Rural versus urban academic hospital mortality following stroke in Canada

Risk of major adverse cardiovascular events in rural vs urban settings among patients with erectile dysfunction: a propensity-weighted retrospective cohort study of 430 621 men

BACKGROUND

The relationship between erectile dysfunction (ED) and cardiovascular (CV) events has been postulated, with ED being characterized as a potential harbinger of CV disease. Location of residence is another important consideration, as the impact of rural residence has been associated with worse health outcomes.

AIM

To investigate whether men from rural settings with ED are associated with a higher risk of major adverse CV events (MACEs).

METHODS

A propensity-weighted retrospective cohort study was conducted with provincial health administrative databases. ED was defined as having at least 2 ED prescriptions filled within 1 year. MACE was defined as the first hospitalization for an episode of acute myocardial infarction, heart failure, or stroke that resulted in a hospital visit >24 hours. We classified study groups into ED urban, ED rural, no ED urban, and no ED rural. A multiple logistic regression model was used to determine the propensity score. Stabilized inverse propensity treatment weighting was then applied to the propensity score.

OUTCOMES

A Cox proportional hazard model was used to examine our primary outcome of time to a MACE.

RESULTS

The median time to a MACE was 2731, 2635, 2441, and 2508 days for ED urban (n = 32 341), ED rural (n = 18 025), no ED rural (n = 146 358), and no ED urban (n = 233 897), respectively. The cohort with ED had a higher proportion of a MACE at 8.94% (n = 4503), as opposed to 4.58% (n = 17 416) for the group without ED. As compared with no ED urban, no ED rural was associated with higher risks of a MACE in stabilized time-varying comodels based on inverse probability treatment weighting (hazard ratio, 1.06-1.08). ED rural was associated with significantly higher risks of a MACE vs no ED rural, with the strength of the effect estimates increasing over time (hazard ratio, 1.10-1.74).

CLINICAL IMPLICATIONS

Findings highlight the need for physicians treating patients with ED to address CV risk factors for primary and secondary prevention of CV diseases.

STRENGTHS AND LIMITATIONS

This is the most extensive retrospective study demonstrating that ED is an independent risk factor for MACE. Due to limitations in data, we were unable to assess certain comorbidities, including obesity and smoking.

CONCLUSIONS

Our study confirms that ED is an independent risk factor for MACE. Rural men had a higher risk of MACE, with an even higher risk among those who reside rurally and are diagnosed with ED.

Through the big top: An exploratory study of circus-based artistic knowledge translation in rural healthcare services, Québec, Canada

BACKGROUND

The conventional methods and strategies used for knowledge translation (KT) in academic research often fall short in effectively reaching stakeholders, such as citizens, practitioners, and decision makers, especially concerning complex healthcare issues. In response, a growing number of scholars have been embracing arts-based knowledge translation (ABKT) to target a more diverse audience with varying backgrounds and expectations. Despite the increased interest, utilization, and literature on arts-based knowledge translation over the past three decades, no studies have directly compared traditional knowledge translation with arts-based knowledge translation methods. Thus, our study aimed to evaluate and compare the impact of an arts-based knowledge translation intervention-a circus show-with two traditional knowledge translation interventions (webinar and research report) in terms of awareness, accessibility, engagement, advocacy/policy influence, and enjoyment.

METHODS

To conduct this exploratory convergent mixed method study, we randomly assigned 162 participants to one of the three interventions. All three knowledge translation methods were used to translate the same research project: "Rural Emergency 360: Mobilization of decision-makers, healthcare professionals, patients, and citizens to improve healthcare and services in Quebec's rural emergency departments (UR360)."

RESULTS

The findings revealed that the circus show outperformed the webinar and research report in terms of accessibility and enjoyment, while being equally effective in raising awareness, increasing engagement, and influencing advocacy/policy. Each intervention strategy demonstrates its unique array of strengths and weaknesses, with the circus show catering to a diverse audience, while the webinar and research report target more informed participants. These outcomes underscore the innovative and inclusive attributes of Arts-Based Knowledge translation, showcasing its capacity to facilitate researchers' engagement with a wider array of stakeholders across diverse contexts.

CONCLUSION

As a relevant first step and a complementary asset, arts-based knowledge translation holds immense potential in increasing awareness and mobilization around crucial health issues.

Computer-aided diagnosis of chest X-ray for COVID-19 diagnosis in external validation study by radiologists with and without deep learning system

To evaluate the diagnostic performance of our deep learning (DL) model of COVID-19 and investigate whether the diagnostic performance of radiologists was improved by referring to our model. Our datasets contained chest X-rays (CXRs) for the following three categories: normal (NORMAL), non-COVID-19 pneumonia (PNEUMONIA), and COVID-19 pneumonia (COVID). We used two public datasets and private dataset collected from eight hospitals for the development and external validation of our DL model (26,393 CXRs). Eight radiologists performed two reading sessions: one session was performed with reference to CXRs only, and the other was performed with reference to both CXRs and the results of the DL model. The evaluation metrics for the reading session were accuracy, sensitivity, specificity, and area under the curve (AUC). The accuracy of our DL model was 0.733, and that of the eight radiologists without DL was 0.696 ± 0.031. There was a significant difference in AUC between the radiologists with and without DL for COVID versus NORMAL or PNEUMONIA (p = 0.0038). Our DL model alone showed better diagnostic performance than that of most radiologists. In addition, our model significantly improved the diagnostic performance of radiologists for COVID versus NORMAL or PNEUMONIA.

An Age-Stratified Cross-Sectional Study of Physical Activity and Exercise Adherence of Stroke Survivors in Rural Regions

Objective

To describe the Physical Activity and Exercise (PAE) adherence of stroke survivors in rural regions, additionally, to analyze the influential factors through age stratification.

Methods

This is a cross-sectional study. Totally, 596 stroke patients (65.70±10.76 years) from three rural regions were selected, PAE scale was used for measuring compliance. The influential factors among different age groups were explored separately. This study adheres to the EQUATOR checklist, SROBE.

Results

Only 17.8% (106) of participants regularly participated in PAE. Altogether, 42.45% were classified as a young-middle age group, and the rest 57.55% were in the old age group. Positive attitudes and better PAE-relevant knowledge were protective factors for adherence in the young and middle-aged group (OR=0.683; 95% CI 0.173~0.588 and OR=0.939; 95% CI 0.013~0.114), as well as in the old group (OR=0.704; 95% CI 0.193~0.534 and OR=0.929; 95% CI 0.035~0.118); having no home rehabilitation equipment was a strong risk factor for younger patients (OR=16.078; 95% CI 1.235~4.320); however, without hemiplegia can positively affect their adherence (OR=0.891; 95% CI 0.045~0.229). In addition, the presence of a spouse can lead to a better compliance among old patients (OR=0.436; 95% CI -0.496~-0.165).

Conclusion

It is necessary to improve the knowledge of physical activity in rural stroke patients of all ages. It is of great significance to install home rehabilitation equipment to promote exercise for young and middle-aged stroke patients. While for the old stroke patients, we strongly suggest focusing on the role of spouses, which would be more useful in low-income regions.

Relationship between perceptions of recurrence risk and depression state among first-episode ischemic stroke patients in rural areas: The mediating role of coping style

AIMS

To investigate the relationship between stroke survivors' perceptions of recurrence risk, coping styles and depression state, and the role coping styles play in mediating that relationship.

DESIGN

A cross-sectional descriptive study.

METHODS

From one hospital in Huaxian, China, 320 stroke survivors were randomly selected as a convenience sample. In this research, the Simplified Coping Style Questionnaire, the Patient Health Questionnaire-9 and the Stroke Recurrence Risk Perception Scale were all used. Structural equation modelling and correlation analysis were used to analyse the data. This research followed the EQUATOR and STROBE checklists.

RESULTS

There were 278 valid survey responses. There were mild to severe depressive symptoms in 84.8% of stroke survivors. In stroke survivors, there was a significant negative relationship (p < 0.01) between the positive coping of perceptions of recurrence risk and their depression state. Recurrence risk perception's impact on depression state was partly mediated, according to mediation studies, by coping style, with the mediation effect accounting for 44.92% of the overall effect.

CONCLUSIONS

The connection between perceptions of recurrence risk and depression state was mediated by the coping mechanisms of stroke survivors. A lower degree of depression state among survivors was connected with positive coping to the beliefs of recurrence risk.

Predicting DWI-FLAIR mismatch on NCCT: the role of artificial intelligence in hyperacute decision making

Background

The presence of diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) mismatch was used to determine eligibility for intravenous thrombolysis in clinical trials. However, due to the restricted availability of MRI and the ambiguity of image assessment, it is not widely implemented in clinical practice.

Methods

A total of 222 acute ischemic stroke patients underwent non-contrast computed tomography (NCCT), DWI, and FLAIR within 1 h of one another. Human experts manually segmented ischemic lesions on DWI and FLAIR images and independently graded the presence of DWI-FLAIR mismatch. Deep learning (DL) models based on the nnU-net architecture were developed to predict ischemic lesions visible on DWI and FLAIR images using NCCT images. Inexperienced neurologists evaluated the DWI-FLAIR mismatch on NCCT images without and with the model's results.

Results

The mean age of included subjects was 71.8 ± 12.8  years, 123 (55%) were male, and the baseline NIHSS score was a median of 11 [IQR, 6-18]. All images were taken in the following order: NCCT - DWI - FLAIR, starting after a median of 139 [81-326] min after the time of the last known well. Intravenous thrombolysis was administered in 120 patients (54%) after NCCT. The DL model's prediction on NCCT images revealed a Dice coefficient and volume correlation of 39.1% and 0.76 for DWI lesions and 18.9% and 0.61 for FLAIR lesions. In the subgroup with 15  mL or greater lesion volume, the evaluation of DWI-FLAIR mismatch from NCCT by inexperienced neurologists improved in accuracy (from 0.537 to 0.610) and AUC-ROC (from 0.493 to 0.613).

Conclusion

The DWI-FLAIR mismatch may be reckoned using NCCT images through advanced artificial intelligence techniques.

A critical analysis of Discovery Health's claims-based risk adjustment of mortality rates in South African private sector hospitals

In 2019, Discovery Health published a risk adjustment model to determine standardised mortality rates across South African private hospital systems, with the aim of contributing towards quality improvement in the private healthcare sector. However, the model suffers from limitations due to its design and its reliance on administrative data. The publication's aim of facilitating transparency is unfortunately undermined by shortcomings in reporting. When designing a risk prediction model, patient-proximate variables with a sound theoretical or proven association with the outcome of interest should be used. The addition of key condition-specific clinical data points at the time of hospital admission will dramatically improve model performance. Performance could be further improved by using summary risk prediction scores such as the EUROSCORE II for coronary artery bypass graft surgery or the GRACE risk score for acute coronary syndrome. In general, model reporting should conform to published reporting standards, and attempts should be made to test model validity by using sensitivity analyses. In particular, the limitations of machine learning prediction models should be understood, and these models should be appropriately developed, evaluated and reported.

Evaluating delays for emergent CT scans from a rural British Columbia hospital

OBJECTIVES

Computed Tomography (CT) scans help diagnose and triage life-threatening and time-sensitive emergency conditions, but most rural hospitals in British Columbia do not have access to a local CT scanner. We investigate how many transfers from a rural British Columbia hospital were for CT scans and describe the time delays to emergent CT imaging.

METHODS

This was a prospective cohort study, over a 1-year period, on all patients requiring a transfer from the Golden and District Hospital, located 247 km from the closest CT scanner. Data collection forms were completed prospectively and the main measurements included age, transport triage level, reason for transfer, referral hospital, transfer request time, and CT scan time. The time interval between the CT request and CT imaging was calculated and represents the 'delay to CT scan' interval.

RESULTS

The study hospital received 8672 emergency department (ED) visits and 220 were transferred to referral centres (2.5%). 61% of all transfers received a CT scan. Transfers for time-sensitive emergencies took an average of 6 h 52 min. Patients with acute stroke experienced a 4 h 44 min time interval. Less urgent and non-urgent conditions entailed an even greater time delay.

CONCLUSIONS

This study highlights that the lack of a rural CT scanner is associated with increased transfers and significant time delays. Improving access to CT scanners for rural communities may be one of the many steps in addressing healthcare disparities between rural and urban communities.

Geographic Access to Stroke Care Services in Rural Communities in Ontario, Canada

BACKGROUND

Optimal stroke care requires access to resources such as neuroimaging, acute revascularization, rehabilitation, and stroke prevention services, which may not be available in rural areas. We aimed to determine geographic access to stroke care for residents of rural communities in the province of Ontario, Canada.

METHODS

We used the Ontario Road Network File database linked with the 2016 Ontario Acute Stroke Care Resource Inventory to estimate the proportion of people in rural communities, defined as those with a population size <10,000, who were within 30, 60, and 240 minutes of travel time by car from stroke care services, including brain imaging, thrombolysis treatment centers, stroke units, stroke prevention clinics, inpatient rehabilitation facilities, and endovascular treatment centers.

RESULTS

Of the 1,496,262 people residing in rural communities, the majority resided within 60 minutes of driving time to a center with computed tomography (85%), thrombolysis (81%), a stroke unit (68%), a stroke prevention clinic (74%), or inpatient rehabilitation (77.0%), but a much lower proportion (32%) were within 60 minutes of driving time to a center capable of providing endovascular thrombectomy (EVT).

CONCLUSIONS

Most rural Ontario residents have appropriate geographic access to stroke services, with the exception of EVT. This information may be useful for jurisdictions seeking to optimize the regional organization of stroke care services.

Regional differences in the care and outcomes of acute stroke patients in Australia: an observational study using evidence from the Australian Stroke Clinical Registry (AuSCR)

OBJECTIVE

To compare the processes and outcomes of care in patients who had a stroke treated in urban versus rural hospitals in Australia.

DESIGN

Observational study using data from a multicentre national registry.

SETTING

Data from 50 acute care hospitals in Australia (25 urban, 25 rural) which participated in the Australian Stroke Clinical Registry during the period 2010-2015.

PARTICIPANTS

Patients were divided into two groups (urban, rural) according to the Australian Standard Geographical Classification Remoteness Area classification. Data pertaining to 28 115 patients who had a stroke were analysed, of whom 8159 (29%) were admitted to hospitals located within rural areas.

PRIMARY AND SECONDARY OUTCOME MEASURES

Regional differences in processes of care (admission to a stroke unit, thrombolysis for ischaemic stroke, discharge on antihypertensive medication and provision of a care plan), and survival analyses up to 180 days and health-related quality of life at 90-180 days.

RESULTS

Compared with those admitted to urban hospitals, patients in rural hospitals less often received thrombolysis (urban 12.7% vs rural 7.5%, p<0.001) or received treatment in stroke units (urban 82.2% vs rural 76.5%, p<0.001), and fewer were discharged with a care plan (urban 61.3% vs rural 44.7%, p<0.001). No significant differences were found in terms of survival or overall self-reported quality of life.

CONCLUSIONS

Rural access to recommended components of acute stroke care was comparatively poorer; however, this did not appear to impact health outcomes at approximately 6 months.

Access to Endovascular Thrombectomy for Stroke in Rural Versus Urban Regions

PURPOSE

Endovascular thrombectomy (EVT) significantly improves outcomes for acute ischemic stroke patients with large vessel occlusion (LVO) who present in a time sensitive manner. Prolonged EVT access times may reduce benefits for eligible patients. We evaluated the efficiency of EVT services including EVT rates, onset-to-CTA time and onset-to-groin puncture time in our province.

MATERIALS AND METHODS

Three areas were defined: zone I- urban region, zone II-areas within 1 h drive distance from the Comprehensive Stroke Center (CSC); and zone III-areas more than 1hr drive distance from the CSC. In this retrospective cohort study, EVT rate, onset-to-groin puncture time and onset-to-CTA time were compared among the three groups using Krustal-Wallis and Wilcoxon tests.

RESULTS

The EVT rate per 100,000 inhabitants for urban zone I was 8.6 as compared to 5.1 in zone II, and 7.5 in zone III. Compared to zone I (114 min; 95% CI (96, 132); n = 128), mean onset-to-CTA time was 19 min longer in zone II (133 min; 95% CI (77, 189); n = 23; p = 0.0459) and 103 min longer in zone III (217 min, 95% CI (162, 272); n = 44; p < 0.0001). Compared to zone I (209 min, 95% CI (181, 238)), mean onset-to-groin puncture time was 22 min longer in zone II (231 min, 95% CI (174, 288); p = 0.046) but 163 min longer in zone III (372 min, 95% CI (312, 432); p < 0.0001).

CONCLUSION

EVT access in rural areas is considerably reduced with significantly longer onset-to-groin puncture times and onset-to-CTA times when compared to our urban area. This may help in modifying the patient transfer policy for EVT referral.

Impact of telemedicine on diagnosis, clinical management and outcomes in rural trauma patients: A rapid review

Introduction

Rural trauma patients are at increased risk of morbidity and mortality compared to trauma patients treated in urban facilities. Factors contributing to this disparity include differences in resource availability and increased time to definitive treatment for rural patients. Telemedicine can improve the early management of these patients by enabling rural providers to consult with trauma specialists at urban centres. The purpose of this study was to assess the impact of telemedicine utilisation on the diagnosis, clinical management and outcomes of rural trauma patients.

Materials and Methods

A rapid review of the literature was performed using the concepts 'trauma', 'rural' and 'telemedicine'. Fifteen electronic databases were searched from inception to 29^th June 2018. Manual searches were also conducted in relevant systematic reviews, key journals and bibliographies of included studies.

Results

The literature search identified 187 articles, of which 8 articles were included in the review. All 8 studies reported on clinical management, while the impact of telemedicine use on diagnosis and outcomes was reported in 4 and 5 studies, respectively. Study findings suggest that the use of telemedicine may improve patient diagnosis, streamline the process of transferring patients and reduce length of stay. Use of telemedicine had minimal impact on mortality and complications in rural trauma patients.

Conclusions

The evidence identified by this rapid review suggests that telemedicine may improve the diagnosis, management and outcomes of rural trauma patients. Further research is required to validate these findings by performing large and well-designed studies in rural areas, ideally as randomised clinical trials.

Trends in hospital standardized mortality ratios for stroke in Japan between 2012 and 2016: a retrospective observational study

OBJECTIVE

Stroke is one of the leading causes of death and disability, and imposes a major healthcare burden. The aim of this study was to determine the characteristics of hospital standardized mortality ratios (HSMRs) for stroke in Japan for the year 2012-16 to describe the trend.

DESIGN

Retrospective observational study.

SETTING

Data from the Japanese administrative database.

PARTICIPANTS

All hospital admissions for stroke were identified from diagnostic procedures combination (DPC) database from 2012 to 2016.

MAIN OUTCOME MEASURES

HSMR was calculated using the actual number of in-hospital deaths and expected deaths. To obtain the expected death number, a logistic regression model was developed to get the coefficient with a number of explanatory variables. Predictive accuracy of the logistic models was assessed using c-index and calibration was evaluated using the Hosmer-Lemeshow test.

RESULTS

A total of 63 084 patients admitted for stroke from January 2012 to December 2016 were analyzed. HSMRs showed declining tendency over these 5 years, suggesting stroke-related mortality has been improving. While the HSMRs varied from year to year, a wide variation was also seen among the different hospitals in Japan. The proportion of hospitals with HSMR less than 100 increased from 41.0% in 2012 to 59.0% in 2016.

CONCLUSION

This study demonstrated that HSMR can be calculated using DPC data and found wide variation in HSMR of stroke among hospitals in Japan and enabled us to image the trend. By examining these trends, facilities, authorities and provinces can initiate designs that will ultimately lead to an upgraded healthcare delivery system.

Comparison between urban and rural mortality in patients with acute myocardial infarction: a nationwide longitudinal cohort study in South Korea

OBJECTIVES

This study investigated the risk associated with interhospital transfer of patients with acute myocardial infarction (AMI) and clinical outcomes according to the location of the patient' residence.

DESIGN

A nationwide longitudinal cohort.

SETTING

National Health Insurance Service database of South Korea.

PARTICIPANTS

This study included 69 899 patients with AMI who visited an emergency centre from 2013 to 2015, as per the Korea National Health Insurance Service database.

PRIMARY OUTCOME MEASURE

The clinical outcome of a patient with AMI was defined as mortality within 7 days, 30 days and 1 year.

RESULTS

Clinical outcomes were analysed and compared with respect to the location of the patient's residence and occurrence of interhospital transfer. We concluded that the HR of mortality within 7 days was 1.49 times higher (95% CI 1.18 to 1.87) in rural patients than in urban patients not subjected to interhospital transfer and 1.90 times higher (95% CI 1.13 to 3.19) in transferred rural patients than in non-transferred urban patients.

CONCLUSIONS

To reduce health inequality in rural areas, a healthcare policy considering regional characteristics, rather than a central government-led, catch-all approach to healthcare policy, must be formulated. Additionally, a local medical emergency delivery system, based on allocation of roles between different medical facilities in the region, must be established.

Potentially avoidable inter-facility transfer from Veterans Health Administration emergency departments: A cohort study

BACKGROUND

Inter-facility transfer is an important strategy for improving access to specialized health services, but transfers are complicated by over-triage, under-triage, travel burdens, and costs. The purpose of this study is to describe ED-based inter-facility transfer practices within the Veterans Health Administration (VHA) and to estimate the proportion of potentially avoidable transfers.

METHODS

This observational cohort study included all patients treated in VHA EDs between 2012 and 2014 who were transferred to another VHA hospital. Potentially avoidable transfers were defined as patients who were either discharged from the receiving ED or admitted to the receiving hospital for ≤1 day without having an invasive procedure performed. We conducted facility- and diagnosis-level analyses to identify subgroups of patients for whom potentially avoidable transfers had increased prevalence.

RESULTS

Of 6,173,189 ED visits during the 3-year study period, 18,852 (0.3%) were transferred from one VHA ED to another VHA facility. Rural residents were transferred three times as often as urban residents (0.6% vs. 0.2%, p < 0.001), and 22.8% of all VHA-to-VHA transfers were potentially avoidable transfers. The 3 disease categories most commonly associated with inter-facility transfer were mental health (34%), cardiac (12%), and digestive diagnoses (9%).

CONCLUSIONS

VHA inter-facility transfer is commonly performed for mental health and cardiac evaluation, particularly for patients in rural settings. The proportion that are potentially avoidable is small. Future work should focus on improving capabilities to provide specialty evaluation locally for these conditions, possibly using telehealth solutions.

A Canadian Rural Living Lab Hospital: Implementing solutions for improving rural emergency care

INTRODUCTION

More than 6 million Canadians live in rural areas (approximately 20% of the population) and emergency services are a critical safety net for them.

OBJECTIVES

We want to create, in Baie-Saint-Paul (rural emergency department, Québec, Canada), an experimental milieu where all stakeholders develop, implement and evaluate solutions to address the problems that beset their environment.

METHOD

The Living Lab will rely on the quadruple aim approach to improve health system performance and will use a multimethod approach based on the philosophy of open and user-driven innovation. Three pilot projects will be implemented (quality of work life programme, computed tomography implementation study and telemedicine in ambulances). Other possible solutions will be evaluated and prioritised (in situ simulation, care protocol, telemedicine, point-of-care ultrasound, helicopters and drones).

CONCLUSION

We are confident that this Living Lab will contribute to saving lives, will improve the quality of work life for rural healthcare professionals, and will inspire similar innovation internationally.

Case-Control Study of Endovascular Thrombectomy in a Canadian Stroke Center

BACKGROUND

Although the efficacy of endovascular thrombectomy (EVT) for acute ischemic stroke caused by intracranial anterior circulation large vessel occlusion (LVO) is proven, demonstration of local effectiveness is critical for health system planning and resource allocation because of the complexity and cost of this treatment.

METHODS

Using our prospective registry, we identified all patients who underwent EVT for out-of-hospital LVO stroke from February 1, 2013 through January 31, 2017 (n = 44), and matched them 1:1 in a hierarchical fashion with control patients not treated with EVT based on age (±5 years), prehospital functional status, stroke syndrome, severity, and thrombolysis administration. Demographics, in-hospital mortality, discharge disposition from acute care, length of hospitalization, and functional status at discharge from acute care and at follow-up were compared between cases and controls.

RESULTS

For EVT-treated patients (median age 66, 50% women), the median onset-to-recanalization interval was 247 min, and successful recanalization was achieved in 30/44 (91%). Alteplase was administered in 75% of cases and 57% of controls (p = 0.07). In-hospital mortality was 11% among the cases and 36% in the control group (p = 0.006); this survival benefit persisted during follow-up (p = 0.014). More EVT patients were discharged home from acute care (50% vs. 18%, p = 0.002). Among survivors, there were nonsignificant trends in favor of EVT for median length of hospitalization (14 vs. 41 days, p = 0.11) and functional independence at follow-up (51% vs. 32%, p = 0.079).

CONCLUSION

EVT improved survival and decreased disability. This demonstration of single-center effectiveness may help facilitate expansion of EVT services in similar health-care jurisdictions.

Canadian in-hospital mortality for patients with emergency-sensitive conditions: a retrospective cohort study

Background

The emergency department (ED) sensitive hospital standardized mortality ratio (ED-HSMR) measures risk-adjusted mortality for patients admitted to hospital with conditions for which ED care may improve health outcomes. This study aimed to describe in-hospital mortality across Canadian provinces using the ED-HSMR.

Methods

Hospital discharge data were analyzed from April 2009 to March 2012. The ED-HSMR was calculated as the ratio of observed deaths among patients with emergency-sensitive conditions in a hospital during a year (2010–11 or 2011–12) to the expected deaths for the same patients during the reference year (2009–10), multiplied by 100. The expected deaths were estimated using predictive models fitted from the reference year. Aggregated provincial ED-HSMR values were calculated. A HSMR value above or below 100 respectively means that more or fewer deaths than expected occurred within a province.

Results

During the study period, 1,335,379 patients were admitted to hospital in Canada with an emergency-sensitive condition as the most responsible diagnosis. More in-hospital deaths (95% confidence interval) than expected were respectively observed for the years 2010–11 and 2011–12 in Newfoundland [124.3 (116.3–132.6); & 117.6 (110.1–125.5)] and Nova Scotia [116.4 (110.7–122.5) & 108.7 (103.0–114.5)], while mortality was as expected in Prince Edward Island [99.9 (86.5–114.8) & 100.7 (87.5–115.3)] and Manitoba [99.2 (94.5–104.1) & 98.3 (93.5–103.3)], and less than expected in all other provinces and territories.

Conclusions

Our study revealed important variation in risk-adjusted mortality for patients admitted to hospital with emergency-sensitive conditions among Canadian provinces. The ED-HSMR may be a useful outcome indicator to complement existing process indicators in measuring ED performance.

Trial registration

N/A – Retrospective cohort study.

Urban-rural differences in the care and outcomes of acute stroke patients: Systematic review

OBJECTIVE

To describe literature pertaining to urban-rural differences in both the quality of care and outcomes of acute stroke patients.

METHODS

We systematically searched CINAHL, PubMed, ProQuest Dissertations & Theses, and Scopus for published and unpublished literature until 9th December 2017. Studies were included if they compared the acute care provided to, or outcomes of, patients hospitalised for stroke in urban versus rural settings. Abstract, full-text review, and data extraction were conducted in duplicate. Findings are presented in the form of narrative syntheses.

RESULTS

A total of 28 studies were included in the review (16 on care, 12 on outcomes). With few exceptions, studies addressing the provision of care suggested that rural patients have less access to most aspects of acute stroke care. Studies reporting urban-rural differences in patient outcomes were inconsistent in their findings, however, few of these studies were primarily focused on the issue of urban-rural disparities. Overall, study findings did not appear to differ in line with study quality ratings, stroke subtypes included, or how inter-facility patient transfers were accounted for.

CONCLUSIONS

There is convincing, albeit not unanimous, evidence to suggest that stroke patients in rural areas receive less acute care than their urban counterparts. Despite this, the available data and methodology have largely not been used to study urban-rural differences in patient outcomes. PROSPERO registration information: URL: https://www.crd.york.ac.uk/prospero. Unique identifier: CRD42017073262.