Bekelis Kimon, Missios Symeon, Coy Shannon, MacKenzie Todd A
Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.
The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA.
J Neurointerv Surg. 2016 Dec;8(12):1221-1225. doi: 10.1136/neurintsurg-2015-012145. Epub 2016 Jan 5.
Reperfusion times for ischemic stroke occurring in the outpatient setting have improved significantly in recent years. However, quality improvement efforts have largely ignored ischemic stroke occurring in patients hospitalized for unrelated indications.
We performed a cohort study involving patients with ischemic stroke (with inpatient or outpatient onset) from 2009 to 2013 who were registered in the Statewide Planning and Research Cooperative System (SPARCS) database. A propensity score-adjusted regression analysis was used to assess the association of location of onset and outcomes. Mixed effects methods were employed to control for clustering at the hospital level.
Of the 176 571 ischemic strokes, 160 157 (90.7%) occurred outside of a hospital and 16 414 (9.3%) occurred in patients hospitalized for unrelated indications. Using a logistic regression model with propensity score adjustment, we demonstrated that inpatient stroke onset was associated with increased inpatient mortality (OR 3.09; 95% CI 2.81 to 3.38), rate of discharge to rehabilitation (OR 2.57; 95% CI 2.37 to 2.79), and length of stay (LOS) (β=11.58; 95% CI 10.73 to 12.42). In addition, it was associated with lower odds (OR 0.69; 95% CI 0.62 to 0.77) of undergoing stroke-related interventions (mechanical thrombectomy and intravenous tissue plasminogen activator) compared with outpatient stroke onset.
Using a comprehensive all-payer cohort of patients with ischemic stroke in New York State, we identified an association of inpatient stroke onset with fewer stroke-related interventions and increased mortality, rate of discharge to rehabilitation, and LOS.
近年来，门诊环境中发生的缺血性卒中再灌注时间有了显著改善。然而，质量改进工作在很大程度上忽略了因无关指征住院的患者发生的缺血性卒中。
我们进行了一项队列研究，纳入了2009年至2013年在全州规划与研究合作系统（SPARCS）数据库中登记的缺血性卒中患者（包括住院起病或门诊起病）。采用倾向评分调整回归分析来评估起病部位与结局之间的关联。采用混合效应方法来控制医院层面的聚类情况。
在176571例缺血性卒中患者中，160157例（90.7%）发生在院外，16414例（9.3%）发生在因无关指征住院的患者中。使用倾向评分调整的逻辑回归模型，我们证明住院卒中起病与住院死亡率增加（比值比3.09；95%置信区间2.81至3.38）、转至康复机构的出院率（比值比2.57；95%置信区间2.37至2.79）以及住院时间（β=11.58；95%置信区间10.73至12.42）相关。此外，与门诊卒中起病相比，住院卒中起病接受卒中相关干预（机械取栓和静脉注射组织纤溶酶原激活剂）的几率较低（比值比0.69；95%置信区间0.62至0.77）。
通过对纽约州一个全面的所有付费方缺血性卒中患者队列进行研究，我们发现住院卒中起病与较少的卒中相关干预以及死亡率增加、转至康复机构的出院率和住院时间延长相关。
