院内发病与社区发病缺血性卒中患者的临床特征、院内管理及结局：一项基于医院的队列研究
Clinical characteristics, in-hospital management, and outcomes of patients with in-hospital vs. community-onset ischaemic stroke: a hospital-based cohort study.
作者信息
Gu Hong-Qiu, Wang Chun-Juan, Yang Xin, Zhao Xing-Quan, Wang Yi-Long, Liu Li-Ping, Jiang Yong, Li Hao, Wang Yong-Jun, Li Zi-Xiao
机构信息
China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
出版信息
Lancet Reg Health West Pac. 2023 Aug 31;38:100890. doi: 10.1016/j.lanwpc.2023.100890. eCollection 2023 Sep.
BACKGROUND
Lack of high-quality national-level data on in-hospital ischaemic stroke hinders the development of tailored strategies for this subgroup's identification, treatment, and management.
METHODS
We analyzed and compared clinical characteristics, in-hospital management measures, and outcomes, including death or discharge against medical advice (DAMA), major adverse cardiovascular events (MACEs), disability at discharge, and in-hospital complications between in-hospital and community-onset ischaemic stroke enrolled in the Chinese Stroke Center Association registry from August 2015 to December 2022.
FINDINGS
The cohort comprised 14,948 in-hospital and 1,366,898 community-onset ischaemic stroke patients. In-hospital ischaemic stroke exhibited greater stroke severity, higher prevalence of comorbidities, more pre-admission medications, and had suboptimal management measures, for example, the onset-to-needle time within 4.5 h (83.3% vs. 93.1%; difference, -9.8% [-11.4% to -8.3%]), and antithrombotics at discharge (78.6% vs. 90.0%; difference, -11.4% [95% CI, -12.1% to -10.7%]). After adjusting for covariates, in-hospital ischaemic stroke remains associated with higher risks of unfavorable outcomes, including in-hospital death/DAMA (13.9% vs. 8.6%; adjusted risk difference [aRD], 2.2% [95% CI, 1.8%-2.7%]; adjusted odds ratio [aOR], 1.35 [95% CI, 1.25-1.45]), MACE (12.6% vs. 6.5%; aRD, 4.1% [95% CI, 3.5%-4.7%]; aOR, 1.68 [95% CI, 1.52-1.85]), and complications (23.7% vs. 12.1%; aRD, 6.5% [95% CI, 5.1%-7.9%]; aOR, 1.72 [95% CI, 1.64-1.80]), except for disability at discharge (41.1% vs. 33.1%; aRD, 0.4% [95% CI, -1.7% to 2.5%]; aOR, 0.99 [95% CI, 0.88-1.11]).
INTERPRETATION
In-hospital ischaemic stroke demonstrated more severe strokes, worse vascular risk profiles, suboptimal management measures, and worse outcomes compared to community-onset ischaemic stroke. This emphasizes the urgent need for improved hospital systems of care and targeted quality improvement initiatives for better outcomes in in-hospital ischaemic stroke.
FUNDING
National Key R&D Programme of China and Beijing Hospitals Authority.
背景
缺乏关于院内缺血性卒中的高质量国家级数据，阻碍了针对该亚组患者的识别、治疗和管理制定个性化策略。
方法
我们分析并比较了2015年8月至2022年12月在中国卒中中心联盟登记处登记的院内和社区发病缺血性卒中患者的临床特征、院内管理措施及结局，包括死亡或自动出院（DAMA）、主要不良心血管事件（MACE）、出院时残疾情况及院内并发症。
结果
该队列包括14948例院内缺血性卒中和1366898例社区发病缺血性卒中患者。院内缺血性卒中表现出更严重的卒中严重程度、更高的合并症患病率、更多的入院前用药，且管理措施欠佳，例如4.5小时内的发病至穿刺时间（83.3%对93.1%；差异为-9.8%[-11.4%至-8.3%]）以及出院时使用抗栓药物的情况（78.6%对90.0%；差异为-11.4%[95%CI，-12.1%至-10.7%]）。在对协变量进行调整后，院内缺血性卒中仍与不良结局的较高风险相关，包括院内死亡/DAMA（13.9%对8.6%；调整后风险差异[aRD]，2.2%[95%CI，1.8%-2.7%]；调整后比值比[aOR]，1.35[95%CI，1.25-1.45]）、MACE（12.6%对6.5%；aRD，4.1%[95%CI，3.5%-4.7%]；aOR，1.68[95%CI，1.52-1.85]）和并发症（23.7%对12.1%；aRD，6.5%[95%CI，5.1%-7.9%]；aOR，1.72[95%CI，1.64-1.80]），但出院时残疾情况除外（41.1%对33.1%；aRD，0.4%[95%CI，-1.7%至2.5%]；aOR，0.99[95%CI，0.88-1.11]）。
解读
与社区发病缺血性卒中相比，院内缺血性卒中表现出更严重的卒中、更差的血管风险状况、欠佳的管理措施及更差的结局。这强调了迫切需要改善医院护理系统并开展针对性的质量改进举措，以改善院内缺血性卒中的结局。
资助
中国国家重点研发计划和北京市医院管理局。
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