Door to Needle Time Trends after Transition to Tenecteplase: A Multicenter Texas Stroke Registry

BACKGROUND

Tenecteplase (TNK) is considered a promising option for the treatment of acute ischemic stroke (AIS) with the potential to decrease door-to-needle times (DTN). This study investigates DTN metrics and trends after transition to tenecteplase.

METHODS

The Lone Star Stroke (LSS) Research Consortium TNK registry incorporated data from three Texas hospitals that transitioned to TNK. Subject data mapped to Get-With-the-Guidelines stroke variables from October 1, 2019 to March 31, 2023 were limited to patients who received either alteplase (ALT) or TNK within the 90 minute DTN times. The dataset was stratified into ALT and TNK cohorts with univariate tables for each measured variable and further analyzed using descriptive statistics. Logistic regression models were constructed for both ALT and TNK to investigate trends in DTN times.

RESULTS

In the overall cohort, the TNK cohort (n=151) and ALT cohort (n=161) exhibited comparable population demographics, differing only in a higher prevalence of White individuals in the TNK cohort. Both cohorts demonstrated similar clinical parameters, including mean NIHSS, blood glucose levels, and systolic blood pressure at admission. In the univariate analysis, no difference was observed in median DTN time within the 90 min time window compared to the ALT cohort [40 min (30-53) vs 45 min (35-55); P=.057]. In multivariable models, DTN times by thrombolytic didn't significantly differ when adjusting for NIHSS, age (P = .133), or race and ethnicity (P = .092). Regression models for the overall cohort indicate no significant DTN temporal trends for TNK (P=.84) after transition; nonetheless, when stratified by hospital, a single subgroup demonstrated a significant DTN upward trend (P=0.002).

CONCLUSION

In the overall cohort, TNK and ALT exhibited comparable temporal trends and at least stable DTN times. This indicates that the shift to TNK did not have an adverse impact on the DTN stroke metrics. This seamless transition is likely attributed to the similarity of inclusion and exclusion criteria, as well as the administration processes for both medications. When stratified by hospital, the three subgroups demonstrated variable DTN time trends which highlight the potential for either fatigue or unpreparedness when switching to TNK. Because our study included a multi-ethnic cohort from multiple large Texas cities, the stable DTN times after transition to TNK is likely applicable to other healthcare systems.

Health Care Disparities in Stroke Rehabilitation

Stroke outcomes are influenced by factors such as education, lifestyle, and access to care, which determine the extent of functional recovery. Disparities in stroke rehabilitation research have traditionally included age, race/ethnicity, and sex, but other areas make up a gap in the literature. This article conducted a literature review of original research articles published between 2008 and 2022. The article also expands on research that highlights stroke disparities in risk factors, rehabilitative stroke care, language barriers, outcomes for stroke survivors, and interventions focused on rehabilitative stroke disparities.

Multicenter exploration of tenecteplase transition factors: A quantitative analysis

BACKGROUND

Tenecteplase (TNK) is gaining recognition as a novel therapy for acute ischemic stroke (AIS). Despite TNK offering a longer half-life, time and cost saving benefits and comparable treatment and safety profiles to Alteplase (ALT), the adoption of TNK as a treatment for AIS presents challenges for hospital systems.

OBJECTIVE

Identify barriers and facilitators of TNK implementation at acute care hospitals in Texas.

METHODS

This prospective survey used open-ended questions and Likert statements generated from content experts and informed by qualitative research. Stroke clinicians and nurses working at 40 different hospitals in Texas were surveyed using a virtual platform.

RESULTS

The 40 hospitals had a median of 34 (IQR 24.5-49) emergency department beds and 42.5 (IQR 23.5-64.5) inpatient stroke beds with 506.5 (IQR 350-797.5) annual stroke admissions. Fifty percent of the hospitals were Comprehensive Stroke Centers, and 18 (45 %) were solely using ALT for treatment of eligible AIS patients. Primary facilitators to TNK transition were team buy-in and a willingness of stroke physicians, nurses, and pharmacists to adopt TNK. Leading barriers were lack of clinical evidence supporting TNK safety profile inadequate evidence supporting TNK use and a lack of American Heart Association guidelines support for TNK administration in all AIS cases.

CONCLUSION

Understanding common barriers and facilitators to TNK adoption can assist acute care hospitals deciding to implement TNK as a treatment for AIS. These findings will be used to design a TNK adoption Toolkit, utilizing implementation science techniques, to address identified obstacles and to leverage facilitators.

Racial and Ethnic Disparities in the Medical Management of Poststroke Complications Among Patients With Acute Stroke

BACKGROUND

To inform clinical practice, we sought to identify racial and ethnic differences in the medical management of common poststroke complications.

METHODS AND RESULTS

A cohort of acutely hospitalized, first-time non-Hispanic White (NHW), non-Hispanic Black, and Hispanic patients with stroke was identified from electronic medical records of 51 large health care organizations (January 1, 2003 to December 5, 2022). Matched propensity scores were used to account for baseline differences. Primary outcomes included receipt of medication(s) associated with the management of the following poststroke complications: arousal/fatigue, spasticity, mood, sleep, neurogenic bladder, neurogenic bowel, and seizure. Differences were measured at 14, 90, and 365 days. Subgroup analyses included differences restricted to patients with ischemic stroke, younger age (<65 years), and stratified by decade (2003-2012 and 2013-2022). Before matching, the final cohort consisted of 348 286 patients with first-time stroke. Matching resulted in 63 722 non-Hispanic Black-NHW pairs and 24 009 Hispanic-NHW pairs. Non-Hispanic Black (versus NHW) patients were significantly less likely to be treated for all poststroke complications, with differences largest for arousal/fatigue (relative risk (RR), 0.58 [95% CI, 0.54-0.62]), spasticity (RR, 0.64 [95% CI, 0.0.62-0.67]), and mood disorders (RR, 0.72 [95% CI, 0.70-0.74]) at 14 days. Hispanic-NHW differences were similar, albeit with smaller magnitudes, with the largest differences present for spasticity (RR, 0.67 [95% CI, 0.63-0.72]), arousal/fatigue (RR, 0.77 [95% CI, 0.70-0.85]), and mood disorders (RR, 0.79 [95% CI, 0.77-0.82]). Subgroup analyses revealed similar patterns for ischemic stroke and patients aged <65 years. Disparities for the current decade remained significant but with smaller magnitudes compared with the prior decade.

CONCLUSIONS

There are significant racial and ethnic disparities in the treatment of poststroke complications. The differences were greatest at 14 days, outlining the importance of early identification and management.

A qualitative study of barriers and facilitators to using tenecteplase to treat acute ischemic stroke

BACKGROUND

Tenecteplase (TNK) is emerging as an alternative to alteplase (ALT) for thrombolytic treatment of acute ischemic stroke (AIS). Compared to ALT, TNK has a longer half-life, shorter administration time, lower cost, and similarly high efficacy in treating large vessel occlusion. Nevertheless, there are barriers to adopting TNK as a treatment for AIS. This study aimed to identify thematic barriers and facilitators to adopting TNK as an alternative to ALT as a thrombolytic for eligible AIS patients.

METHODS

Qualitative research methodology using hermeneutic cycling and purposive sampling was used to interview four stroke clinicians in Texas. Interviews were recorded and transcribed verbatim. Enrollment was complete when saturation was reached. All members of the research team participated in content analysis during each cycle and in thematic analysis after saturation.

RESULTS

Interviews were conducted between November 2022 and February 2023 with stroke center representatives from centers that either had successfully adopted TNK, or had not yet adopted TNK. Three themes and eight sub-themes were identified. The theme "Evidence" had three sub-themes: Pro-Con Balance, Fundamental Knowledge, and Pharmacotherapeutics. The theme "Process Flow" had four subthemes: Proactive, Reflective self-doubt, Change Process Barriers, and Parameter Barriers. The theme "Consensus" had one sub-theme: Getting Buy-In.

CONCLUSION

Clinicians experience remarkably similar barriers and facilitators to adopting TNK. The results lead to a hypothesis that providing evidence to support a practice change, and identifying key change processes, will help clinicians achieve consensus across teams that need to 'buy in' to adopting TNK for AIS treatment.

Variability in the Transition of Care to Poststroke Rehabilitation During the First Wave of COVID-19

OBJECTIVE

The aim of the study is to evaluate transitions of acute stroke and inpatient rehabilitation facility care during the first wave of COVID-19.

DESIGN

This is a retrospective observational study (3 comprehensive stroke centers with hospital-based inpatient rehabilitation facilities) between January 1, 2019, and May 31, 2019 (acute stroke = 584, inpatient rehabilitation facility = 210) and January 1, 2020, and May 31, 2020 (acute stroke = 534, inpatient rehabilitation facility = 186). Acute stroke characteristics included stroke type, demographics, and medical comorbidities. The proportion of patients admitted for acute stroke and inpatient rehabilitation facility care was analyzed graphically and using t test assuming unequal variances.

RESULTS

The proportion of intracerebral hemorrhage patients (28.5% vs. 20.5%, P = 0.035) and those with history of transient ischemic attack (29% vs. 23.9%; P = 0.049) increased during the COVID-19 first wave in 2020. Uninsured acute stroke admissions decreased (7.3% vs. 16.6%) while commercially insured increased (42.7% vs. 33.4%, P < 0.001).Acute stroke admissions decreased from 116.5 per month in 2019 to 98.8 per month in 2020 ( P = 0.008) with no significant difference in inpatient rehabilitation facility admissions (39 per month in 2019, 34.5 per month in 2020; P = 0.66).In 2019, monthly changes in acute stroke admissions coincided with inpatient rehabilitation facility admissions.In 2020, acute stroke admissions decreased 80.6% from January to February, while inpatient rehabilitation facility admissions remained stable. Acute stroke admissions increased 12.8% in March 2020 and remained stable in April, while inpatient rehabilitation facility admissions decreased by 92%.

CONCLUSIONS

Acute stroke hospitalizations significantly decreased per month during the first wave of COVID-19, with a delayed effect on the transition from acute stroke to inpatient rehabilitation facility care.

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage.

METHODS

A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Effect of inpatient rehabilitation facility care on ninety day modified Rankin score in ischemic stroke patients

OBJECTIVE

To determine Inpatient Rehabilitation Facility (IRF) treatment effect on modified Rankin Scale (mRS) scores at 90 days in acute ischemic stroke (AIS) patients.

MATERIALS AND METHODS

This prospective cross-sectional study included 738 AIS patients admitted 1/1/2018-12/31/2020 to a Comprehensive Stroke Center with a Stroke Rehabilitation program. We compared outcomes for patients who went directly home versus went to IRF at hospital discharge: (1) acute care length of stay (LOS), (2) National Institutes of Health Stroke Scale (NIHSS) score, (3) mRS score at hospital discharge and 90 days, (4) the proportion of mRS scores ≤ 2 from hospital discharge to 90 days.

RESULTS

Among 738 patients, 499 went home, and 239 went to IRF. IRF patients were more likely to have increased acute LOS (10.7 vs 3.9 days; t-test, P<0.0001), increased mean NIHSS score (7.8 vs 4.8; t-test, P<0.0001) and higher median mRS score (3 vs 1, t-test, P<0.0001) compared to patients who went home. At 90 days, ischemic stroke patients who received IRF care were more likely to progress to a mRS ≤ 2 (18.7% increase) compared to patients discharged home from acute care (16.3% decrease). Home patients experienced a one-point decrease in mRS at 90 days compared to those who received IRF treatment (median mRS of 3 vs. 2, t-test, P<0.05).

CONCLUSIONS

In ischemic stroke patients, IRF treatment increased the likelihood of achieving mRS ≤ 2 at 90 days indicating the ability to live independently, and decreased the likelihood of mRS decrease, compared with patients discharged directly home after acute stroke care.

Abstract 146: Racial Disparities In The Treatment Of Post-stroke Complications Among Acute Stroke Patients

Introduction: Racial differences in the treatment of post-stroke sequelae may contribute to known disparities in post-stroke function. Our objective was to quantify the magnitude and timing of racial differences in the treatment of common stroke post-complications to better inform and modify clinical practice.

Methods: Electronic medical record data from 65 large health care organizations (August 2002-July 2022) were used to identify a cohort of non-Hispanic White (NHW), Black and Hispanic hospitalized acute stroke patients. Baseline differences between populations were adjusted for using a matched propensity score which accounted for 41 demographic and clinical factors. Outcomes included the use of medication(s) for treatment of arousal, spasticity, mood, sleep, bladder incontinence and seizure. Differences were measured at 14-, 90-, and 365-days.

Results: Prior to matching, the final cohort consisted of 428,155 patients of which n= 309,029 were NHW, n= 82,564 were black, and 28,375 were Hispanic. For the NHW-Black comparison 80,564 pairs were matched, whereas 28,375 pairs were matched for the NHW-Hispanic comparison. All baseline covariates were balanced after matching. Compared to NHW, black patients were significantly less likely to receive treatment for every condition at nearly every timepoint. The largest differences were present for the treatment of arousal (RR: 0.70, 95% CI: 0.66- 0.74), spasticity (RR: 0.73, 95% CI: 0.71-0.76), and mood (RR: 0.83 (0.82, 0.85) at 14-days. Differences for the NHW-Hispanic comparison were similar but with slightly smaller magnitudes.

Conclusions: There are significant racial disparities in the treatment of common post-stroke sequelae. Differences were greatest at 14-days indicating the acute hospitalization and rehabilitation are crucial to identify and treat complications to reduce disparities in post-stroke function.

Abstract WMP64: Increased Risk Of Adverse Outcomes With Methocarbamol Versus Cyclobenzaprine Use In Medication Naïve Acute Stroke Patients

Introduction: Methocarbamol and Cyclobenzaprine are often used interchangeably as muscle relaxants for acute stroke patients. There is limited data comparing medication side effect profiles within this hemodynamically vulnerable population.

Methods: Electronic medical records from 65 health care organizations (Aug 2002-Jul 2022) were used to identify a cohort of medication naïve acute stroke patients (ICD-10 codes I61-I63) who received Methocarbamol or Cyclobenzaprine. A 1:1 matched propensity score was used to adjust for baseline demographic and comorbidity differences. Outcomes included the 30-day relative risk (RR) and risk difference (RD) for: falls, sedation/fatigue, bradycardia, hypotension, seizure, urinary retention, and death. Sensitivity analysis focused on 30-day risk among patients aged > 65 years.

Results: Prior to matching, the final cohort consisted of 34,865 stroke patients who received Methocarbamol (n=20,150) or Cyclobenzaprine (n=14,715). A total of 13,667 pairs were matched, all baseline covariates were well balanced. In the adjusted analyses, Methocarbamol (vs. Cyclobenzaprine) use during the acute stroke period was associated with a 44% increased risk of fall (RR: 1.44; 95% CI: 1.31-1.50) sedation/fatigue (RR: 1.54 95% CI: 1.44-1.65), bradycardia (RR: 1.32; 95% CI: 1.19-1.44), hypotension (RR: 1.29 95% CI: 1.20-1.38), and seizure (RR: 1.32 95%CI: 1.24-1.40). Results were not affected by age as adverse event risks were similar among patients aged >65.

Conclusions: Compared to Cyclobenzaprine, Methocarbamol use was associated with increased 30-day risk of a range of adverse outcomes across the age spectrum for acute stroke patients.

Sex differences in endovascular thrombectomy outcomes in large vessel occlusion: a propensity-matched analysis from the SELECT study

BACKGROUND

Sex disparities in acute ischemic stroke outcomes are well reported with IV thrombolysis. Despite several studies, there is still a lack of consensus on whether endovascular thrombectomy (EVT) outcomes differ between men and women.

OBJECTIVE

To compare sex differences in EVT outcomes at 90-day follow-up and assess whether progression in functional status from discharge to 90-day follow-up differs between men and women.

METHODS

From the Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT) prospective cohort study (2016-2018), adult men and women (≥18 years) with anterior circulation large vessel occlusion (internal carotid artery, middle cerebral artery M1/M2) treated with EVT up to 24 hours from last known well were matched using propensity scores. Discharge and 90-day modified Rankin Scale (mRS) scores were compared between men and women. Furthermore, we evaluated the improvement in mRS scores from discharge to 90 days in men and women using a repeated-measures, mixed-effects regression model.

RESULTS

Of 285 patients, 139 (48.8%) were women. Women were older with median (IQR) age 69 (57-81) years vs 64.5 (56-75), p=0.044, had smaller median perfusion deficits (Tmax >6 s) 109 vs 154 mL (p<0.001), and had better collaterals on CT angiography and CT perfusion but similar ischemic core size (relative cerebral blood flow <30%: 7.6 (0-25.2) vs 11.4 (0-38) mL, p=0.22). In 65 propensity-matched pairs, despite similar discharge functional independence rates (women: 42% vs men: 48%, aOR=0.55, 95% CI 0.18 to 1.69, p=0.30), women exhibited worse 90-day functional independence rates (women: 46% vs men: 60%, aOR=0.41, 95% CI 0.16 to 1.00, p=0.05). The reduction in mRS scores from discharge to 90 days also demonstrated a significantly larger improvement in men (discharge 2.49 and 90 days 1.88, improvement 0.61) than in women (discharge 2.52 and 90 days 2.44, improvement 0.08, p=0.036).

CONCLUSION

In a propensity-matched cohort from the SELECT study, women had similar discharge outcomes as men following EVT, but the improvement from discharge to 90 days was significantly worse in women, suggesting the influence of post-discharge factors. Further exploration of this phenomenon to identify target interventions is warranted.

TRIAL REGISTRATION NUMBER

NCT02446587.

Creating a resident-centric rehabilitation research team

BACKGROUND

The 36-month Physical Medicine and Rehabilitation (PM&R) or Physiatry residency provides a number of multidisciplinary clinical experiences. These experiences often translate to novel research questions, which may not be pursued by residents due to several factors, including limited research exposure and uncertainty of how to begin a project. Limited resident participation in clinical research negatively affects the growth of Physiatry as a field and medicine as a whole. The two largest Physiatry organizations - the Association of Academic Physiatrists and the American Academy of Physical Medicine and Rehabilitation - participate in the Disability and Rehabilitation Research Coalition (DRRC), seeking to improve the state of rehabilitation and disability research through funding opportunities by way of the National Institutes of Health (NIH), the National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR) and the Patient-Centered Outcomes Research Institute (PCORI). A paucity of new Physiatry researchers neutralizes these efforts.

RESULTS

This paper details the creation of a novel, multidisciplinary Rehabilitation Resident Research program that promotes resident research culture and production. Mirroring our collaborative clinical care paradigm, this program integrates faculty mentorship, institutional research collaborates (Neuroscience Nursing Research Center, Neuroscience Research Development Office) and departmental resources (Shark Tank competition) to provide resident-centric research support.

CONCLUSIONS

The resident-centric rehabilitation research team has formed a successful research program that was piloted from the resident perspective, facilitating academic productivity while respecting the clinical responsibilities of the 36-month PM&R residency. Resident research trainees are uniquely positioned to become future leaders of multidisciplinary and multispecialty collaborative teams, with a focus on patient function and health outcomes.

Abstract WMP98: Association Between Serotonin Receptor Antidepressant Use And 90-day Mortality After Acute Ischemic Stroke: Propensity Score Analysis Of 10-year Real-world Data

Introduction: Post-stroke depression is associated with higher mortality. Unfortunately, the use of antidepressants (AD) as stroke treatment adjuvants has not been established due to a lack of placebo controls and concerns that selective serotonin reuptake inhibitor (SSRI) initiation after stroke may increase mortality.

Methods: Using ICD-10 diagnosis/procedure, procedural terminology codes and medications, we identified index ischemic strokes (IS) with and without AD use (SSRIs, Serotonin Antagonist Reuptake Inhibitors, Serotonin Norepinephrine Reuptake Inhibitors) 1 year pre and post event, using deidentified pooled data from a 50 healthcare organization network (8/2011-7/2021). Non adult (<18 yrs) and intracerebral hemorrhage were excluded. AD and no AD patients were propensity score (PS) matched for demographic, comorbidity and clinical variables. Standardized mean difference (SMD) assessed match adequacy. Absolute Risk Difference (RD) and Risk Ratios (RR) with 95% Confidence Intervals (CI) were reported for 90-day mortality in the PS-matched sample. Kaplan-Meier (KM) analysis with log rank test (LRT) was performed.

Results: Among 910,749 patients with an index IS, 634,599 met the inclusion criteria, of whom 136,219 (21.5%) had AD use before and after IS. Significant pre-match differences in demographic and clinical parameters were observed between the AD and no-AD groups (table). PS algorithm generated a 1:1 optimally matched sample (95% SMD reduction) of 78,815 AD and no AD IS patients each, with significant covariate differences for female sex, mood disorder diagnosis, systolic blood pressure and cardiovascular medication use (table). In the matched sample, the 90-day mortality risk post-IS was significantly lower in the AD group. RD: -3.4%, RR(CI) 0.54(0.52-0.56). LRT P<0.0001, KM curve shown in the graphic.

Conclusion: AD utilization before and after IS demonstrates significantly lower 90-day mortality in real world multicenter data.

Abstract WMP84: High Morbidity And Mortality Associated With Anticoagulation Prior To Intracerebral Hemorrhage: Propensity Score Analysis Of 10-year Real-world Data

Introduction: Anticoagulation for prevention of cardioembolic stroke is safe and effective. However, there is a paucity of data on morbidity and mortality among non-traumatic intracerebral hemorrhage (ICH) patients with history of anticoagulant (AC) use.

Methods: Using ICD-10 diagnosis/procedure, procedural terminology codes and medications, we identified index ICH events with and without prior AC use from deidentified pooled data; in a network of 50 healthcare organizations (Aug 2011-July 2021). Non adult (<18 years) and the presence of a prosthetic heart valve were excluded. AC and no-AC patients were propensity score (PS) matched for demographic, comorbidity and clinical variables. Match adequacy was assessed by standardized mean difference (SMD). Absolute Risk Difference (RD) and Risk Ratios (RR) with 95% Confidence Intervals (CI) are reported for morbidity [seizure, sepsis, intraventricular hemorrhage or external ventricular drain(IVH/EVD)] and mortality at 5 years post index ICH event in the PS-matched sample.

Results: Among 193,600 patients with an index ICH event, 171,561 met the inclusion criteria, of whom, 62,578 (36.5%) had prior AC use. Significant pre-match differences in demographic and clinical parameters were observed between the AC and no AC groups (table). PS algorithm generated a 1:1 optimally matched sample (95% SMD reduction) of 21,808 AC and no AC ICH patients each, without significant covariate differences. In the matched sample, the risk of post-ICH seizure, sepsis, IVH/EVD, and mortality were significantly higher in the AC group. RR (CI) for seizure: 1.27(1.22-1.32), sepsis: 1.56(1.46-1.67), IVH/EVD: 1.78(1.66-1.92), mortality: RR (CI) 1.05 (1.02 - 1.09). RD of 5-year death between AC and no-AC groups was 1.3%, compared to a 4.1% RD of seizure, 3.2% RD of sepsis and a 3.7% RD of IVH/EVD.

Conclusion: In Real World multicenter data, utilization of AC prior to ICH demonstrates significantly high long-term morbidity and mortality.

Abstract WP63: The Effect Of Inpatient Rehabilitation Facility Treatment On 90 Day Outcomes: A Shift Analysis Of Modified Rankin Scale Score In Ischemic Stroke Patients

Introduction: Several AHA Guidelines recommend inpatient rehabilitation facility (IRF) care to enhance post-stroke recovery. We evaluated the IRF treatment effect on modified Rankin scale (mRS) score change at 90 days in ischemic stroke (IS) patients.

Methods: Using prospectively collected data from Get With the Guidelines-Stroke, the Uniformed Data System for Medical Rehabilitation registry and the electronic medical record, we identified IS patients with discharge disposition of home or IRF between 1/1/2018-12/31/2020. Sociodemographics, clinical variables and IS treatment rates were summarized. IRF outcomes, including length of stay (LOS), improvement in mobility and self-care scores and discharge disposition were compared in thrombectomy vs no thrombectomy groups. mRS at IRF discharge was calculated with a Cronbach interrater score of 0.88; shift analyses of mRS at hospital discharge and 90 days were completed for IS patients in the Home and IRF care groups.

Results: Among 738 patients, 499 went home, 239 went to IRF. IRF patients were more likely to have Medicare insurance (49.2 vs 28.9%), undergo thrombectomy (16.3 vs 4.6%) have increased LOS (12.7 vs 4.8 days) and stroke severity (mean NIHSS 7.8 vs 4.8; mean mRS 3.1 vs 1.7) compared to Home (Table 1). At IRF, 39 patients previously underwent thrombectomy, 200 did not. Both groups had a IRF LOS >14 days and considerable recovery in the self-care and mobility domains (Table 2). Shift analysis of mRS at hospital discharge compared to 90 days yielded significant improvements in mRS of 0-2 and lower mortality in the IRF group compared to home group (Figure).

Conclusion: In ischemic stroke patients with higher disease severity, IRF treatment is a catalyst for improved functional recovery.

Abstract TP187: Contemporary Estimates Of Poor Cardiovascular Health Among Individuals With Stroke: Nationwide Analysis Of The American Heart Association’s Simple 7

Introduction: The American Heart Association’s (AHA) “Simple 7” are lifestyle behaviors for maintenance of ideal cardiovascular health (CVH).

Methods: We analyzed 2019 Behavioral Risk Factor Surveillance System (BRFSS) data (nationally representative, annual, health-related survey of community dwelling US adults), and flagged individuals with a stroke diagnosis. Among stroke individuals (SI), we identified validated CVH features (diabetes, hypertension, BMI ≥ 25 kg/m 2 , hypercholesterolemia, smoking, poor eating habits, and lack of exercise) based on AHA’s simple 7. SI with ≥ 5 CVH features were categorized as ‘Poor CVH’ (PCVH). We evaluated socio-demographic, regional and healthcare utilization factors associated with PCVH. We fit survey design logistic regression models, and report nationally representative estimates as adjusted Odds Ratios (aOR) and 95% confidence intervals (CI).

Results: The 2019 estimated national count of SI is 8,570,876 translating into a nationwide stroke prevalence of 3.4% among US adults (7.9% among ≥ 65 years). SI who were divorced/separated (vs. married), non-Hispanic Black or Native American (vs. Non-Hispanic White - NHW), had lower income, resided in the stroke belt had higher likelihood of PCVH. In our adjusted model (Figure), males had a significantly higher PCVH aOR (CI) 1.26 (1.00 - 1.59). Moreover, Asian American and Pacific Islanders vs. NHW demonstrated higher PCVH, aOR (CI) 4.74 (1.25 - 17.95). Compared to the New England region, residence in following divisions was associated with higher PCVH; aOR (CI) for West South-Central: 1.73 (1.05 -2.85), East North Central: 1.64 (1.11 - 2.43), East South Central: 2.29 (1.37 - 3.83), South Atlantic: 1.74 (1.18 - 2.57). Analyses for 2020 BRFSS data will be presented.

Conclusion: National stroke prevalence rates are provided. Poor CVH among stroke individuals continues to be disparately high. These analyses are important to identify and target high-risk population sub-groups.

The "Network Effect" on Interfacility Transfers Among Regional Stroke Certified Hospitals

INTRODUCTION AND PURPOSE

Timely inter-facility transfer of thrombectomy-eligible patients is a mainstay of Stroke Systems of Care. We investigated transfer patterns among stroke certified hospitals in the Dallas-Fort Worth (DFW) Metroplex (19 counties, 9,286 sq mi, > 7.7 million people), by hospital network and stroke center status.

METHODS

We conducted a North Central Texas Trauma Regional Advisory Council (NCTTRAC) Stroke Regional Care Survey at all 44 centers involved in the treatment of MT-eligible ischemic stroke patients between June-September 2019, with a response rate of 100%. All hospitals identified network status, stroke designation - Acute Stroke Ready Hospital (ASRH), Primary Stroke Center (PSC), Comprehensive Stroke Center (CSC) - and geographic location. Stroke Assessment and Large Vessel Occlusion (LVO) screening tool use was evaluated. The distance between the sending and receiving facility was calculated using GPS coordinates. If the closest CSC was not used, the average distance between the selected and the closest CSC was geospatially mapped via R statistical analysis software (Vienna, Austria) gmapsdistance package.

RESULTS

Of the 44 facilities, 6 were ASRHs, 27 were PSCs, 11 were CSCs. Seventy-seven percent (n=34) belonged to one of four hospital networks. All facilities used stroke assessment tools; 57% completed LVO screening. There was significant heterogeneity in inter-facility transfer patterns with no regional standardization. Seventeen percent of ASRHs (n=1) and 56% of PSCs (n=15) conducted inter-facility transfers using ground transportation via EMS. Sixty percent of non-network facilities transferred to the closest CSC. Of the remaining 40%, the average distance between the closest and the selected CSC was 1.5 miles (min max 0.2-2.9 miles). Seventeen percent of network facilities transferred to the closest CSC. Among the remaining 83%, the average distance between the closest and the selected CSC was 4.1 miles (min-max 1-8 miles).

CONCLUSIONS

Non-network facility status increased the likelihood of transfer to the closest Comprehensive Stroke Center. Transfer distance variability among network facilities may contribute to delays in reperfusion therapy.

Association Between 2010 Medicare Reform and Inpatient Rehabilitation Access in People With Intracerebral Hemorrhage

Background

Evidence suggests intracerebral hemorrhage survivors have earlier recovery compared with ischemic stroke survivors. The Centers for Medicare and Medicaid Services prospective payment system instituted documentation rules for inpatient rehabilitation facilities (IRFs) in 2010, with the goal of optimizing patient selection. We investigated whether these requirements limited IRF and increased skilled nursing facility (SNF) use compared with home discharge.

Methods and Results

Intracerebral hemorrhage discharges to IRF, SNF, or home were estimated using GWTG (Get With The Guidelines) Stroke registry data between January 1, 2008, and December 31, 2015 (n=265 444). Binary hierarchical models determined associations between the 2010 Rule and discharge setting; subgroup analyses evaluated age, geographic region, and hospital type. From January 1, 2008, to December 31, 2009, 45.5% of patients with intracerebral hemorrhage had home discharge, 22.2% went to SNF, and 32.3% went to IRF. After January 1, 2010, there was a 1.06% absolute increase in home discharge, a 0.46% increase in SNF, and a 1.52% decline in IRF. The adjusted odds of IRF versus home discharge decreased 3% after 2010 (adjusted odds ratio [aOR], 0.97; 95% CI, 0.95–1.00). Lower odds of IRF versus home discharge were observed in people aged <65 years (aOR, 0.92; 95% CI, 0.89–0.96), Western states (aOR, 0.89; 95% CI, 0.84–0.95), and nonteaching hospitals (aOR, 0.90; 95% CI, 0.86–0.95). Adjusted odds of SNF versus home discharge increased 14% after 2010 (aOR, 1.14; 95% CI, 1.11–1.18); there were significant associations in all age groups, the Northeast, the South, the Midwest, and teaching hospitals.

Conclusions

The Centers for Medicare and Medicaid Services 2010 IRF prospective payment system Rule resulted in fewer discharges to IRF and more discharges to SNF in patients with intracerebral hemorrhage. Health policy changes potentially affect access to intensive postacute rehabilitation.

Implementation of the MATRIX Staffing Grid Improves Nurse Satisfaction With Rehabilitation Unit Staffing

ABSTRACT

BACKGROUND: Information on nurse satisfaction and unit acuity is scarce in the literature. The purpose of this study is to evaluate the effect of the MATRIX Staffing Grid (MSG) on nurse assignment satisfaction in a 20-bed inpatient rehabilitation facility. METHODS: Prospective systematic implementation study of the MSG occurred in 5 phases: development, baseline, run-in, implementation, and sustainability. Pretest/posttest nursing satisfaction data were analyzed using Wilcoxon-Mann-Whitney tests. RESULTS: Analysis of 128 satisfaction surveys demonstrated that the median total satisfaction score increased by 35% after MSG implementation (P < .05), with no change in patient satisfaction or adverse event rates. CONCLUSION: A systematic approach to implementation of the MSG evidence-based practice significantly improved nursing satisfaction with patient assignment in a way that addressed specific needs. The MSG has now been adopted into practice at our institution. The MSG may be feasible for implementation in inpatient rehabilitation units to improve staffing satisfaction.

Association Between 2010 Medicare Reforms and Utilization of Postacute Inpatient Rehabilitation in Ischemic Stroke

OBJECTIVE

The aim of the study was to investigate whether the elimination of trial admissions and the initiation of documentation requirements, via the 2010 Centers for Medicare and Medicaid Services Inpatient Rehabilitation Facility Prospective Payment System Rule, limited inpatient rehabilitation facility access while increasing skilled nursing facility utilization compared with home discharge in ischemic stroke patients.

DESIGN

This is a retrospective observational study using Get with the Guidelines - Stroke hospital data between January 1, 2008 and December 31, 2015 (N = 1,643,553).

RESULTS

Between January 1, 2008 and December 31, 2009, 54.1% of patients went home, 25.4% to inpatient rehabilitation facility and 20.5% to skilled nursing facility. Between January 1, 2010 and December 31, 2015, there was a 1.4% absolute increase in home discharge, a 1.1% inpatient rehabilitation facility decline and a 0.3% skilled nursing facility decline.Within the 1.1% absolute decline in inpatient rehabilitation facility discharge, the adjusted odds of inpatient rehabilitation facility versus home discharge decreased 12% after 2010 Rule (adjusted odds ratio = 0.88, 95% confidence interval = 0.87-0.89, P < 0.0001). There was no statistically significant change in skilled nursing facility versus home discharge.Lower adjusted odds of inpatient rehabilitation facility discharge versus home discharge were identical across age groups and were present in all geographic regions.

CONCLUSIONS

In populations with ischemic stroke, the Centers for Medicare and Medicaid Services 2010 Inpatient Rehabilitation Facility Prospective Payment System Rule was associated with a 1.1% absolute decrease in inpatient rehabilitation facility discharge, with a concomitant increase in home discharge rather than to skilled nursing facility.

Abstract P155: The Network Effect on Inter-Facility Transfers Among Regional Stroke Certified Hospitals

Introduction and Purpose: Timely inter-facility transfer of thrombectomy-eligible patients is a mainstay of Stroke Systems of Care. We investigated transfer patterns among stroke certified hospitals in the Dallas-Fort Worth Metroplex (19 counties, 9,286 sq mi, >7.7 million people), by hospital network and stroke center status.

Methods: In Feb 2020, all 44 North Central Texas Trauma Regional Advisory Council (NCTTRAC) hospitals identified network status, stroke designation and geographic location. Stroke Assessment and Large Vessel Occlusion (LVO) screening tool use was evaluated. The distance between the sending and receiving facility was calculated using GPS coordinates. If the closest Comprehensive Stroke Center (CSC) was not used, the average distance between the selected and the closest CSC was geospatially mapped via R statistical analysis software (Vienna, Austria) gmapsdistance package.

Results: Of the 44 facilities, 6 were Acute Stroke Ready Hospitals (ASRHs), 27 were Primary Stroke Centers (PSCs), 11 were CSCs (Fig 1). Seventy-seven percent (n=34) were part of four hospital networks. All facilities used stroke assessment tools; 57% completed LVO screening. Seventeen percent of ASRHs (n=1) and 56% of PSCs (n=15) conducted inter-facility transfers. Sixty percent of non-network facilities transferred to the closest CSC. Of the remaining 40%, the average distance between the closest and the selected CSC was 1.5 miles (min max 0.2-2.9). Seventeen percent of network facilities transferred to the closest CSC. Among the remaining 83%, the average distance between the closest and the selected CSC was 4.1 miles (min-max 1-8).

Conclusions: Non-network facility status increased the likelihood of transfer to the closest Comprehensive Stroke Center. Transfer distance variability among network facilities may contribute to delays in reperfusion therapy.

Figure 1 . Transfer Patterns (in Blue) of Dallas Fort-Worth Metroplex Hospitals by Stroke Center Designation

Factors Associated with Duration of Rehabilitation Among Older Adults with Prolonged Hospitalization

BACKGROUND/OBJECTIVES

Older adults are prone to functional decline during prolonged hospitalization. Although rehabilitation therapy is critical to preserving function, little is known about rehabilitation duration (RD) in this population. We sought to determine the extent of rehabilitation therapy provided to older adults during prolonged hospitalization, and whether this differs by sociodemographic and clinical characteristics.

DESIGN

Retrospective cohort.

SETTING

Single-site safety-net hospital.

PARTICIPANTS

Older adults (≥65 years) hospitalized for ≥14 days between 2016 and 2017.

MEASUREMENTS

The primary outcome was RD, defined as the average number of minutes of physical and occupational therapy per week. We used a multivariable generalized linear model to assess for differences in RD by sociodemographic and clinical characteristics. For a sub-cohort of hospitalizations with a baseline mobility assessment, we repeated analyses including mobility limitation as a covariate.

RESULTS

Among 1,031 hospitalizations by 925 unique patients (median age 72, 49% female, 79% non-white, 40% non-English speaking), the median RD was 61.3 minutes/week (interquartile range = 16.5-127.3). Covariates associated with lesser RD included black (57.2 fewer minutes/week; 95% confidence interval (CI) = 22.9-91.4) and Hispanic (75.6 fewer minutes/week; 95% CI = 33.8-117.4) race/ethnicity, speaking a language other than English or Spanish (51.7 fewer minutes/week; 95% CI = 21.3-82.0), prolonged mechanical ventilation (30.0 fewer minutes/week; 95% CI = 6.6-53.3), and do-not-resuscitate code status (36.0 fewer minutes/week; 95% CI = 17.1-54.8). The inclusion of mobility limitation among the sub-cohort (n = 350) did not meaningfully change the associations.

CONCLUSION

We found large disparities in RD for racial/ethnic and language minorities and clinically vulnerable older adults (mechanical ventilation and do-not-resuscitate code status), independent of clinical severity and functional and cognitive impairment. Greater RD for these groups may improve functional outcomes and narrow the disparity gap.

Characteristics of Acute Stroke Patients Readmitted to Inpatient Rehabilitation Facilities: A Cohort Study

BACKGROUND

Reducing acute care readmissions from inpatient rehabilitation facilities (IRFs) is a healthcare reform goal. Stroke patients have higher acute readmission rates and persistent impairments, warranting second IRF hospitalization consideration.

OBJECTIVE

To provide evidence-based information to justify IRF readmission for patients with post-stroke impairments.

MAIN OUTCOME MEASURE

Variables that increase the likelihood of a second IRF hospitalization.

DESIGN

Retrospective cohort study.

SETTING

Seven-center rehabilitation network.

PARTICIPANTS

Stroke patients, readmitted to acute care, who returned or did not return to an in-network IRF between 1 October 2014-31 December 2017(n = 380).

INTERVENTIONS

Univariable analyses (Returned/Did Not Return to IRF) described demographics, stroke type and risk factors. Between group differences in readmission causes, motor impairments and functional independence measure (FIM) scores were examined. Return to IRF logistic regression model included variables with P < .1. Odds ratio and 95% CI were calculated; Relative risk was calculated for categorical variables. P < .05 equaled statistical significance.

RESULTS

One hundred ninety-two stroke patients returned to IRF, 188 did not. Returned to IRF patients were younger (60.6 vs. 66 years; P < .001), sustained hemorrhagic strokes (22.4 vs. 14.2%; P = .01), had lower cardiac disease prevalence (41.7 vs. 55.3%; P = .008) or non-Medicare insurance (59.9 vs. 39.4%; P < .001). Did Not Return to IRF patients had higher admission and discharge motor and total FIM scores. Per point decrease in discharge FIM, second IRF hospitalization odds increased 4% (OR 1.04; 95% CI 1.01-1.07; P = .02). Hemorrhagic stroke patients had 33% increased odds or a 15% higher relative risk of second IRF hospitalization than patients with ischemic stroke [OR 1.33; 95% CI 1.21-1.47; RR 1.15; 95% CI 1.1-1.2; P < .001]. Non-Medicare insurance was associated with 39% increased odds or a 20% higher relative risk of second IRF hospitalization than Medicare [OR 1.39; 95% CI 1.01-1.92; RR 1.2, 95% CI 1.006-1.404; P = .04).

CONCLUSIONS

Hemorrhagic stroke, non-Medicare insurance or lower discharge FIM score during the first IRF hospitalization predict a second IRF stay. Further work is needed to establish the validity of within IRF stay readmission measures.

Use of a Smartphone-Based Mobile App for Weight Management in Obese Minority Stroke Survivors: Pilot Randomized Controlled Trial With Open Blinded End Point

Background

Minorities have an increased incidence of early-onset, obesity-related cerebrovascular disease. Unfortunately, effective weight management in this vulnerable population has significant barriers.

Objective

Our objective was to determine the feasibility and preliminary treatment effects of a smartphone-based weight loss intervention versus food journals to monitor dietary patterns in minority stroke patients.

Methods

Swipe out Stroke was a pilot prospective randomized controlled trial with open blinded end point. Minority stroke patients and their caregivers were screened for participation using cluster enrollment. We used adaptive randomization for assignment to a behavior intervention with (1) smartphone-based self-monitoring or (2) food journal self-monitoring. The smartphone group used Lose it! to record meals and communicate with us. Reminder messages (first 30 days), weekly summaries plus reminder messages on missed days (days 31-90), and weekly summaries only (days 91-180) were sent via push notifications. The food journal group used paper diaries. Both groups received 4 in-person visits (baseline and 30, 90, and 180 days), culturally competent counseling, and educational materials. The primary outcome was reduced total body weight.

Results

We enrolled 36 stroke patients (n=23, 64% African American; n=13, 36% Hispanic), 17 in the smartphone group, and 19 in the food journal group. Mean age was 54 (SD 9) years; mean body mass index was 35.7 (SD 5.7) kg/m2; education, employment status, and family history of stroke or obesity did not differ between the groups. Baseline rates of depression (Patient Health Questionnaire-9 [PHQ-9] score median 5.5, IQR 3.0-9.5), cognitive impairment (Montreal Cognitive Assessment score median 23.5, IQR 21-26), and inability to ambulate (5/36, 14% with modified Rankin Scale score 3) were similar. In total, 25 (69%) stroke survivors completed Swipe out Stroke (13/17 in the smartphone group, 12/19 in the food journal group); 1 participant in the smartphone group died. Median weight change at 180 days was 5.7 lb (IQR –2.4 to 8.0) in the smartphone group versus 6.4 lb (IQR –2.2 to 12.5; P=.77) in the food journal group. Depression was significantly lower at 30 days in the smartphone group than in the food journal group (PHQ-9 score 2 vs 8; P=.03). Clinically relevant depression rates remained in the zero to minimal range for the smartphone group compared with mild to moderate range in the food journal group at day 90 (PHQ-9 score 3.5 vs 4.5; P=.39) and day 180 (PHQ-9 score 3 vs 6; P=.12).

Conclusions

In a population of obese minority stroke survivors, the use of a smartphone did not lead to a significant difference in weight change compared with keeping a food journal. The presence of baseline depression (19/36, 53%) was a confounding variable, which improved with app engagement. Future studies that include treatment of poststroke depression may positively influence intervention efficacy.

Trial Registration

ClinicalTrials.gov NCT02531074; https://www.clinicaltrials.gov/ct2/show/NCT02531074

Abstract TMP47: Impact of Medicare Reform on Inpatient Rehabilitation Facility Access for Hemorrhagic Stroke Patients

Introduction: There is growing evidence that ICH patients make larger & faster recovery gains compared to ischemic stroke patients. Inpatient rehabilitation facility (IRF) care can significantly facilitate improvement. In 2010, changes to IRF admission criteria potentially restricted access. We hypothesize the Centers for Medicare and Medicaid Services (CMS) 2010 IRF Prospective Payment System Rule decreased IRF access & increased skilled nursing facility (SNF) utilization in ICH patients.

Methods: The proportion of ICH survivors discharged to IRF, SNF or home was estimated using GWTG-Stroke data between 1/1/2008 & 12/31/2015 (n=265,444). Two binary hierarchical models determined the association between the 1/1/2010 CMS admission criteria change for IRFs and discharge setting, adjusting for patient & hospital characteristics. Subgroup analyses evaluated the effects of age, region & hospital type. Sensitivity analyses used complete NIHSS data (≈49%).

Results: The prevalence of the 3 discharge destinations changed significantly over time (CMH row-mean-score P<0.0001; Figure 1). IRF rehab odds decreased and SNF rehab odds increased for ICH patients compared to home after the CMS 2010 IRF PPS Rule (Figure 2a & 2b). Decreased IRF rehab odds were found in patients age<65, Western US location or at non-teaching hospitals (Figure 2a). Increased SNF rehab odds were found in patients age≥65, Midwest location or at teaching hospitals (Figure 2b).

Conclusions: IRF Rehab odds decreased and SNF rehab odds increased during the time period after CMS 2010 IRF PPS Rule implementation in ICH patients. The impact of such legislative changes on patient outcomes warrants further study.

The Transition from the Hospital to an Inpatient Rehabilitation Setting for Neurologic Patients

Transitions of care from acute hospitalization to postacute rehabilitation settings evolved as a function of cost-saving changes to the Medicare Prospective Payment System. Restricted criteria for inpatient rehabilitation facility admission limited access for patients with severe physical and cognitive deficits. Once used as a resource-intense supplement to hospital care, skilled nursing facilities have metamorphosed into rehabilitation settings with limited nursing staff, lower intensity of therapies, and decreased community discharge rates. A collaborative approach to care transitions, using acute and postacute health care providers, provides the opportunity to improve this process. Early physiatry consultation is a strategy for patients with neurologic disease.

Abstract WP180: Association Between Medicare Reform and Access to Rehabilitation in Ischemic Stroke Patients

Introduction: In 2010, the Centers for Medicare and Medicaid Services (CMS) implemented the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) Rule, requiring IRF patients to tolerate 3 hours of daily therapy (PT &OT/SLP). If unable, rehab at a skilled nursing facility (SNF) is recommended, contrasting the 2016 AHA Stroke Rehabilitation Guidelines for optimal recovery.

Hypothesis: Stroke patients are more likely to receive rehab at a SNF compared to an IRF after implementation of the CMS 2010 IRF PPS Rule.

Methods: We calculated the proportion of stroke patients discharged to IRF vs home and SNF vs home using prospectively collected registry data from Get with the Guidelines - Stroke, for a cohort of ischemic (85.7%) and hemorrhagic (14.3%) stroke patients between 2008 and 2015 (n=1,962,933). Univariate analyses compared stroke severity by NIHSS, sociodemographic/clinical characteristics and in hospital rehabilitation assessments. Multivariable regression modeling assessed the association between CMS 2010 IRF PPS Rule and age, teaching versus non-teaching hospital and US geographic region.

Results: Post CMS 2010 IRF PPS Rule, 1 out of 15 ischemic stroke patients had lower IRF rehab odds (OR 0.94; 95%CI 0.92-0.95; P<0.0001); 1 out of 9 ischemic stroke patients had higher SNF rehab odds (OR 1.12, 95% CI 1.10-1.14; P<0.0001). Multivariable regression - ischemic stroke: Across all ages, in the South, Northeast and at teaching hospitals, the odds of IRF rehab decreased and the odds of SNF rehab increased after implementation of CMS 2010 IRF PPS Rule (Fig 1 & 2).

Conclusions: Ischemic stroke patients, with similar clinical histories & stroke severity, had decreased odds of inpatient rehabilitation facility rehab and increased odds of skilled nursing facility rehab after implementation of the CMS 2010 IRF PPS Rule. Additional studies analyzing the effects of low intensity SNF rehab versus IRF rehab on return home and long-term disability are needed.

The difficulty of studying race-ethnic stroke rehabilitation disparities in a community

OBJECTIVE

Minority populations have worse stroke outcomes compared with non-Hispanic whites (NHWs). One possible explanation for this disparity is differential allocation of stroke rehabilitation. We utilized a population-based stroke study to determine the feasibility of studying Mexican American-NHW differences in stroke rehabilitation in a population-based design including identification of community partners, development of standardized data collection instruments, and collection of pilot data.

METHODS

As part of the Brain Attack Surveillance in Corpus Christi project, we followed 48 patients for the first 90 days after stroke, and attempted to work with community partners to garner information on rehabilitation modalities used. With input from local occupational and physical therapists and speech language pathologists, we created data collection forms to capture rehabilitation activities and time spent on these activities and conducted a 3-month data collection pilot.

RESULTS

Of the 79 rehabilitation venues in the community, 63 (80%) agreed to participate. During the pilot, 545 data forms from 20 stroke patients were collected corresponding to ~18% of stroke patients. Forms were used by 13 partners during the pilot including 3 of 4 inpatient rehabilitation facilities, 4 of 13 skilled nursing facilities, 4 of 26 home health agencies, and 2 of 36 outpatient rehabilitation providers.

CONCLUSIONS

Initial agreement from rehabilitation providers to participate in research was excellent, but completion of study related data collection forms was sub-optimal suggesting this approach is not feasible for a future population-based stroke rehabilitation study. Further methods to study post-stroke rehabilitation disparities in communities are needed.

Abstract 24: Nationwide Trends and Disparities in Utilization of Inpatient Rehabilitation for Stroke Patients

Introduction: Transfer to an inpatient rehabilitation (IR) facility (IRF) provides multiple benefits to stroke patients including improvements in functional independence measures, neurological impairments, stroke-related medical complications, and reduction in readmissions. We report nationwide trends and disparities in post-stroke IR utilization.

Methods: We analyzed the National Inpatient Sample for years 2006 - 2011 and used ICD-9 codes to identify adult patients with ischemic stroke, intracerebral hemorrhage and subarachnoid hemorrhage. Institutionalized care (IC) included transfer to skilled nursing and long term care facilities. We fit survey design multivariable logistic regression models to determine nationally representative trends in IR utilization and report crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) for factors associated with IR utilization, including level of care (LOC) as defined by teaching status of the hospital.

Results: Based on our criteria 3,112,120 patients were included in analyses, of whom 16.2% utilized IRF. There was a significantly increasing trend in post-stroke IR utilization over the period of investigation (OR 1.06, 95%CI 1.04-1.09), with 19.5% patients discharged to IRF in 2011 (Figure 1). Older age and female gender were independently associated with decreased IR utilization (Table 1). Patients utilizing IR had significantly greater odds of being discharged from a teaching hospital after controlling for demographic, clinical, comorbidity, and resource utilization factors (OR 1.40, 95% CI 1.23 - 1.47).

Conclusion: Our analysis indicates overall low nationwide IR utilization. However, there is an increasing trend in utilization of IR, albeit with age, gender, and LOC disparities. After adjustments, patients discharged from non-teaching hospitals are 29% less likely to receive IR. Further studies should focus on barriers to utilizing post-stroke IR, including socioeconomic status.

Mexican Americans Receive Less Intensive Stroke Rehabilitation Than Non-Hispanic Whites

BACKGROUND AND PURPOSE

Mexican Americans (MAs) have worse neurological, functional, and cognitive outcomes after stroke. Stroke rehabilitation is important for good outcome. In a population-based study, we sought to determine whether allocation of stroke rehabilitation services differed by ethnicity.

METHODS

Patients with stroke were identified as part of the Brain Attack Surveillance in Corpus Christi (BASIC) project, TX, USA. Cases were validated by physicians using source documentation. Patients were followed prospectively for 3 months after stroke to determine rehabilitation services and transitions. Descriptive statistics were used to depict the study population. Continuous baseline variables were compared using 2 sample t tests or Wilcoxon rank-sum tests by ethnicity. Categorical baseline variables were compared using χ² tests. Ethnic comparisons of rehabilitation services were compared using χ² tests, Fisher's exact tests, and logistic regression.

RESULTS

Seventy-two subjects (50 MA and 22 non-Hispanic white [NHW]) were followed. Mean age, NHW-69 (SD 13), MA-66 (SD 11) years, sex (NHW 55% male, MA 50% male) and median presenting National Institutes of Health Stroke Scale did not differ significantly. There were no ethnic differences among the proportion of patients who were sent home without any rehabilitation services (P=0.9). Among those who received rehabilitation, NHWs were more likely to get inpatient rehabilitation (73%) compared with MAs (30%), P=0.016. MAs (51%) were much more likely to receive home rehabilitation services compared with NHWs (0%) (P=0.0017).

CONCLUSIONS

In this population-based study, MAs were more likely to receive home-based rehabilitation, whereas NHWs were more likely to get inpatient rehabilitation. This disparity may, in part, explain the worse stroke outcome in MAs.

Abstract TMP40: Sociodemographic Predictors of Return to Home after Inpatient Stroke Rehabilitation

Background: Interpersonal relationships are understudied components of the stroke treatment paradigm, which become important when patients require long-term care. In this study, we analyzed sociodemographic factors that impact return to home after inpatient rehabilitation (IR).

Methods: Stroke patients were identified by ICD9/10 code from a prospective multicenter rehabilitation registry between Jan 2005 & July 2016 (n=6447). Patients were analyzed based upon "Home" vs "Not Home" or "Married" vs "Not Married" groups. Descriptive statistics were provided for all patients. Marital status was used as a proxy for caregiver support. We hypothesized that increased discharge functional independence measure (FIM), ambulation and no insurance predicted return to home. A “return home model” was developed using multivariable regression with a stepwise approach. Odds ratio & 95% CI were calculated.

Results: 5378 patients returned Home, 1069 did not return Home. Home patients tended to be younger, married, ambulatory and minorities, with a discharge FIM>75 (p<0.0001). Aphasia, dysphagia and UTI were significantly higher in the “Not Home” group (p<0.0001). Married patients had more stroke risk factors and impairments, indicating increased caregiver needs (Figure). In the model, being a minority and being a woman increased the odds of returning home. Advancing age, being widowed, divorced, separated or never married decreased the odds of returning home. We confirmed that ambulation, increasing discharge FIM and no insurance predicted return to home (Figure).

Conclusions: Being married, a woman or a minority increases the odds of returning home after inpatient rehabilitation. Caregiver training and social support for unmarried and male patients are important areas of improvement. Strategies to ensure the successful transition of stroke rehabilitation patients to home are needed, including prospective studies of non-spousal caregiver support.

Abstract WP390: The UTHealth Stomp Out Stroke Festival- A City Wide Public Education Initiative

Introduction: TJC certification for comprehensive stroke centers requires two annual public education activities on stroke prevention. One of our stroke faculty designed a multidisciplinary and multicultural program to educate the region and involved local businesses by establishing the UTHealth Stomp Out Stroke Festival.

Hypothesis: We analyzed the benefits to the community of sponsoring a city wide, multicultural stroke educational event

Methods: Implementation included establishing leadership and health screening providers, engaging educators and community stakeholders, recruiting volunteers and healthcare workers from hospital affiliates, pharmacy, rehabilitation and the schools of public health, nursing, dentistry, and medicine and developing a marketing and communication plan. Three areas for the event were created for Stroke Prevention, Stroke Recovery and a Kids Zone.

Results: 1st Festival was in 2013 with 100 participants, the 2nd in 2014 with 609 participants and the 3rd in 2015 with 1,261 participants. Over the 3 years, we have progressively increased the number of attendees, volunteers, health educators and community partners. Table 1 shows demographics for year 3. In year 3, we provided over 20,000 patient education materials, conducted 224 blood pressure screenings, completed 145 stroke risk scorecards, and provided FAST education to 109 children. Other assessments included BMI, cholesterol, bone density, fall risks, sleep apnea. We had 23 Chinese, 25 Spanish, and 10 Vietnamese health worker-translators.

Conclusion: We implemented a city wide public health initiative providing medical education, health screenings, and risk assessments to a highly ethnically diverse population in Houston. Major challenges include funding, needing volunteers and translators, engaging media, and maximizing community participation. Next steps will focus on determining the effectiveness to improve health literacy and behavioral health changes.

Acute Intravenous Tissue Plasminogen Activator Therapy does not Impact Community Discharge after Inpatient Rehabilitation

BACKGROUND AND PURPOSE

Discharge status and acute re-hospitalization are used as indicators of stroke severity and recovery. Intravenous t-PA (tissue plasminogen activator) is one of two treatments shown to have a positive impact. Stroke rehabilitation patients are an important population who will end up integrated back into the community, institutionalized or hospitalized due to late stroke complications. We sought to determine factors contributing to post rehabilitation discharge and acute re-hospitalization, in particular, the impact of t-PA therapy.

METHODS

Retrospective analysis of census data from ischemic stroke patients on the UTHealth Stroke/Neurorehabilitation Services at Memorial Hermann Hospital - Texas Medical Center between Jan 2011 and Nov 2013, discharged to the Community, SNF (Skilled Nursing Facility) or AC (Acute Care). Demographics and NIHSS (National Institutes of Health Stroke Scale) were collected. Discharge FIM (Functional Independence Measure) was the reference standard. Genitourinary infections were a negative mediator in the multivariate regression.

RESULTS

Of 346 patients, 274 returned to the community, 47 to SNF, and 25 to AC.

NIHSS AND T-PA THERAPY

Median NIHSS values were 8 in the community group, 11 in SNF and 9.5 in AC. 31.8% of patients received IV t-PA in the community group, 23.4% in SNF and 24% in AC. There were no statistically differences in community discharge rates.

COMMUNITY VS AC

One day increase in rehabilitation hospitalization correlated with 19% decreased odds of AC readmission (OR 0.81; P=0.001). One unit discharge FIM increase correlated with 13% decreased odds of AC readmission (OR 0.87; P=0.003).

COMMUNITY VS SNF

One year age increase correlated with 4% increased odds of SNF admission (OR 1.04; P=0.02).

CONCLUSIONS

Intense rehabilitation evidenced by FIM improvement and length of stay, impacts community discharge in mild to moderate stroke patients. t-PA had no effect. This study is limited by sample size, retrospective design and undetermined psychosocial factors.

Abstract T P227: The Safety of Pioglitazone for Hematoma Resolution in IntraCerebral Hemorrhage (SHRINC) Trial: Safety Results

Background and Objectives: Peroxisome proliferator activated receptor-gamma agonists, such as pioglitazone (PIO) enhanced hematoma resolution and improved functional recovery in our animal model of intracerebral hemorrhage (ICH). We conducted a translational Phase II randomized, controlled clinical trial to determine the maximum tolerated dose (MTD) of PIO in patients with spontaneous ICH and to explore the rate of hematoma resolution and clinical outcome.

Methods: Patients with spontaneous ICH within 24 hours of symptom onset were randomly allocated 1:1 to placebo or PIO. Patients received escalating doses of PIO daily for three days, followed by a 30mg maintenance dose for the duration of treatment. Duration of treatment was when 75% of the ICH had resolved as determined by serial MRI or 10 weeks of treatment, whichever occurred first. The primary safety outcome was mortality at Day 14. Secondary measures of safety include any mortality, symptomatic cerebral edema, congestive heart failure, edema, hypoglycemia, anemia, and hepatotoxicity. Secondary measures of efficacy include hematoma resolution and clinical outcome. The MTD was determined using the Continual Reassessment Method.

Results: From March 2009 to April 2013, 84 patients (42 PIO, 42 control) were enrolled into 11 dose tiers, with a planned range from 0.1-2.0 mg/kg/d. Table 1 demonstrates preliminary baseline and clinical characteristics of patients by treatment group. Overall, 2/84 patients died within 2 weeks after ICH; however mortality rate never exceeded prespecified criteria. The study will be complete in October 2013 and the treatment team remains blinded to treatment allocation. Secondary outcomes by treatment group and the MTD of PIO will be reported.

Conclusions: We have completed the treatment phase of the SHRINC Trial. Long term follow-up is on-going. These results will provide the foundation for an efficacy trial evaluating PIO as a potential treatment for patients with spontaneous ICH.

Neurorehabilitation: Five new things

Neurologists have a new toolbox of options for neurorehabilitation of disabling brain disorders such as stroke and traumatic brain injury. An emerging intellectual paradigm for neurologic recovery that includes neural regeneration, repair, and dynamic reorganization of functional neural systems, as well as increasing awareness of behavioral principles that may support best return to function and freedom, brought forward treatments based on experience-dependent learning, neurophysiologic stimulation, and a combination of these concepts. In this article, we summarize five rehabilitative approaches to watch: constraint therapy for motor and language recovery, synergy of motor-language rehabilitation, prism adaptation training and other virtual feedback approaches, and noninvasive magnetic and electrical brain stimulation.

Recovery after ischemic stroke: criteria for good outcome by level of disability at day 7

BACKGROUND

Ischemic stroke is a leading cause of morbidity. Assessing the chances of recovery is critical to optimize poststroke care.

METHODS

We used a cohort of patients from the Virtual International Stroke Trial Archive that participated in acute stroke trials (control arm) and were followed for 90 days. The cohort was grouped by day 7 (D7) modified Rankin scale (mRS) scores. Variables that were associated with good outcome (mRS 0-2 at 90 days) in the univariate analysis were entered into a logistic regression model to determine the independent good outcome criteria for each D7 mRS tier.

RESULTS

We analyzed 1,798 patients. The independent good outcome criteria identified for different mRS tiers were: D7 mRS of 3: age < or =70, 0-2 vascular risk factors, D7 NIH Stroke Scale (NIHSS) arm strength < or =1, D7 NIHSS language score = 0; D7 mRS of 4: age < or =70, male, D7 NIHSS facial palsy < or =1, D7 NIHSS visual = 0, D7 NIHSS leg strength < or =1, D7 NIHSS dysarthria = 0; D7 mRS of 5: age < or =70, IV tPA treatment, D7 NIHSS dysarthria = 0, D7 NIHSS leg strength < or =2. For each mRS tier, we observed a graded increase in the percentage of the primary and secondary end points with increase in the number of criteria.

CONCLUSIONS

We identified clinical variables that predict good outcome, are specific to each day 7 mRS tier, and enable easy and informative assessment of the patient's likelihood of achieving varying degrees of recovery at day 90. These results may be useful in both clinical practice and research but require validation in an independent patient cohort.