TY - JOUR
T1 - Does Emergency Medical Services Transportation Mitigate Post-stroke Discharge Disability? A Prospective Observational Study
AU - Xirasagar, Sudha
AU - Wu, Yuqi
AU - Heidari, Khosrow
AU - Zhou, Jiera
AU - Tsai, Meng han
AU - Hardin, James W.
AU - Wronski, Robert
AU - Hurley, Dana
AU - Jauch, Edward C.
AU - Sen, Souvik
N1 - Funding Information:
SX: SX received a part of her summer salary for 2 years from the grant. The grant partially supported her time-effort on the project, the remaining time-effort being covered by her 9-month institutional salary from the University of South Carolina. SX’s travel to the American College of Emergency Physicians Annual Meeting 2018 to present the study findings was reimbursed from the grant. SX has not received any other financial or in-kind support/revenue from Genentech, Inc. or its allied subsidiaries, nor has any financial interest in Genentech or allied industry.
Funding Information:
The authors are grateful to Ms. Iris Smith, Director of Rehabilitation Services, Prisma Health (formerly Palmetto Health Richland hospital), and the Prisma Health Stroke Unit staff, Amanda Cotter, Andrea Griffin, Karen Cartrett, and Taylor Kizer, for advisory input regarding the GWTG data elements and logistical organization of the study, extraction of additional data from patient EMRs, preparing the de-identified study database out of GWTG data, and coordination assistance during the study. We appreciate the helpful comments on an earlier version of the manuscript by Marquita Decker-Palmer, MD, PhD, of Genentech, Inc.
Funding Information:
Authors’ time-effort for the study were partially funded by a grant from Genentech, Inc. to the University of South Carolina Research Foundation, a registered 501 (c) non-profit institution. Genentech, Inc. is the sole manufacturer of alteplase, the key thrombolytic drug used in ischemic stroke. It may be noted, however, that the study topic and research questions are not related in any way to alteplase drug effectiveness, clinical indications or any commercially relevant aspect. None of the authors has any conflict of interest. All authors received financial support for their time-effort via the university foundation as itemized below.
Funding Information:
This study was supported by a grant from F. Hoffmann-La Roche, Ltd., and Genentech, Inc. All funds were used towards study staff time-effort and data collection costs. Acknowledgments
Publisher Copyright:
© 2020, Society of General Internal Medicine.
PY - 2020/11
Y1 - 2020/11
N2 - Background: Whether emergency medical services (EMS) transport improves disability outcomes compared with other transport among acute ischemic stroke (AIS) patients is unknown. Objective: To study severity-adjusted associations of hospital arrival mode (EMS vs. other transport) with in-hospital and discharge disability outcomes. Design: Prospective observational study. Participants: AIS patients discharged April 2016 to October 2017 from a safety-net hospital in South Carolina. Main Measures: National Institutes of Health Stroke Scale (NIHSS) change at discharge (admission NIHSS score minus discharge NIHSS, continuous variable), 24-h NIHSS change (attaining high improvement, admission NIHSS minus 24-h NIHSS being 75th percentile or higher), door to neuroimaging (DTI) time, and IV alteplase receipt. NIHSS change was assessed within stroke severity groups, mild, moderate, and severe (admission NIHSS 0–5, 6–14, and ≥ 15, respectively). Key Results: Of 1168 patients, 838 were study-eligible (52% male, 52.4% Black, 72.2% EMS arrivals, 56.6% mild strokes). Severe and moderate stroke patients were more likely than mild stroke patients to use EMS (adjusted odds ratios, AOR [95% CI] 11.7 [5.0, 27.4] and 4.0 [2.6, 6.3], respectively). EMS arrival was associated with shorter DTI time (adjusted difference − 88.4 min) and higher likelihood of alteplase administration (AOR 5.3 [2.5, 11.4]), both key mediating variables in disability outcomes. High 24-h NIHSS improvement was more likely for EMS arrivals vs. other arrivals among moderate strokes (AOR 3.4 [1.1, 10.9]) and severe strokes (AOR > 999). EMS arrivals had substantially higher NIHSS improvement at discharge within the severe stroke group (adjusted NIHSS change at discharge, 5.9 points higher, p = 0.01). Alteplase recipients showed higher discharge NIHSS improvement than non-recipients (by 2.8 and 1.9 points among severe and moderate strokes, respectively; p = 0.01, 0.02). Conclusions: The findings offer evidence for including stroke education as a standard of care in the primary care management of patients with stroke-risk comorbidities/lifestyle in order to minimize post-stroke disability.
AB - Background: Whether emergency medical services (EMS) transport improves disability outcomes compared with other transport among acute ischemic stroke (AIS) patients is unknown. Objective: To study severity-adjusted associations of hospital arrival mode (EMS vs. other transport) with in-hospital and discharge disability outcomes. Design: Prospective observational study. Participants: AIS patients discharged April 2016 to October 2017 from a safety-net hospital in South Carolina. Main Measures: National Institutes of Health Stroke Scale (NIHSS) change at discharge (admission NIHSS score minus discharge NIHSS, continuous variable), 24-h NIHSS change (attaining high improvement, admission NIHSS minus 24-h NIHSS being 75th percentile or higher), door to neuroimaging (DTI) time, and IV alteplase receipt. NIHSS change was assessed within stroke severity groups, mild, moderate, and severe (admission NIHSS 0–5, 6–14, and ≥ 15, respectively). Key Results: Of 1168 patients, 838 were study-eligible (52% male, 52.4% Black, 72.2% EMS arrivals, 56.6% mild strokes). Severe and moderate stroke patients were more likely than mild stroke patients to use EMS (adjusted odds ratios, AOR [95% CI] 11.7 [5.0, 27.4] and 4.0 [2.6, 6.3], respectively). EMS arrival was associated with shorter DTI time (adjusted difference − 88.4 min) and higher likelihood of alteplase administration (AOR 5.3 [2.5, 11.4]), both key mediating variables in disability outcomes. High 24-h NIHSS improvement was more likely for EMS arrivals vs. other arrivals among moderate strokes (AOR 3.4 [1.1, 10.9]) and severe strokes (AOR > 999). EMS arrivals had substantially higher NIHSS improvement at discharge within the severe stroke group (adjusted NIHSS change at discharge, 5.9 points higher, p = 0.01). Alteplase recipients showed higher discharge NIHSS improvement than non-recipients (by 2.8 and 1.9 points among severe and moderate strokes, respectively; p = 0.01, 0.02). Conclusions: The findings offer evidence for including stroke education as a standard of care in the primary care management of patients with stroke-risk comorbidities/lifestyle in order to minimize post-stroke disability.
KW - 24-h disability improvement
KW - acute ischemic stroke
KW - discharge disability outcome
KW - emergency medical services use
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U2 - 10.1007/s11606-020-06114-4
DO - 10.1007/s11606-020-06114-4
M3 - Article
C2 - 32869194
AN - SCOPUS:85090009905
SN - 0884-8734
VL - 35
SP - 3173
EP - 3180
JO - Journal of General Internal Medicine
JF - Journal of General Internal Medicine
IS - 11
ER -