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Kiefer L, Daniel D, Polineni S, Dhamoon M. Racial disparities in access to, and outcomes of, acute ischaemic stroke treatments in the USA. Stroke Vasc Neurol 2024:svn-2023-003051. [PMID: 38777349 DOI: 10.1136/svn-2023-003051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 05/07/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Racism contributes to higher comorbid risk factors and barriers to preventive measures for black Americans. Advancements in systems of care, tissue plasminogen activator (tPA) availability and endovascular thrombectomy (ET) have impacted practice and outcomes while outpacing contemporary investigation into acute ischaemic stroke (AIS) care disparities. We examined whether recent data suggest ongoing disparity in AIS interventions and outcomes, and if hospital characteristics affect disparities. METHODS We examined 2016-2019 fee-for-service Medicare inpatient data. We ran unadjusted logistic regression models to calculate ORs and 95% CI for two interventions (tPA and ET) and four outcomes (inpatient mortality, 30-day mortality, discharge home and outpatient visit within 30 days), with the main predictor black versus white race, additionally adjusting for demographics, hospital characteristics, stroke severity and comorbidities. RESULTS 805 181 AIS admissions were analysed (12.4% black, 87.6% white). Compared with white patients, black patients had reduced odds of receiving tPA (OR 0.71, 95% CI 0.69 to 0.74, p<0.0001) and ET (0.69, 95% CI 0.65 to 0.72, p<0.0001). After tPA, black patients had reduced odds of 30-day mortality (0.77, 95% CI 0.72 to 0.82, p<0.0001), discharge home (0.72, 95% CI 0.68 to 0.77, p<0.0001) and outpatient visit within 30 days (0.89, 95% CI 0.84 to 0.95, p=0.0002). After ET, black patients had reduced odds of 30-day mortality (0.71, 95% CI 0.63 to 0.79, p<0.0001) and discharge home (0.75, 95% CI 0.64 to 0.88, p=0.0005). Adjusted models showed little difference in the magnitude, direction or significance of the main effects. CONCLUSIONS Black patients were less likely to receive AIS treatments, and if treated had lower likelihood of 30-day mortality, discharge home and outpatient visits. Despite advancements in practice and therapies, racial disparities remain in the modern era of AIS care and are consistent with inequalities previously identified over the last 20 years. The impact of hospital attributes on AIS care disparities warrants further investigation.
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Affiliation(s)
- Luke Kiefer
- Department of Neurology, Icahn School of Medicine, New York, New York, USA
| | - David Daniel
- Department of Neurology, Icahn School of Medicine, New York, New York, USA
| | - Sai Polineni
- Department of Neurology, Icahn School of Medicine, New York, New York, USA
| | - Mandip Dhamoon
- Department of Neurology, Icahn School of Medicine, New York, New York, USA
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Pérez-Sánchez S, Barragán-Prieto A, Loscertales JB, Cabezas Rodríguez JA, Zapata-Arriaza E, Amaya Pascasio L, Hermosín Gómez A, Gamero García MÁ, Galeano B, Fernández J, Pardo Galiana B, Domínguez Mayoral A, Ainz Gómez L, Fernández Navarro J, Del Toro C, Medina M, de Torres R, Baena P, Moniche F, Valverde Moyano R, Martínez P, González A, Montaner J. Closing the Sex-Based Differences in Stroke Care: Insights from a Large Telestroke Network on Treatment and Postacute Management. Health Equity 2024; 8:301-306. [PMID: 39011077 PMCID: PMC11249131 DOI: 10.1089/heq.2023.0175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2024] [Indexed: 07/17/2024] Open
Abstract
Background The evolution of ischemic stroke is different accordin'g to sex and is one of the main causes of death in women. Previous studies have shown that women are less likely to receive acute treatment, and stroke center type is an important predictor of door-to-needle times. We investigated whether women are attended in a similar way to men in the telestroke network with specialized stroke physicians. Methods A prospective registry of ischemic strokes recorded in the centralized Andalusian telestroke network was analyzed, focusing on sex differences. Demographic data, clinical characteristics, neuroimaging data, treatment intervals, follow-up visits, and clinical outcomes were collected. Results A total of 3009 suspected stroke patients were attended to in the telestroke network from 2019 to 2023, of which 42.74% were women. Women were older (p < 0.001) and less independent upon arrival (p = 0.006) than men. There was no difference in the treatment received or in the treatment time intervals between the groups. Importantly, there was no difference in modified Rankin scale scores at 3 months between sexes. At 3 months post-stroke follow-up, women had fewer imaging tests (p = 0.018) and fewer outpatient visits (p < 0.001) than men. Conclusions No significant difference between men and women has been found in the acute treatment of stroke in a large telestroke network. However, the same is not true for the follow-up and management of patients after the acute phase. This fact supports that strict adherence to protocols and specialization of care lead to equal care that avoids sex differences in stroke treatment and functional outcomes.
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Affiliation(s)
- Soledad Pérez-Sánchez
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
| | - Ana Barragán-Prieto
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
| | - Juan Bautista Loscertales
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
| | - Juan Antonio Cabezas Rodríguez
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
- Department of Neurology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Elena Zapata-Arriaza
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
- Department of Radiology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | | | - Miguel Ángel Gamero García
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
| | - Benito Galeano
- Department of Neurology, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - Javier Fernández
- Department of Neurology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Blanca Pardo Galiana
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
- Department of Neurology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Ana Domínguez Mayoral
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
| | - Leire Ainz Gómez
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
- Department of Neurology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Cristina Del Toro
- Department of Neurology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Manuel Medina
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
- Department of Neurology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Reyes de Torres
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
| | - Pablo Baena
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
- Department of Neurology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Francisco Moniche
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
- Department of Neurology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Patricia Martínez
- Department of Neurology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Alejandro González
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
- Department of Radiology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Joan Montaner
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
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Hunter BD, Brown-Gentry KD, Santilli MA, Prasla K. Combining zip code-based population data and pharmacy administrative claims data to create measures of social determinants of health. J Manag Care Spec Pharm 2024; 30:364-375. [PMID: 38555626 PMCID: PMC10982573 DOI: 10.18553/jmcp.2024.30.4.364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
BACKGROUND Social determinants of health (SDoH) are key factors that impact health outcomes. However, there are many barriers to collecting SDoH data (eg, cost of data collection, technological barriers, and lack of standardized measures). Population data may provide an accessible alternative to collecting SDoH data for patients. OBJECTIVE To explain how population data can be leveraged to create SDoH measures, assess the association of population SDoH measures with diabetic medication adherence, and discuss how understanding a patient's SDoH can inform care plans and patient engagement. METHODS A nationally representative commercial sample of patients who were aged 18 years and older and met Pharmacy Quality Alliance inclusion criteria for diabetes mellitus were analyzed (N = 37,789). US Census and North American Industry Classification System data were combined with pharmacy administrative claims data to create SDoH measures. Derived measures represent 2 SDoH domains: (1) economic stability (housing density, housing relocation, jobs per resident, and average salary) and (2) health care access and quality (urban/rural classification, distance traveled to prescriber and pharmacy, use of a primary care provider [PCP], and residents per PCP). The association of population SDoH measures with diabetic medication adherence (proportion of days covered) was assessed via logistic regression, which included covariates (eg, sex, age, comorbidities, and prescription plan attributes). RESULTS As housing density (houses per resident) increased, so did the likelihood of adherence (odds ratio = 1.54, 95% CI = 1.21-1.97, P = 0.001). Relative to patients who did not move, patients who moved once had 0.87 (95% CI = 0.81-0.93, P < 0.001) the odds of being adherent, and patients who moved 2 or more times had 0.82 (95% CI = 0.71-0.95, P = 0.008) the odds of being adherent. Compared with areas with fewer jobs per resident, patients living within a zip code with 0.16 to 0.26 jobs per resident were 1.12 (95% CI = 1.04-1.20, P = 0.002) times more likely to be adherent. Patients who lived in an urban cluster were 1.11 (95% CI = 1.01-1.22, P = 0.037) times more likely to be adherent than patients living in a rural area. Patients who travel at least 25 miles to their prescriber had 0.82 (95% CI = 0.77-0.86, P < 0.001) the odds of being adherent. Community pharmacy users had 0.65 (95% CI = 0.59-0.71, P < 0.001) the odds of being adherent compared with mail order pharmacy users. Patients who had a PCP were 1.26 (95% CI = 1.18-1.34, P < 0.001) times more likely to be adherent to their medication. CONCLUSIONS Leveraging publicly available population data to create SDoH measures is an accessible option to overcome barriers to SDoH data collection. Derived measures can be used to increase equity in care received by identifying patients who could benefit from assistance with medication adherence.
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Affiliation(s)
| | | | | | - Karim Prasla
- Magellan Rx Management, a Prime Therapeutics company, Eagan, MN
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4
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Daniel D, Maillie L, Dhamoon MS. Provider Care Segregation and Hospital-Region Racial Disparities in the United States for Acute Ischemic Stroke and Endovascular Therapy Outcomes. J Am Heart Assoc 2024; 13:e029255. [PMID: 38214294 PMCID: PMC10926824 DOI: 10.1161/jaha.122.029255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 09/27/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Reasons for racial disparities in the use and outcomes of endovascular treatment (ET) are not known. We examined patterns in care segregation for acute ischemic stroke (AIS) in the United States, and outcomes of segregation of care after ET. METHODS AND RESULTS We used deidentified Medicare data sets to identify AIS admissions between January 1, 2016 and December 31, 2019, using validated International Classification of Diseases, Tenth Revision (ICD-10) codes. For AIS, we calculated (1) the proportion of White patients at the hospital, (2) the proportional difference in the proportion of White patients between hospital patients and the county, and (3) provider care segregation by the dissimilarity index for ET cases. Using unadjusted and adjusted multilevel logistic models, we examined associations between measures of segregation and outcomes of discharge home, inpatient mortality, and 30-day mortality. The mean proportional difference in the proportion of White patients comparing hospitalized patients with AIS to the county race distribution was 0.015 (SD, 0.219) at the hospital level. For ET, the mean proportional difference in the proportion of White patients comparing patients receiving ET to the county race distribution was much higher, at 0.146 (SD, 0.374). The dissimilarity index for ET providers was high, with a mean of 0.48 (SD, 0.29) across all hospitals. Black patients with AIS (compared with White patients) had reduced odds of discharge home, inpatient mortality, and 30-day mortality. CONCLUSIONS In this national study with contemporary data in the endovascular era of AIS treatment, we found substantial evidence for segregation of care in the United States, not for only AIS in general but also especially for ET.
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Affiliation(s)
- David Daniel
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Luke Maillie
- Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Mandip S. Dhamoon
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNYUSA
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5
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Sevilis T, Avila A, McDonald M, Fowler M, Chalfin R, Amir M, Heath G, Zaman M, Avino L, Boyd C, Gao L, Devlin T. Sex differences in acute telestroke care: more to the story. Front Neurol 2023; 14:1203502. [PMID: 37426435 PMCID: PMC10325705 DOI: 10.3389/fneur.2023.1203502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 05/30/2023] [Indexed: 07/11/2023] Open
Abstract
Background Previous studies have shown sex differences in stroke care. Female patients have both lower thrombolytic treatment rates with OR reported as low as 0.57 and worse outcomes. With updated standards of care and improved access to care through telestroke, there is potential to reduce or alleviate these disparities. Methods Acute stroke consultations seen by TeleSpecialists, LLC physicians in the emergency department in 203 facilities (23 states) from January 1, 2021 to April 30, 2021 were extracted from the Telecare by TeleSpecialists™ database. The encounters were reviewed for demographics, stroke time metrics, thrombolytics candidate, premorbid modified Rankin Score, NIHSS score, stroke risk factors, antithrombotic use, admitting diagnosis of suspected stroke, and reason not treated with thrombolytic. The treatment rates, door to needle (DTN) times, stroke metric times, and variables of treatment were compared for females and males. Results There were 18,783 (10,073 female and 8,710 male) total patients included. Of the total, 6.9% of females received thrombolytics compared to 7.9% of males (OR 0.86, 95% CI 0.75-0.97, p = 0.006). Median DTN times were shorter for males than females (38 vs. 41 min, p < 0.001). Male patients were more likely to have an admitting diagnosis of suspected stroke, p < 0.001. Analysis by age showed the only decade with significant difference in thrombolytics treatment rate was 50-59 with increased treatment of males, p = 0.047. When multivariant logistic regression analysis was performed with stroke risk factors, NIHSS score, age, and admitting diagnosis of suspected stroke, the adjusted odds ratio for females was 0.9 (95% CI 0.8, 1.01), p = 0.064. Conclusion While treatment differences between sexes existed in the data and were apparent in univariate analysis, no significant difference was seen in multivariate analysis once stroke risk factors, age, NIHSS score and admitting diagnosis were taken into consideration in the telestroke setting. Differences in rates of thrombolysis between sexes may therefore be reflective of differences in risk factors and symptomatology rather than a healthcare disparity.
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Affiliation(s)
| | - Amanda Avila
- TeleSpecialists, LLC, Fort Myers, FL, United States
| | | | | | | | - Murtaza Amir
- TeleSpecialists, LLC, Fort Myers, FL, United States
| | - Gregory Heath
- Public Health, University of Tennessee at Chattanooga, Chattanooga, TN, United States
| | | | | | - Caitlyn Boyd
- TeleSpecialists, LLC, Fort Myers, FL, United States
| | - Lan Gao
- Mathematics, University of Tennessee at Chattanooga, Chattanooga, TN, United States
| | - Thomas Devlin
- TeleSpecialists, LLC, Fort Myers, FL, United States
- Neurology Department, University of Tennessee Health Science Center, Memphis, TN, United States
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6
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Sharrief A, Guzik AK, Jones E, Okpala M, Love M, Ranasinghe TIJ, Bushnell C. Telehealth Trials to Address Health Equity in Stroke Survivors. Stroke 2023; 54:396-406. [PMID: 36689591 PMCID: PMC11061884 DOI: 10.1161/strokeaha.122.039566] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Telehealth has seen rapid expansion into chronic care management in the past 3 years because of the COVID-19 pandemic. Telehealth for acute care management has expanded access to equitable stroke care to many patients over the past two decades, but there is limited evidence for its benefit for addressing disparities in the chronic care of patients living with stroke. In this review, we discuss advantages and disadvantages of telehealth use for the outpatient management of stroke survivors. Further, we explore opportunities and potential barriers for telehealth in addressing disparities in stroke outcomes related to various social determinants of health. We discuss two ongoing large randomized trials that are utilizing telehealth and telemonitoring for management of blood pressure in diverse patient populations. Finally, we discuss strategies to address barriers to telehealth use in patients with stroke and in populations with adverse social determinants of health.
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Affiliation(s)
- Anjail Sharrief
- University of Texas Health Sciences Center at Houston, McGovern Medical School, Department of Neurology
- University of Texas Health Sciences Center, McGovern Medical School, Stroke Institute
| | - Amy K Guzik
- Wake Forest Baptist Health, Wake Forest University School of Medicine, Department of Neurology
| | - Erica Jones
- University of Texas Southwestern Medical Center, Department of Neurology
| | - Munachi Okpala
- University of Texas Health Sciences Center at Houston, McGovern Medical School, Department of Neurology
| | - Mary Love
- University of Houston College of Nursing
| | | | - Cheryl Bushnell
- Wake Forest Baptist Health, Wake Forest University School of Medicine, Department of Neurology
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Avery EW, Behland J, Mak A, Haider SP, Zeevi T, Sanelli PC, Filippi CG, Malhotra A, Matouk CC, Griessenauer CJ, Zand R, Hendrix P, Abedi V, Falcone GJ, Petersen N, Sansing LH, Sheth KN, Payabvash S. CT angiographic radiomics signature for risk stratification in anterior large vessel occlusion stroke. Neuroimage Clin 2022; 34:103034. [PMID: 35550243 PMCID: PMC9108990 DOI: 10.1016/j.nicl.2022.103034] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 03/27/2022] [Accepted: 05/03/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND PURPOSE As "time is brain" in acute stroke triage, the need for automated prognostication tools continues to increase, particularly in rapidly expanding tele-stroke settings. We aimed to create an automated prognostication tool for anterior circulation large vessel occlusion (LVO) stroke based on admission CTA radiomics. METHODS We automatically extracted 1116 radiomics features from the anterior circulation territory on admission CTAs of 829 acute LVO stroke patients who underwent mechanical thrombectomy in two academic centers. We trained, optimized, validated, and compared different machine-learning models to predict favorable outcome (modified Rankin Scale ≤ 2) at discharge and 3-month follow-up using four different input sets: "Radiomics", "Radiomics + Treatment" (radiomics, post-thrombectomy reperfusion grade, and intravenous thrombolysis), "Clinical + Treatment" (baseline clinical variables and treatment), and "Combined" (radiomics, treatment, and baseline clinical variables). RESULTS For discharge outcome prediction, models were optimized/trained on n = 494 and tested on an independent cohort of n = 100 patients from Yale. Receiver operating characteristic analysis of the independent cohort showed no significant difference between best-performing Combined input models (area under the curve, AUC = 0.77) versus Radiomics + Treatment (AUC = 0.78, p = 0.78), Radiomics (AUC = 0.78, p = 0.55), or Clinical + Treatment (AUC = 0.77, p = 0.87) models. For 3-month outcome prediction, models were optimized/trained on n = 373 and tested on an independent cohort from Yale (n = 72), and an external cohort from Geisinger Medical Center (n = 232). In the independent cohort, there was no significant difference between Combined input models (AUC = 0.76) versus Radiomics + Treatment (AUC = 0.72, p = 0.39), Radiomics (AUC = 0.72, p = 0.39), or Clinical + Treatment (AUC = 76, p = 0.90) models; however, in the external cohort, the Combined model (AUC = 0.74) outperformed Radiomics + Treatment (AUC = 0.66, p < 0.001) and Radiomics (AUC = 0.68, p = 0.005) models for 3-month prediction. CONCLUSION Machine-learning signatures of admission CTA radiomics can provide prognostic information in acute LVO stroke candidates for mechanical thrombectomy. Such objective and time-sensitive risk stratification can guide treatment decisions and facilitate tele-stroke assessment of patients. Particularly in the absence of reliable clinical information at the time of admission, models solely using radiomics features can provide a useful prognostication tool.
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Affiliation(s)
- Emily W Avery
- Section of Neuroradiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States
| | - Jonas Behland
- Section of Neuroradiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States; CLAIM - Charité Lab for Artificial Intelligence in Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Adrian Mak
- Section of Neuroradiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States; CLAIM - Charité Lab for Artificial Intelligence in Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan P Haider
- Section of Neuroradiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States; Department of Otorhinolaryngology, University Hospital of Ludwig Maximilians Universität München, Munich, Germany
| | - Tal Zeevi
- Section of Neuroradiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States
| | - Pina C Sanelli
- Section of Neuroradiology, Department of Radiology, Northwell Health, Manhasset, NY, United States
| | - Christopher G Filippi
- Section of Neuroradiology, Department of Radiology, Tufts School of Medicine, Boston, MA, United States
| | - Ajay Malhotra
- Section of Neuroradiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States
| | - Charles C Matouk
- Division of Neurovascular Surgery, Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger Medical Center, Danville, PA, United States; Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria; Department of Neurosurgery, Paracelsus Medical University, Salzburg, Austria
| | - Ramin Zand
- Department of Neurology, Geisinger, Danville, PA, United States
| | - Philipp Hendrix
- Department of Neurosurgery, Geisinger Medical Center, Danville, PA, United States; Department of Neurosurgery, Saarland University Medical Center, Homburg, Germany
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Geisinger, Danville, PA, United States; Biocomplexity Institute, Virginia Tech, Blacksburg, VA, USA
| | - Guido J Falcone
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Nils Petersen
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Lauren H Sansing
- Division of Stroke and Vascular Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Seyedmehdi Payabvash
- Section of Neuroradiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States.
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Sheriff F, Xu H, Maud A, Gupta V, Vellipuram A, Fonarow GC, Matsouaka RA, Xian Y, Reeves M, Smith EE, Saver J, Rodriguez G, Cruz-Flores S, Schwamm LH. Temporal Trends in Racial and Ethnic Disparities in Endovascular Therapy in Acute Ischemic Stroke. J Am Heart Assoc 2022; 11:e023212. [PMID: 35229659 PMCID: PMC9075329 DOI: 10.1161/jaha.121.023212] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Introduction Endovascular therapy (EVT) use increased following clinical trials publication in 2015, but limited data suggest there may be persistent race and ethnicity differences. Methods and Results We included all patients with acute ischemic stroke arriving within 6 hours of last known well and with National Institute of Health Stroke Scale (NIHSS) score ≥6 between April 2012 and June 2019 in the Get With The Guidelines‐Stroke database and evaluated the association between race and ethnicity and EVT use and outcomes, comparing the era before versus after 2015. Of 302 965 potentially eligible patients; 42 422 (14%) underwent EVT. Although EVT use increased over time in all racial and ethnic groups, Black patients had reduced odds of EVT use compared with non‐Hispanic White (NHW) patients (adjusted odds ratio [aOR] before 2015, 0.68 [0.58‒0.78]; aOR after 2015, 0.83 [0.76‒0.90]). In‐hospital mortality/discharge to hospice was less frequent in Black, Hispanic, and Asian patients compared with NHW. Conversely discharge home was more frequent in Hispanic (29.7%; aOR, 1.28 [1.16‒1.42]), Asian (28.2%; aOR, 1.23 [1.05‒1.44]), and Black (29.1%; aOR, 1.08 [1.00‒1.18]) patients compared with NHW (24%). However, at 3 months, functional independence (modified Rankin Scale, 0–2) occurred less frequently in Black (37.5%; aOR, 0.84 [0.75‒0.95]) and Asian (33%; aOR, 0.79 [0.65‒0.98]) patients compared with NHW patients (38.1%). Conclusions In a large cohort of patients treated with EVT, Black versus NHW patient disparities in EVT use have narrowed over time but still exist. Discharge related outcomes were slightly more favorable in racial and ethnic underrepresented groups; 3‐month functional outcomes were worse but improved across all groups with time.
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Affiliation(s)
| | - Haolin Xu
- Duke Clinical Res Inst Durham Durham NC
| | - Alberto Maud
- Texas Tech University Health Sciences Center El Paso TX
| | - Vikas Gupta
- Texas Tech University Health Sciences Center El Paso TX
| | | | - Gregg C Fonarow
- UCLA Division of CardiologyRonald Reagan-UCLA Medical Center Los Angeles CA
| | | | - Ying Xian
- University of Texas Southwestern Medical Center Dallas TX
| | - Mathew Reeves
- College of Human Medicine Michigan State University East Lansing MI
| | | | | | | | | | - Lee H Schwamm
- Mass General HospitalHarvard Medical School Boston MA
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Verma A, Towfighi A, Brown A, Abhat A, Casillas A. Moving Towards Equity With Digital Health Innovations for Stroke Care. Stroke 2022; 53:689-697. [PMID: 35124973 PMCID: PMC8885852 DOI: 10.1161/strokeaha.121.035307] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Digital health has long been championed as a means to expanding access to health care. Now that the COVID-19 pandemic accelerated many health systems' integration of digital tools for care, digital health may provide a path towards more accessible stroke prevention and treatment, particularly for historically disadvantaged patient populations. Stroke management is composed of multiple time points where digital health innovations have the potential to augment health access and treatment: from primary prevention, to the time-sensitive detection of ischemic stroke, administration of thrombolytic agents and consideration for endovascular interventions, to appropriate post-acute care, rehabilitation, and lifelong secondary stroke prevention-stroke care relies on a multidisciplinary and standardized approach. However, as we discuss pointedly in this Focused Update, underrepresented individuals face multilevel digital health disparities that potentially diminish the benefits of these digital advances. As such, these multilevel needs must be discussed and accounted for as health systems seek to integrate innovative and equitable digital health solutions towards stroke care.
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Affiliation(s)
- Aradhana Verma
- Department of Internal Medicine, David Geffen School of
Medicine at UCLA, Los Angeles, CA
| | - Amytis Towfighi
- LA County Department of Health Services, Los Angeles,
CA,Department of Neurology, University of Southern California,
Los Angeles, CA
| | - Arleen Brown
- Department of Internal Medicine, David Geffen School of
Medicine at UCLA, Los Angeles, CA
| | - Anshu Abhat
- LA County Department of Health Services, Los Angeles,
CA
| | - Alejandra Casillas
- Department of Internal Medicine, David Geffen School of
Medicine at UCLA, Los Angeles, CA
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10
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Ikeme S, Kottenmeier E, Uzochukwu G, Brinjikji W. Evidence-Based Disparities in Stroke Care Metrics and Outcomes in the United States: A Systematic Review. Stroke 2022; 53:670-679. [PMID: 35105178 DOI: 10.1161/strokeaha.121.036263] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke disproportionately affects racial minorities, and the level to which stroke treatment practices differ across races is understudied. Here, we performed a systematic review of disparities in stroke treatment between racial minorities and White patients. A systematic literature search was performed on PubMed to identify studies published from January 1, 2010, to April 5, 2021 that investigated disparities in access to stroke treatment between racial minorities and White patients. A total of 30 studies were included in the systematic review. White patients were estimated to use emergency medical services at a greater rate (59.8%) than African American (55.6%), Asian (54.7%), and Hispanic patients (53.2%). A greater proportion of White patients (37.4%) were estimated to arrive within 3 hours from onset of stroke symptoms than African American (26.0%) and Hispanic (28.9%) patients. A greater proportion of White patients (2.8%) were estimated to receive tPA (tissue-type plasminogen activator) as compared with African American (2.3%), Hispanic (2.6%), and Asian (2.3%) patients. Rates of utilization of mechanical thrombectomy were also lower in minorities than in the White population. As shown in this review, racial disparities exist at key points along the continuum of stroke care from onset of stroke symptoms to treatment. Beyond patient level factors, these disparities may be attributed to other provider and system level factors within the health care ecosystem.
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Affiliation(s)
- Shelly Ikeme
- CERENOVUS, Johnson & Johnson, Irvine, CA (S.I., E.K.)
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11
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Kim SY, Daley K, Pruski AD, AlFarra T, Azola A, Gonzalez Fernandez M, Keszler MS, Friedel S, Haaf H, Segall H, Lien P, Cypher J, Mazariegos J, Raghavan P. Implementation of a Framework for Telerehabilitation in Clinical Care Across the Continuum During COVID-19 and Beyond. Am J Phys Med Rehabil 2022; 101:53-60. [PMID: 34915545 PMCID: PMC8667677 DOI: 10.1097/phm.0000000000001904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT The COVID-19 pandemic has propelled an unprecedented global implementation of telemedicine and telerehabilitation as well as its integration into the healthcare system. Here, we describe the clinical implementation of the A3E framework for the deployment of telerehabilitation in the inpatient and outpatient rehabilitation continuum by addressing accessibility, adaptability, accountability, and engagement during the COVID-19 pandemic. By using an organized, coordinated, and stratified approach, we increased our telerehabilitation practice from 0 to more than 39,000 visits since the pandemic began. Learning from both the successes and challenges can help address the need to increase access to rehabilitation services even beyond the COVID-19 pandemic.
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12
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Wiebert E, Berglund A, Sjöstrand C, Eriksson EE, Mazya MV. Sex Equitable Prehospital Stroke Triage Using Symptom Severity and Teleconsultation. Front Neurol 2021; 12:765296. [PMID: 34912286 PMCID: PMC8667028 DOI: 10.3389/fneur.2021.765296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/28/2021] [Indexed: 11/25/2022] Open
Abstract
Objectives: We aimed to determine whether there are sex differences in prehospital accuracy of the Stockholm Stroke Triage System (SSTS) to predict large artery occlusion (LAO) stroke, and endovascular thrombectomy (EVT), and whether clinical characteristics differ between men and women undergoing “code stroke” ambulance transport. Materials and Methods: This prospective observational study collected data between October 2017 and October 2018. We included 2,905 patients, transported as “code stroke,” by nurse-staffed ground ambulance, to a Stockholm Region hospital. Exclusion criteria were private or helicopter transport, onset outside Stockholm, and in-hospital stroke. We compared overall accuracy, sensitivity, specificity, positive and negative predictive values, and clinical characteristics between sexes. Results: No significant sex differences in SSTS predictive performance for LAO or EVT were found, overall accuracy for LAO 87.3% in women vs. 86.7% in men. Women were median 4 years older and more frequently had stroke mimics (46.2 vs. 41.8%). Women more commonly had decreased level of consciousness (14.0 vs. 10.2%) and moderate-to-severe motor symptoms (by 2.7–3.8 percentage points), and less commonly limb ataxia (7.2 vs. 9.7%). Conclusions: The SSTS had equal predictive performance for LAO and EVT among men and women, despite minor sex differences in the clinical characteristics in patients undergoing ambulance transport for suspected stroke.
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Affiliation(s)
- Elin Wiebert
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Annika Berglund
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Christina Sjöstrand
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Danderyd Hospital, Stockholm, Sweden
| | - Einar E Eriksson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Michael V Mazya
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
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