院内与院外发病卒中患者的卒中治疗与结局变化趋势比较——南伦敦卒中登记。
A comparison of trends in stroke care and outcomes between in-hospital and community-onset stroke - The South London Stroke Register.
机构信息
School of Population Health & Environmental Sciences, King's College London, London, United Kingdom.
NIHR Comprehensive Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom.
出版信息
PLoS One. 2019 Feb 21;14(2):e0212396. doi: 10.1371/journal.pone.0212396. eCollection 2019.
BACKGROUND
Stroke care and outcomes have improved significantly over the past decades. It is unclear if patients who had a stroke in hospital (in-hospital stroke, IHS) experienced similar improvements to those who were admitted with stroke (community-onset stroke, COS).
METHODS
Data from the South London Stroke Register were analysed to estimate trends in processes of care and outcomes across three cohorts (1995-2001, 2002-2008, 2009-2015). Kaplan-Meier survival curves were calculated for each cohort. Associations between patient location at stroke onset, processes of care, and outcomes were investigated using multiple logistic regression and Cox proportional hazards models.
RESULTS
Of 5,119 patients admitted to hospital and registered between 1995 and 2015, 552(10.8%) had IHS. Brain imaging rates increased from 92.4%(COS) and 78.3%(IHS) in 1995-2001 to 100% for COS and IHS in 2009-2015. Rates of stroke unit admission rose but remained lower for IHS (1995-2001: 32.2%(COS) vs. 12.4%(IHS), 2002-2008: 77.1%(COS) vs. 50.0%(IHS), 2009-2015: 86.3%(COS) vs. 65.4%(IHS)). After adjusting for patient characteristics and case-mix, IHS was independently associated with lower rates of stroke unit admission in each cohort (1995-2001: OR 0.49, 95%CI 0.29-0.82, 2002-2008: 0.29, 0.18-0.45, 2009-2015: 0.22, 0.11-0.43). In 2009-2015, thrombolysis rates were lower for ischaemic IHS (17.8%(COS) vs. 13.8%(IHS)). Despite a decline, in-hospital mortality remained significantly higher after IHS in 2009-2015 (13.7%(COS) vs. 26.7%(IHS)). Five-year mortality rates declined for COS from 58.9%(1995-2001) to 35.2%(2009-2015) and for IHS from 80.8%(1995-2001) to 51.1%(2009-2015). In multivariable analysis, IHS was associated with higher mortality over five years post-stroke in each cohort (1995-2001: HR 1.27, 95%CI 1.03-1.57, 2002-2008: 1.24, 0.99-1.55, 2009-2016: 1.39, 0.95-2.04).
CONCLUSIONS
Despite significant improvements for IHS patients similar to those for COS patients, rates of stroke unit admission and thrombolysis remain lower, and short- and long-term outcomes poorer after IHS. Factors preventing IHS patients from entering evidence-based stroke-specific hospital pathways in a timely fashion need further investigation.
背景
在过去的几十年中，中风护理和结果有了显著的改善。目前尚不清楚在医院发生中风的患者（院内中风，IHS）是否经历了与因中风入院的患者（社区发病中风，COS）类似的改善。
方法
分析了来自伦敦南部中风登记处的数据，以估计三个队列（1995-2001 年、2002-2008 年和 2009-2015 年）的护理流程和结果趋势。为每个队列计算了 Kaplan-Meier 生存曲线。使用多因素逻辑回归和 Cox 比例风险模型研究了患者发病时的位置、护理流程和结果之间的关系。
结果
在 1995 年至 2015 年期间登记的 5119 名住院患者中，有 552 名（10.8%）患有 IHS。脑部成像率从 1995-2001 年的 92.4%（COS）和 78.3%（IHS）增加到 2009-2015 年的 100%，COS 和 IHS 均为 100%。卒中单元入院率上升，但仍低于 IHS（1995-2001 年：32.2%（COS）与 12.4%（IHS），2002-2008 年：77.1%（COS）与 50.0%（IHS），2009-2015 年：86.3%（COS）与 65.4%（IHS））。在调整患者特征和病例组合后，IHS 与每个队列中卒中单元入院率较低独立相关（1995-2001 年：OR 0.49，95%CI 0.29-0.82，2002-2008 年：0.29，0.18-0.45，2009-2015 年：0.22，0.11-0.43）。在 2009-2015 年，缺血性 IHS 的溶栓率较低（17.8%（COS）与 13.8%（IHS））。尽管有所下降，但 2009-2015 年 IHS 后的院内死亡率仍显著较高（13.7%（COS）与 26.7%（IHS））。COS 的五年死亡率从 1995-2001 年的 58.9%下降到 2009-2015 年的 35.2%，IHS 的五年死亡率从 1995-2001 年的 80.8%下降到 2009-2015 年的 51.1%。多变量分析显示，IHS 与每个队列五年后卒中死亡率升高相关（1995-2001 年：HR 1.27，95%CI 1.03-1.57，2002-2008 年：1.24，95%CI 0.99-1.55，2009-2016 年：1.39，95%CI 0.95-2.04）。
结论
尽管 IHS 患者的改善与 COS 患者相似，但卒中单元入院率和溶栓率仍较低，IHS 后短期和长期结果较差。需要进一步调查导致 IHS 患者未能及时进入基于证据的中风特定医院途径的因素。
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