Black Americans have worse stroke outcome compared with non-Hispanic whites

INTRODUCTION

We studied racial differences in post-stroke outcomes using a prospective, population-based cohort of stroke survivors as part of the Brain Attack Surveillance in Corpus Christi (BASIC) project.

METHODS

Neurologic (NIHSS, range of 0-42, higher scores are worse), functional (ADLs/IADLs, range 1-4, higher scores are worse), and cognitive (3MSE, range 0-100, higher scores are better) outcomes were measured 90 days after stroke. Cox proportional hazards and negative binomial linear regression models were used to examine the associations between race and 90-day all-cause mortality and NIHSS, respectively, whereas linear regression was used for ADLs/IADLs and 3MSE scores. Covariates included demographics, initial NIHSS, comorbidities, prior stroke history, tPA treatment status, pre-stroke disability, and pre-stroke cognition. The mortality model was also adjusted for DNR status.

RESULTS

At 90 days post-stroke, Black American individuals (BAs) (n = 122) had a median (IQR) NIHSS of 2 (1,6) compared to NIHSS of 1 (0,3) in non-Hispanic White American individuals (NHWs) (n = 795). BAs had a median (IQR) ADL/IADL score of 2.41 (1.50, 3.39) compared to 2.00 (1.27, 2.95) in NHWs. BAs scored a median of 84 (75, 92) on the 3MSE compared to NHWs' score of 91.5 (83, 96). Death occurred in 23 (8%) of BAs and 268 (15%) of NHWs within 90 days among those who participated in baseline. After adjustment for covariates, functional outcomes at 90 days were worse in BAs compared to NHWs, with 15.8% (95% CI=5.2, 26.4) greater limitations in ADLs/IADLs and 43.9% (95% CI=12.0, 84.9) greater severity of stroke symptoms. Cognition at 90 days was 6.5% (95% CI=2.4, 10.6) lower in BAs compared to NHWs. BAs had a 35.4% lower (95% CI=-9.8, 61.9) hazard rate of mortality than NHWs.

CONCLUSIONS

In this prospective, population-based community sample, BAs had worse neurologic, functional and cognitive outcomes at 90 days compared to NHWs. Future research should investigate how social determinants of health including structural racism, neighborhood factors and access to preventive and recovery services influences these racial disparities.

Trends in Stroke Recurrence in Mexican Americans and Non-Hispanic Whites

BACKGROUND AND PURPOSE

Stroke incidence and mortality are declining rapidly in developed countries. Little data on ethnic-specific stroke recurrence trends exist. Fourteen-year stroke recurrence trend estimates were evaluated in Mexican Americans and non-Hispanic whites in a population-based study.

METHODS

Recurrent stroke was ascertained prospectively in the population-based BASIC (Brain Attack Surveillance in Corpus Christi) project in Texas, between 2000 and 2013. Incident cases were followed forward to determine 1- and 2-year recurrence. Fine & Gray subdistribution hazard models were used to estimate adjusted trends in the absolute recurrence risk and ethnic differences in the secular trends. The ethnic difference in the secular trend was examined using an interaction term between index year and ethnicity in the models adjusted for age, sex, hypertension, diabetes mellitus, smoking, atrial fibrillation, insurance, and cholesterol and relevant interaction terms.

RESULTS

From January 1, 2000 to December 31, 2013 (N=3571), the cumulative incidence of 1-year recurrence in Mexican Americans decreased from 9.26% (95% CI, 6.9%-12.43%) in 2000 to 3.42% (95% CI, 2.25%-5.21%) in 2013. Among non-Hispanic whites, the cumulative incidence of 1-year recurrence in non-Hispanic whites decreased from 5.67% (95% CI, 3.74%-8.62%) in 2000 to 3.59% (95% CI, 2.27%-5.68%) in 2013. The significant ethnic disparity in stroke recurrence existed in 2000 (risk difference, 3.59% [95% CI, 0.94%-6.22%]) but was no longer seen by 2013 (risk difference, -0.17% [95% CI, -1.96% to 1.5%]). The competing 1-year mortality risk was stable over time among Mexican Americans, while for non-Hispanic whites it was decreasing over time (difference between 2000 and 2013: -4.67% [95% CI, -8.72% to -0.75%]).

CONCLUSIONS

Mexican Americans had significant reductions in stroke recurrence despite a stable death rate, a promising indicator. The ethnic disparity in stroke recurrence present early in the study was gone by 2013.

Abstract WP282: Use of Emergent Ambulance Transport With Lights and Siren Leads to Significant Time Savings for Inter-Facility Transfers of Patients With Large Vessel Occlusion

Introduction: When emergency medical services (EMS) responds to a field call for a patient experiencing stroke symptoms, the response is emergent, necessitating the use of lights and siren (L&S) to allow for expedited transport to a stroke-capable center. With the expanded use of endovascular therapy (EVT) for large-vessel occlusion (LVO), many stroke-capable centers are transferring larger numbers of LVO patients to EVT-capable centers for definitive care. Interestingly, many EMS systems do not respond to or transport inter-facility transfers emergently with L&S. This can potentially lead to delays in care and worse clinical outcomes. Given increased scrutiny surrounding the safety and utility of L&S transport among EMS providers, we investigated the difference between emergent and non-emergent transfer of confirmed LVO stroke patients from two institutions with varied distances and traffic patterns.

Methods: A retrospective analysis was performed of 127 consecutive inter-facility transfers for LVO from two facilities, Hospital A (38.5 miles) and Hospital B (5.5 miles), to the University of Michigan Comprehensive Stroke Center over 3 years and 2 years respectively. Transfers by helicopter (17/127; 13.4%) and those without available EMS data (9/127; 7.1%) were excluded. Final review included 50 cases from Hospital A and 51 from Hospital B. Run times and use of L&S during transport were collected. A t-test was used to examine whether the observed differences in transport times were statistically significant.

Results: Of the 50 transfers from Hospital A, 22 were transported without L&S use and 28 with L&S. The mean transport time was 44 minutes versus 35 minutes, respectively. From Hospital B, there were 14 transfers transported without L&S use and 37 with L&S. The mean transport time was 15 minutes versus 9 minutes, respectively. For both samples, p-value was <0.01.

Conclusion: Despite a small sample size, this analysis demonstrates significant time savings using L&S during inter-facility transfer of stroke patients with confirmed LVO. While inherent risk is associated with the use of L&S during EMS transport, judicious use for confirmed time-sensitive indications seems warranted.

National Institutes of Health StrokeNet Training Core

Background and Purpose- The National Institutes of Health (NIH) StrokeNet provides a nationwide infrastructure to advance stroke research. Capitalizing on this unique opportunity, the NIH StrokeNet Training Core (NSTC) was established with the overarching goal of enhancing the professional development of a diverse spectrum of professionals who are embedded in the stroke clinical trials network of the NIH StrokeNet. Methods- This special report provides a descriptive account of the rationale, organization, and activities of the NSTC since its inception in 2013. Current processes and their evolution over time for facilitating training of NIH StrokeNet trainees have been highlighted. Data collected for monitoring training are summarized. Outcomes data (publications and grants) collected by NSTC was supplemented by publicly available resources. Results- The NSTC comprises of cross-network faculty, trainees, and education coordinators. It helps in the development and monitoring of training programs and organizes educational and career development activities. Trainees are provided directed guidance towards their mandated research projects, including opportunities to present at the International Stroke Conference. The committee has focused on developing sustainable models of peer-to-peer interaction and cross-institutional mentorships. A total of 124 professionals (43.7% female, 10.5% underrepresented minorities) have completed training between 2013 and 2018, of whom 55% were clinical vascular neurologists. Of the total, 85% transitioned to a formal academic position and 95% were involved in stroke research post-training. Altogether, 1659 indexed publications have been authored or co-authored by NIH StrokeNet Trainees, of which 58% were published during or after their training years. Based on data from 109 trainees, 33% had submitted 72 grant proposals as principal or co-principal investigators of which 22.2% proposals have been funded. Conclusions- NSTC has provided a foundation to foster nationwide training in stroke research. Our data demonstrate strong contribution of trainees towards academic scholarship. Continued innovation in educational methodologies is required to adapt to unique training opportunities such as the NIH StrokeNet.

Association of an Emergency Department-Based Intensive Care Unit With Survival and Inpatient Intensive Care Unit Admissions

IMPORTANCE

Increased patient acuity, decreased intensive care unit (ICU) bed availability, and a shortage of intensivist physicians have led to strained ICU capacity. The resulting increase in emergency department (ED) boarding time for patients requiring ICU-level care has been associated with worse outcomes.

OBJECTIVE

To determine the association of a novel ED-based ICU, the Emergency Critical Care Center (EC3), with 30-day mortality and inpatient ICU admission.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used electronic health records of all ED visits between September 1, 2012, and July 31, 2017, with a documented clinician encounter at a large academic medical center in the United States with approximately 75 000 adult ED visits per year. The pre-EC3 cohort included ED patients from September 2, 2012, to February 15, 2015, when the EC3 opened, and the post-EC3 cohort included ED patients from February 16, 2015, to July 31, 2017. Data analyses were conducted from March 2, 2018, to May 28, 2019.

EXPOSURES

Implementation of EC3, an ED-based ICU designed to provide rapid initiation of ICU-level care in the ED setting and seamless transition to inpatient ICUs.

MAIN OUTCOMES AND MEASURES

The main outcomes were 30-day mortality among ED patients and rate of ED to ICU admission.

RESULTS

A total of 349 310 visits from a consecutive sample of ED patients (mean [SD] age, 48.5 [19.7] years; 189 709 [54.3%] women) were examined; the pre-EC3 cohort included 168 877 visits and the post-EC3 cohort included 180 433 visits. Implementation of EC3 was associated with a statistically significant reduction in risk-adjusted 30-day mortality among all ED patients (pre-EC3, 2.13%; post-EC3, 1.83%; adjusted odds ratio, 0.85; 95% CI, 0.80-0.90; number needed to treat, 333 patient encounters; 95% CI, 256-476). The risk-adjusted rate of ED admission to ICU decreased with implementation of EC3 (pre-EC3, 3.2%; post-EC3, 2.7%; adjusted odds ratio, 0.80; 95% CI, 0.76-0.83; number needed to treat, 179 patient encounters; 95% CI, 149-217).

CONCLUSIONS AND RELEVANCE

Implementation of a novel ED-based ICU was associated with improved 30-day survival and reduced inpatient ICU admission. Additional research is warranted to further explore the value of this novel care delivery model in various health care systems.

Sleep apnea screening is uncommon after stroke

OBJECTIVE/BACKGROUND

To assess (1) pre and post-stroke screening for sleep apnea (SA) within a population-based study without an academic medical center, and (2) ethnic differences in post-stroke sleep apnea screening among Mexican Americans (MAs) and non-Hispanic whites (NHWs).

PATIENTS/METHODS

MAs and NHWs with stroke in the Brain Attack Surveillance in Corpus Christi project (2011-2015) were interviewed shortly after stroke about the pre-stroke period, and again at approximately 90 days after stroke in reference to the post-stroke period. Questions included whether any clinical provider directly asked about snoring or daytime sleepiness or had offered polysomnography. Logistic regression tested the association between these outcomes and ethnicity both unadjusted and adjusted for potential confounders.

RESULTS

Among 981 participants, 63% were MA. MAs in comparison to NHWs were younger, had a higher prevalence of hypertension, diabetes, and never smoking, a higher body mass index, and a lower prevalence of atrial fibrillation. Only 17% reported having been offered SA diagnostic testing pre-stroke, without a difference by ethnicity. In the post-stroke period, only 50 (5%) participants reported being directly queried about snoring; 86 (9%) reported being directly queried about sleepiness; and 55 (6%) reported having been offered polysomnography. No ethnic differences were found for these three outcomes, in unadjusted or adjusted analyses.

CONCLUSIONS

Screening for classic symptoms of SA, and formal testing for SA, are rare within the first 90 days after stroke, for both MAs and NHWs. Provider education is needed to raise awareness that SA affects most patients after stroke and is associated with poor outcomes.

Understanding the Struggles to Be a Medical Provider: View Through Medical Student Essays

BACKGROUND

The clinical learning environment helps to shape the professional identity of medical students. This process begins from existing personal identity and is influenced by various factors, including clinical experiences and clinical learning environment.

OBJECTIVE

The purpose of this study was to examine medical students' reflections as a way to identify and better characterize the modern struggles that medical students face, in order to inform the development of professional identity.

METHODS

Students rotating in their emergency medicine clerkship wrote reflections on dilemmas that highlighted common struggles of becoming a doctor. Qualitative analysis was performed to determine common themes from the essays. The research team coded 173 reflections and identified themes and major domains.

RESULTS

The first domain was Patient-Provider Conflict, including challenging patient (34%), difficult communication (25%), competing priorities between patients' interest and trainees need to learn (19%), and bias (13%). The second domain was Provider-Specific Issues, such as the "gray zone," in which there is not a clear standard of practice (29%), end-of-life care (14%), emotional struggle (6%), and fear of litigation (5%). The final domain was Systems Issues, such as cost of care (12%) and role of the emergency department (6%).

CONCLUSIONS

The reflections point to a wide variety of challenges that students confront in practice that will contribute to how they develop into physicians.

Establishing Recommendations for Stroke Systems in the Thrombectomy Era: The Upstate New York Stakeholder Proceedings

Background and Purpose—

The American Heart Association/American Stroke Association and Department of Health Stroke Coverdell Program convened a stakeholder meeting in upstate NY to develop recommendations to enhance stroke systems for acute large vessel occlusion.

Methods—

Prehospital, hospital, and Department of Health leadership were invited (n=157). Participants provided goals/concerns and developed recommendations for prehospital triage and interfacility transport, rating each using a 3-level impact (A [high], B, and C [low]) and implementation feasibility (1 [high], 2, and 3 [low]) scale. Six weeks later, participants finalized recommendations.

Results—

Seventy-one stakeholders (45% of invitees) attended. Six themes around goals/concerns emerged: (1) emergency medical services capacity, (2) validated prehospital screening tools, (3) facility capability, (4) triage/transport guidelines, (5) data capture/feedback tools, and (6) facility competition. In response, high-impact (level A) prehospital recommendations, stratified by implementation feasibility, were (1) use of online medical control for triage (6%); (2) regional transportation strategy (31%), standardized emergency medical services checklists (18%), quality metrics (14%), standardized prehospital screening tools (13%), and feedback for performance improvement (7%); and (3) smartphone application algorithm for screening/decision-making (6%) and ambulance-based telemedicine (6%). Level A interfacility transfer recommendations were (1) standardized transfer process (32%)/timing goals (16%)/regionalized systems (11%), performance metrics (11%), image sharing capabilities (7%); (2) provider education (9%) and stroke toolbox (5%); and (3) interfacility telemedicine (7%) and feedback (2%).

Conclusions—

The methods used and recommendations generated provide models for stroke system enhancement. Implementation may vary based on geographic need/capacity and be contingent on establishing standard care practices. Further research is needed to establish optimal implementation strategies.

Abstract WP308: Impact of Ethnicity on Access to Sleep Apnea Screening and Testing In Stroke Survivors

Introduction: Sleep apnea (SA) following stroke is present in approximately 72% of patients. SA leads to increased stroke risk and is associated with poorer prognosis. Aggressive risk factor modification after stroke is widely accepted, yet evaluation for SA is not routine practice. We hypothesized that fewer Mexican-Americans (MA) are screened for and offered SA testing following stroke than non-Hispanic whites (NHW).

Methods: Between July 2011 and May 2016, MAs and NHWs with ischemic stroke or intracerebral hemorrhage in the Brain Attack Surveillance in Corpus Christi (BASIC) project were asked during a baseline interview (a median 8 days (interquartile range=16) after presentation), if they had reported symptoms of SA to their doctor, had been asked by their doctor about SA symptoms, and if their doctor had offered formal SA testing. Logistic regression was used to test the association between ethnicity and these three outcomes unadjusted and adjusted for potential confounders such as sex, age, insurance status, and BMI.

Results: Of the 1,086 MA and 621 NHW participants, median age was 68 and 49% were women. Two hundred nineteen (20.2%) MAs self-reported symptoms of SA compared with 114 (18.4%) NHW (p=0.36). One hundred forty-seven (13.5%) MAs were asked about symptoms of SA by their doctors compared with 76 (12.2%) NHWs (p=0.44). One hundred ninety-two (17.7%) MAs were offered a SA test compared with 112 (18.0%) NHWs (p=0.86). MA ethnicity was associated with a lower odds of reporting being offered SA testing in the fully adjusted model (odds ratio 0.751 (95% CI: 0.567, 0.995)), but was not associated with the other two outcomes.

Conclusions: Screening for SA in post-stroke patients is poor overall, and worse for MAs. Given the important relationship between SA and stroke, educational interventions are needed to improve provider awareness surrounding SA screening in stroke survivors.

Reporting Achievement of Medical Student Milestones to Residency Program Directors: An Educational Handover

PROBLEM

Competency-based education, including assessment of specialty-specific milestones, has become the dominant medical education paradigm; however, how to determine baseline competency of entering interns is unclear-as is to whom this responsibility falls. Medical schools should take responsibility for providing residency programs with accurate, competency-based assessments of their graduates.

APPROACH

A University of Michigan ad hoc committee developed (spring 2013) a post-Match, milestone-based medical student performance evaluation for seven students matched into emergency medicine (EM) residencies. The committee determined EM milestone levels for each student based on assessments from the EM clerkship, end-of-third-year multistation standardized patient exam, EM boot camp elective, and other medical school data.

OUTCOMES

In this feasibility study, the committee assessed nearly all 23 EM milestones for all seven graduates, shared these performance evaluations with the program director (PD) where each student matched, and subsequently surveyed the PDs regarding this pilot. Of the five responding PDs, none reported using the traditional medical student performance evaluation to customize training, four (80%) indicated that the proposed assessment provided novel information, and 100% answered that the assessment would be useful for all incoming trainees.

NEXT STEPS

An EM milestone-based, post-Match assessment that uses existing assessment data is feasible and may be effective for communicating competency-based information about medical school graduates to receiving residency programs. Next steps include further aligning assessments with competencies, determining the benefit of such an assessment for other specialties, and articulating the national need for an effective educational handover tool between undergraduate and graduate medical education institutions.

Abstract TMP72: Geographic, Demographic and Socioeconomic Analysis of StrokeNet Research Network Population Coverage

Introduction: StrokeNet is an NIH research network to advance research for acute treatment, prevention, and recovery/rehabilitation following stroke.

Hypothesis/Objective: We characterized the adult population with geographic access to a StrokeNet acute care research site and its representativeness of the overall US population.

Methods: Data on research sites was obtained from the StrokeNet National Coordinating Center and geocoded. Ground and air-ambulance data identify transport times of 60, 90 and 120 minutes, corresponding to transport distances of 20, 40 and 65 miles, respectively. Geographic Information System (GIS) software overlaid these radii on thematic maps of StrokeNet adult acute care hospitals, their referral clinics, and participating VAMC hospitals. The analysis used complete 2010 US census data and 2013 data for economic variables, coded to the block group level. Descriptive data presented with comparison to national averages.

Results: 281 sites were identified as of August 1, 2015. 38%, 50%, and 60% of the total US population were within 20, 40 and 65 miles of an identified site. Geographic coverage and analysis for gender, race, age, and income are presented below. High rates of access were identified for Hispanic/Latino, Black, and Asian populations and households with high median incomes. Limited rural access was identified. Data on rehabilitation and pediatric access to be presented.

Conclusions: Current StrokeNet sites provide geographic access to acute care research opportunities for a substantial portion of the US population. The encompassed population reflects the demographic and socioeconomic makeup of the nation as a whole.

Hypertensive emergency presenting as blurry vision in a patient with hypertensive chorioretinopathy

A 42-year-old man presented with 3 weeks of blurry vision in the right eye. His exam was significant for decreased vision in the right eye, diffuse retinopathy in both eyes, and serous retinal detachment in the right eye. The patient was found to be hypertensive with blood pressure of 256/160 mmHg. He was diagnosed with hypertensive emergency with end-organ damage due to features of hypertensive chorioretinopathy. He was admitted with abnormal urinalysis, elevated troponin, and abnormal EKG. After appropriate control of his blood pressure, his vision and his labs normalized. Hypertensive emergencies can be manifested first in the eyes. When the choroid is associated, the hypertensive event is often more acute and associated with increased morbidity. It is imperative to obtain a fundus exam in any patient with elevated blood pressure and concomitant vision complaints.

Medical student milestones in emergency medicine

OBJECTIVES

Medical education is a continuum from medical school through residency to unsupervised clinical practice. There has been a movement toward competency-based medical education prompted by the Accreditation Council for Graduate Medical Education (ACGME) using milestones to assess competence. While implementation of milestones for residents sets specific standards for transition to internship, there exists a need for the development of competency-based instruments to assess medical students as they progress toward internship. The objective of this study was to develop competency-based milestones for fourth-year medical students completing their emergency medicine (EM) clerkships (regardless of whether the students were planning on entering EM) using a rigorous method to attain validity evidence.

METHODS

A literature review was performed to develop a list of potential milestones. An expert panel, which included a medical student and 23 faculty members (four program directors, 16 clerkship directors, and five assistant deans) from 19 different institutions, came to consensus on these milestones through two rounds of a modified Delphi protocol. The Delphi technique builds content validity and is an accepted method to develop consensus by eliciting expert opinions through multiple rounds of questionnaires.

RESULTS

Of the initial 39 milestones, 12 were removed at the end of round 1 due to low agreement on importance of the milestone or because of redundancy with other milestones. An additional 12 milestones were revised to improve clarity or eliminate redundancy, and one was added based on expert panelists' suggestions. Of the 28 milestones moving to round 2, consensus with a high level of agreement was achieved for 24. These were mapped to the ACGME EM residency milestone competency domains, as well as the Association of American Medical Colleges (AAMC) core entrustable professional activities for entering residency to improve content validity.

CONCLUSIONS

This study found consensus support by experts for a list of 24 milestones relevant to the assessment of fourth-year medical student performance by the completion of their EM clerkships. The findings are useful for development of a valid method for assessing medical student performance as students approach residency.

Abstract T P182: Post-tPA ICH: INSTINCT Community Hospitals vs Pooled Analysis Data

Background: The threat of ICH limits community physician use of tPA in stroke. Only the PH2 subtype, however, independently causes clinical deterioration. We explored ICH characteristics in the community-based INSTINCT trial and compared PH2 incidence rates in INSTINCT to the pooled analysis (PA) of the ECASS, ATLANTIS, NINDS and EPITHET trials.

Methods: Secondary analysis of tPA-treated patients in the INSTINCT trial, a prospective, cluster-randomized, controlled trial conducted at 24 randomly selected Michigan community hospitals. Medical records of all tPA-treated strokes from 2007 to 2010 were initially reviewed by an independent physician panel to identify any evidence of possible ICH. In a second stage, 2 vascular neurologists, blinded to clinical data, independently categorized each possible ICH using ECASS criteria. Disagreements resolved by consensus. All images within 72h post-tPA were reviewed, with classification based on the most severe category. Data from pooled subjects with OTT of ≤180 minutes served as a historical control in the comparison. IRB approved.

Results: Neuroimaging was obtained from 23 of 24 INSTINCT sites, with 462 tPA-treated subjects. 85 (18.4%) were identified at initial review as a possible ICH. 82/85 (96%) had post-treatment neuroimaging available. At second-stage review, 19 had no identified hemorrhage, leaving 63/462 (13.6%) with an ICH. ICH subtype is presented in Table 1. In the PA cohort, 464 tPA-treated subjects had OTT ≤ 180 minutes. 161 (34.7%; 95% CI 30.5, 39.1) had an ICH, with 22 (4.7%; 95% CI 3.1%, 7.1%) identified as PH2. In the comparison, the difference did not reach significance (1.1%; 95% CI -1.6%, 3.8%; p = 0.42).

Conclusions: The overall INSTINCT ICH rate was low. Incidence of PH2 was not different from rates reported by investigators in large clinical research trials. This supports the safety of community treatment of stroke.

The impact of emergency physician turnover on planning for prospective clinical trials

INTRODUCTION

Emergency physician (EP) turnover is a significant issue that can have strong economic impact on hospital systems, as well as implications on research efforts to test and improve clinical practice. This work is particularly important to researchers planning randomized trials directed toward EPs because a large degree of turnover within a physician group would attenuate the effectiveness of the desired intervention. We sought to determine the incidence and factors associated with EP workforce changes.

METHODS

In an attempt to determine EP turnover and workforce change, data from the INSTINCT (INcreasing Stroke Treatment through INterventional behavior Change Tactics) trial were used. The INSTINCT trial is a prospective, cluster-randomized, controlled trial evaluating a targeted behavioral intervention to increase appropriate use of tissue plasminogen activator in acute ischemic stroke. Individual EPs staffing each of the study hospitals were identified at baseline and 18 months. Surveys were sent to EPs at both intervals. Models were constructed to investigate relationships between physician/hospital characteristics and workforce change.

RESULTS

A total of 278 EPs were identified at baseline. Surveys were sent to all EPs at baseline and 18 months with a response rate of 72% and 74%, respectively. At 18 months, 37 (15.8%) had left their baseline hospital and 66 (26.3%) new EPs were working. Seven EPs switched hospitals within the sample. The total number of EPs at 18 months was 307, a 10.8% overall increase. Among the 24 hospitals, 6 had no EP departures and 5 had no new arrivals. The median proportion of EP workforce departing by hospital was 16% (interquartile range [IQR] = 4%-25%; range = 0%-73%), and the median proportion added was 21% (IQR = 7%-41%; range = 0%-120%). None of the evaluated covariates investigating relationships between physician/hospital characteristics and workforce change were significant.

CONCLUSION

EP workforce changes over an 18-month period were common. This has implications for emergency department directors, researchers, and individual EPs. Those planning research involving interventions upon EPs should account for turnover as it may have an impact when designing clinical trials to improve performance on healthcare delivery metrics for time-sensitive medical conditions such as stroke, acute myocardial infarction, or trauma.

Abstract WP247: Use and Importance of Emergency Medical Services in Rural Delivery of tPA in Acute Ischemic Stroke

Introduction: Data indicate approximately 60% of stroke patients use Emergency Medical Systems (EMS) to access medical care. EMS use is associated with improved door to physician and CT times in stroke treatment. Rural areas, however, may have limited EMS access and its use and impact on tPA delivery in this setting is unknown.

Hypothesis: We assessed the hypothesis that EMS use in tPA treated stroke patients would be lower in rural areas compared to urban areas. We also examined important time intervals between groups.

Methods: Prospective, observational study using previously collected data from 24 randomly selected Michigan community hospitals in the INSTINCT stroke trial. Hospitals were identified a priori as urban or rural using two models to account for varying rural definitions. Model 1 defined rural hospitals as those outside a Metropolitan Statistical Area (MSA). Model 2 used hospitals outside a major Urban Area (UA > 150 square miles). Descriptive statistics presented; Student’s t and X 2 tests used in the comparisons.

Results: All 557 patients treated with tPA for AIS from 2007 - 2010 were included in the analysis. 82% [95% CI: 79%-85%] used EMS to access stroke care. Patients in both urban and rural groups had similar demographics. EMS transport times were significantly longer for rural patients in both models. Model 2, with a more restrictive geographic definition of a rural hospital, identified a significant reduction in EMS use in rural patients compared to the urban group. See Table.

Conclusions: Overall EMS use among stroke patients receiving tPA was substantially higher than previously reported in the general stroke population. Lower EMS use in rural settings, however, was confirmed in the restrictive model. EMS transport times were longer in the rural setting, likely reflecting greater travel distances. EMS level interventions to improve tPA delivery would reach a large majority of treated patients in both urban and rural settings.

Impact of regional pre-hospital emergency medical services in treatment of patients with acute ischemic stroke

Stroke is a major public health concern afflicting an estimated 795,000 Americans annually. The associated morbidity and mortality is staggering. Early treatment with thrombolytics is beneficial. The window for treatment is narrow and minimization of the time from symptom onset to treatment is vital. The general population is not well informed as to the warning signs or symptoms of stroke, leading to substantial delays in emergency medical services (EMS) activation. Ambulance transport of stroke patients to the hospital has demonstrated improvements in key benchmarks such as door to physician evaluation, door to CT initiation, and increased thrombolytic treatment. Pre-hospital notification of the impending arrival of a stroke patient allows for vital preparation in the treating emergency department, and improving timely evaluation and treatment upon arrival of the stroke patient. EMS systems are a vital component of the management of stroke patients, and resources used to improve these systems are beneficial.

Abstract 174: Economic Benefit of an Educational Intervention to Improve tPA Use in Community Hospitals: Secondary Analysis of the INSTINCT Trial

Introduction: Prior work demonstrates substantial economic benefit from tPA use. We hypothesized a T2 knowledge translation (KT) program to increase community tPA treatment would provide a cost-effective method to increase tPA use in AIS.

Methods: Data were utilized from the INcreasing Stroke Treatment through INterventional behavior Change Tactics (INSTINCT) trial, a prospective, cluster randomized, controlled trial involving 24 randomly selected acute care community hospitals in matched pairs. Within pairs, hospitals were randomly assigned to receive a barrier assessment-interactive educational intervention (BA-IEI) or no intervention (control). Cost analyses were conducted from a societal perspective for 2 cases: 1) using the total trial research costs and 2) using the intervention costs alone (without research overhead) as an estimate of the costs of generalization of the results. Total trial costs were calculated by combining direct and indirect INSTINCT funding with the opportunity costs of local health professionals attending study events. Savings attributable to increased tPA use were determined by applying published stroke economic data, adjusted for inflation, to the study cohorts. These data were integrated in a Markov model to determine the long-term economic impact of the INSTINCT BA-IEI program versus no intervention.

Results: The total INSTINCT trial cost (US)$3.3 million. In the intervention and post-intervention phases, the intervention sites treated 2.30% (244/10,627) of stroke patients with tPA compared to 1.59% (160/10,071) at control sites (per protocol analysis). This increase in tPA use resulted in a direct medical cost savings of approximately $540,000 due to reduced LOS and use of rehab and nursing facilities in the model. In addition, the increased usage resulted in an estimated additional 81 quality adjusted life years (QALY), with an incremental cost-effectiveness ratio of $34,000/QALY. Using $50,000 as a conservative estimate of societal value per QALY, this provided an additional societal benefit of $4,100,000, or a net economic societal benefit of $1.3 million for the trial. Generalizing the intervention in a similar population (excluding the cost of research overhead) would cost an estimated $680,000 and provide a net economic benefit of $3.9 million, assuming similar intervention effectiveness and treatment outcomes.

Conclusions: Due to the underlying cost-effectiveness of tPA, community knowledge translation efforts which show modest absolute gains in tPA usage demonstrate substantial societal economic returns and are considered good value when compared to spending on other health interventions.