Ayubcha Cyrus, Smulowitz Peter, O'Malley James, Moura Lidia, Zaborski Lawrence, McWilliams J Michael, Landon Bruce E
Department of Epidemiology, Harvard Chan School of Public Health, Boston, MA.
Harvard Medical School, Boston, MA.
Neurol Clin Pract. 2025 Apr;15(2):e200436. doi: 10.1212/CPJ.0000000000200436. Epub 2025 Jan 15.
Early presentation and acute treatment for patients presenting with ischemic stroke are associated with improved outcomes. The onset of the COVID-19 pandemic was associated with a large decrease in patients presenting with ischemic stroke, but it is unknown whether these changes persisted.
This study analyzed emergency department (ED) stroke presentations (n = 158,060) to all nonfederal hospitals in the 50 states and Washington, D.C., from 2019 through 2021 using administrative claims data of traditional fee-for-service Medicare enrollees aged 66 years or older. Patients presenting with stroke were identified using the ICD-10 CM (I63.X). We examined the number of beneficiaries presenting with ischemic stroke to the ED, both overall and by demographic categories (race, age, sex, region, Medicaid eligibility, comorbidity status), admission rates conditional on presentation, use of neurovascular interventions, thirty-day mortality, intensive care unit and mechanical ventilation use, length of stay, and discharge destination.
With the onset of the pandemic in March 2020, there was a drop of 32.1% in ED stroke presentations compared with March 2019 levels, and by December 2021, the rate remained 17.7% lower than baseline levels in December 2019. Relative to the prepandemic period, there were decreases in the proportions of those dually eligible for Medicaid (-0.8%, < 0.0001) or Black (-0.8%, < 0.0001), as well as those with atrial fibrillation (-1.1%, < 0.0001), hypertension (-0.7%, < 0.0001), and chronic obstructive pulmonary disease (-1.8%, < 0.0001). Admitted patients were more often discharged to home as opposed to postacute care settings (+3.5%, < 0.0001). The percentage of patients receiving intravenous thrombolysis changed minimally while those receiving intracranial mechanical thrombectomy (+17.8%, < 0.0001) and carotid interventions (+6.9%, < 0.0001) increased from baseline throughout the pandemic. Adjusted thirty-day mortality or referral to hospice increased (+1.81%, < 0.0001) with larger increases seen among Black beneficiaries and those dually eligible for Medicaid.
After an initial sharp decline, stroke presentations remained substantially lower than at baseline through the end of 2021, especially among racial minority and those dually eligible for Medicaid. The observed increased mortality rates for those presenting with stroke may have resulted from later time of presentation after the onset of symptoms or preferential presentation of more vs less severe strokes.
对缺血性卒中患者进行早期诊断和急性治疗可改善预后。2019冠状病毒病（COVID-19）大流行的爆发与缺血性卒中患者数量大幅减少有关，但这些变化是否持续尚不清楚。
本研究利用66岁及以上传统按服务收费医疗保险参保人的行政索赔数据，分析了2019年至2021年美国50个州和华盛顿特区所有非联邦医院急诊科（ED）的卒中就诊情况（n = 158,060）。使用国际疾病分类第十版临床修正版（ICD-10 CM，I63.X）识别卒中患者。我们检查了急诊就诊的缺血性卒中受益人的数量，包括总体数量以及按人口统计学类别（种族、年龄、性别、地区、医疗补助资格、合并症状态）划分的数量、就诊后的住院率、神经血管介入治疗的使用情况、30天死亡率、重症监护病房和机械通气的使用情况、住院时间以及出院去向。
随着2020年3月大流行的爆发，与2019年3月相比，急诊科卒中就诊人数下降了32.1%，到2021年12月，该比率仍比2019年12月的基线水平低17.7%。与大流行前时期相比，同时符合医疗补助资格者（-0.8%，< 0.0001）或黑人（-0.8%，< 0.0001）、以及患有心房颤动者（-1.1%，< 0.0001）、高血压患者（-0.7%，< 0.0001）和慢性阻塞性肺疾病患者（-1.8%，< 0.0001）的比例有所下降。与急性后期护理机构相比，入院患者更多被送回家中（+3.5%，< 0.0001）。接受静脉溶栓治疗的患者比例变化极小，而接受颅内机械取栓治疗的患者（+17.8%，< 0.0001）和接受颈动脉介入治疗的患者（+6.9%，< 0.0001）在整个大流行期间均较基线有所增加。调整后的30天死亡率或临终关怀转诊率有所上升（+1.81%，< 0.0001），黑人受益人和同时符合医疗补助资格者的上升幅度更大。
在最初急剧下降之后，到2021年底，卒中就诊人数仍大幅低于基线水平，尤其是在少数族裔和同时符合医疗补助资格者中。观察到的卒中患者死亡率上升可能是由于症状出现后就诊时间延迟，或者是更严重与不太严重卒中的优先就诊情况所致。
