcomes. Two eight-electrode layouts, a standard ring full array (FA) and a semi-array (SA), were investigated for their ability to detect, localise and quantify simulated intracranial haematomas in vitro on ovine models for the purpose of early diagnosis. SA layout speeds up electrode application and avoids the need to move and lift the patient's head. Haematomas were simulated using gel samples with the same conductivity as blood. Both layouts, FA and SA, could detect the presence of haematomas at any location within the skull. The mean of the relative radial position error with respect to the brain radius was 7% for FA and 6% for SA, for haematomas close to the electrodes, and 11% for SA for haematomas far from the electrodes at the back of the head. Size estimation was not as good; the worst size estimation error for FA being around 30% while the best for SA was 50% for simulated haematomas close to the electrodes.

Criminal Justice Settings as Possible Sites for Early Detection of Psychotic Disorders and Reducing Treatment Delay

Interventions to reduce the duration of untreated psychosis should target institutions and key figures that may interact with individuals who have emerging or untreated psychosis. These individuals may come into contact with criminal justice settings, such as jails and prisons. This study sought to determine the frequency of arrests and incarcerations during the duration of untreated psychosis. Retrospective data were collected from an urban, largely African-American group of 191 patients hospitalized for first-episode psychosis. Thirty-seven percent of participants were incarcerated at some point during their duration of untreated psychosis. Patients who had been incarcerated during this period had a much longer treatment delay, more severe positive symptoms (specifically, hallucinations), and poorer premorbid academic adjustment. For this group, the mean number of incarcerations during the duration of untreated psychosis was 2.0±1.5, the median number of days detained was 30.5, and most were detained for nonviolent, often petty, crimes. Interventions to identify young people with untreated psychosis in jails and prisons and to refer these individuals to appropriate psychiatric care may reach some who would otherwise experience very long delays in treatment initiation. Crisis intervention team training of police officers could serve as one of several approaches for identifying these young people and diverting them into treatment.

Community-based treatment of drug-resistant tuberculosis in Khayelitsha, South Africa

Khayelitsha, South Africa, a peri-urban township with high burdens of tuberculosis (TB), drug-resistant tuberculosis (DR-TB), and human immunodeficiency virus (HIV) infection. To describe case detection and patient outcomes in a community-based DR-TB programme. DR-TB management was integrated into primary health care in Khayelitsha from 2007 onwards. Implementation was incremental, and included training and clinician support, counselling and home visits, tuberculous infection control, a local in-patient service, and routine monitoring. Patients received treatment rapidly through their local clinic, and were only hospitalised if clinically unwell. DR-TB case notification (any rifampicin resistance) increased from 28 per 100 000 population per year (2005-2007) to 55/100 000/year in 2009-2011 (72% HIV-infected). From 2008 to 2011, 754 patients received treatment (86% of those diagnosed). The median time between diagnostic sputum and treatment decreased over the years of implementation to 27 days in 2011 (P < 0.001). Treatment success was 52% in 2010, with 31% default, 13% death and 4% treatment failure. Two-year survival was 65%, with poorer survival in those with HIV (HR 2.0, 95%CI 1.4-2.8), second-line drug resistance (HR 3.3, 95%CI 2.2-4.8), and diagnosis in earlier programme years (HR 1.4, 95%CI 1.1-2.0). Community-based DR-TB management is feasible, and contributes to improved case detection, reduced treatment delay and improved survival. Treatment outcomes remain poor, highlighting the poor efficacy, tolerability and lengthy duration of current treatment.

Abstract MP45: National Women’s Knowledge of Stroke Warning Signs, Overall and by Race/Ethnic Group

Background: Early treatment is associated with better clinical outcomes in stroke, but women must recognize the warning signs of a stroke to reduce delays in treatment. The purpose of this study was to evaluate contemporary knowledge of stroke warning signs and intent to call 9-1-1 first if warning signs occur, among a nationally representative sample of women, overall and by race/ethnic group. Methods: A study of cardiovascular disease awareness and knowledge was conducted by the American Heart Association in 2012 among English speaking US women &gt; 25 years identified through random digit dialing (N=1,205; 54% white, 17% black, 17% Hispanic, 12% other). Demographic data, including race/ethnic group, were evaluated using standardized categorical questions. Knowledge about warning signs of stroke, and what to do first if experiencing signs of a stroke, was assessed by standardized unaided questions. Data were weighted to reflect the US population of women based on the US Census Bureau’s March 2011 Current Population Survey, overall and within ethnic strata. Results: In 2012, half of women surveyed (51%) identified sudden weakness/numbness of face/limb on one side as a stroke warning sign; this did not vary by race/ethnic group. Loss of/trouble talking/understanding speech was identified by 44% of women, and more frequently among white versus Hispanic women (48% vs. 36%; p&lt;.05). Fewer than one in four women identified sudden severe headache (23%), unexplained dizziness (20%), or sudden dizziness/loss of vision (18%) as warning signs, and one in five (20%) did not know one stroke warning sign; these results did not vary by race/ethnicity. The majority of women said that they would call 9-1-1 first if they thought they were experiencing signs of a stroke (84%), and this did not vary among black (86%), Hispanic (79%), or white/other (85%) women. Conclusions: Knowledge of stroke warning signs was low among a nationally representative sample of women, especially among Hispanics. In contrast, knowledge to call 9-1-1 when experiencing signs of stroke was high. These data suggest effort to improve recognition of the warning signs of stroke has potential to reduce treatment delay and improve outcomes among women.

National women's knowledge of stroke warning signs, overall and by race/ethnic group.

Recognition of stroke warning signs may reduce treatment delays. The purpose of this study was to evaluate contemporary knowledge of stroke warning signs and knowledge to call 9-1-1, among a nationally representative sample of women, overall and by race/ethnic group. A study of cardiovascular disease awareness was conducted by the American Heart Association in 2012 among English-speaking US women ≥25 years identified through random-digit dialing (n=1205; 54% white, 17% black, 17% Hispanic, and 12% other). Knowledge of stroke warning signs, and what to do first if experiencing stroke warning signs, was assessed by standardized open-ended questions. Half of women surveyed (51%) identified sudden weakness/numbness of face/limb on one side as a stroke warning sign; this did not vary by race/ethnic group. Loss of/trouble talking/understanding speech was identified by 44% of women, more frequently among white versus Hispanic women (48% versus 36%; P<0.05). Fewer than 1 in 4 women identified sudden severe headache (23%), unexplained dizziness (20%), or sudden dimness/loss of vision (18%) as warning signs, and 1 in 5 (20%) did not know 1 stroke warning sign. The majority of women said that they would call 9-1-1 first if they thought they were experiencing signs of a stroke (84%), and this did not vary among black (86%), Hispanic (79%), or white/other (85%) women. Knowledge of stroke warning signs was low among a nationally representative sample of women, especially among Hispanics. In contrast, knowledge to call 9-1-1 when experiencing signs of stroke was high.

Stroke Thrombolysis

Stroke thrombolysis is highly time-critical, but data on long-term effects of small reductions in treatment delays have not been available. Our objective was to quantify patient lifetime benefits gained from faster treatment. Observational prospective data of consecutive stroke patients treated with intravenous thrombolysis in Australian and Finnish centers (1998-2011; n=2258) provided distributions of age, sex, stroke severity, onset-to-treatment times, and 3-month modified Rankin Scale in daily clinical practice. Treatment effects derived from a pooled analysis of thrombolysis trials were used to model the shift in 3-month modified Rankin Scale distributions with reducing treatment delays, from which we derived the expected lifetime and level of long-term disability with faster treatment. Each minute of onset-to-treatment time saved granted on average 1.8 days of extra healthy life (95% prediction interval, 0.9-2.7). Benefit was observed in all groups: each minute provided 0.6 day in old severe (age, 80 years; National Institutes of Health Stroke Scale [NIHSS] score, 20) patients, 0.9 day in old mild (age, 80 years; NIHSS score, 4) patients, 2.7 days in young mild (age, 50 years; NIHSS score, 4) patients, and 3.5 days in young severe (age, 50 years; NIHSS score, 20) patients. Women gained slightly more than men over their longer lifetimes. In the whole cohort, each 15 minute decrease in treatment delay provided an average equivalent of 1 month of additional disability-free life. Realistically achievable small reductions in stroke thrombolysis delays would result in significant and robust average health benefits over patients' lifetimes. The awareness of concrete importance of speed could promote practice change.