Ferrone Nicholas G, Sanmartin Maria X, O'Hara Joseph, Ferrone Sophia R, Wang Jason J, Katz Jeffrey M, Sanelli Pina C
Northwell Health, New Hyde Park, NY (N.G.F., M.X.S., J.O.H., S.R.F., J.J.W., J.M.K., P.C.S.).
Institute of Health System Science at the Feinstein Institutes for Medical Research, Manhasset, NY (N.G.F., S.R.F., P.C.S.).
Stroke. 2025 Mar;56(3):591-602. doi: 10.1161/STROKEAHA.124.049169. Epub 2025 Jan 30.
Many national initiatives focus on promoting early hospital arrival of patients with acute ischemic stroke (AIS) because treatment effectiveness is time-dependent. However, several studies reported time-delays in hospital arrival, especially during the COVID-19 pandemic. Our purpose was to evaluate the 10-year trends in last known well to arrival (LKWA) time and assess disparities in patients with AIS.
A retrospective study of consecutive patients with AIS in the United States admitted to a large, socioeconomically diverse health care system in the New York metropolitan area was performed from 2014 to 2023. LKWA time groups were categorized according to treatment eligibility: 0 to 4.5, >4.5 to 24, and >24 hours. Demographic and clinical characteristics, treatment utilization, and modified Rankin Scale at discharge were extracted from electronic health records. Trend, bivariable, and multivariable logistic regression analyses were conducted.
A total of 11 563 patients with AIS were included with 53% (6163) LKWA 0 to 4.5, 34% (3988) LKWA >4.5 to 24, and 12% (1412) LKWA >24 groups. From 2014 to 2023, there was a significant downtrend in the early LKWA 0 to 4.5 (61%-46%) with uptrends in the later LKWA >4.5 to 24 (31%-43%) and LKWA >24 (8%-11%) groups (<0.001). In the LKWA >4.5 groups, the gap widened between racial categories after COVID (2021-2023; =0.004). Compared with LKWA 0 to 4.5, the LKWA >4.5 to 24 group was less likely to receive endovascular thrombectomy (<0.001) and more likely to have worse outcomes (modified Rankin Scale, 2-5; <0.001). LKWA >4.5 groups were more likely to be older >80 years of age (odds ratio, 1.33 [95% CIs, 1.11-1.58]), men (1.11 [1.03-1.20]), Black patients (1.21 [1.09-1.34]), Asian patients (1.20 [1.03-1.39]), Medicaid insurance (1.18 [1.08-1.29]), and low-income <$80 000 (1.39 [1.20-1.61]).
In the past decade, there was a significant uptrend in patients with AIS arriving in the late LKWA >4.5 groups. Socioeconomic disparities were observed with a persistent uptrend in non-White patients in the late LKWA >4.5 groups after the COVID pandemic. These findings highlight the need to implement targeted efforts to improve disparities in LKWA time in patients with AIS.
许多国家倡议都聚焦于促进急性缺血性卒中（AIS）患者尽早入院，因为治疗效果具有时间依赖性。然而，多项研究报告了入院延迟情况，尤其是在新冠疫情期间。我们的目的是评估从最后已知健康状态到入院（LKWA）时间的10年趋势，并评估AIS患者中的差异。
对2014年至2023年期间在美国纽约大都市地区一家大型、社会经济多元化医疗保健系统收治的连续AIS患者进行了一项回顾性研究。LKWA时间组根据治疗 eligibility分为：0至4.5小时、>4.5至24小时和>24小时。从电子健康记录中提取人口统计学和临床特征、治疗利用情况以及出院时的改良Rankin量表。进行了趋势分析、双变量分析和多变量逻辑回归分析。
共纳入11563例AIS患者，其中53%（6163例）LKWA为0至4.5小时，34%（3988例）LKWA为>4.5至24小时，12%（1412例）LKWA为>24小时组。从2014年到2023年，早期LKWA为0至4.5小时组有显著下降趋势（61% - 46%），而后期LKWA为>4.5至24小时组（31% - 43%）和LKWA为>24小时组（8% - 11%）有上升趋势（<0.001）。在LKWA为>4.5小时组中，新冠疫情后（2021 - 2023年）不同种族之间的差距扩大（P = 0.004）。与LKWA为0至4.5小时相比，LKWA为>4.5至24小时组接受血管内血栓切除术的可能性较小（<0.001），且预后较差（改良Rankin量表评分为2 - 5分；<0.001）的可能性更大。LKWA为>4.5小时组更有可能年龄大于80岁（优势比，1.33 [95%置信区间，1.11 - 1.58]）、为男性（1.11 [1.03 - 1.20]）、为黑人患者（1.21 [1.09 - 1.34]）、为亚洲患者（1.20 [1.03 - 1.39]）、拥有医疗补助保险（1.18 [1.08 - 1.29]）以及收入低于80000美元（1.39 [1.20 - 1.61]）。
在过去十年中，AIS患者到达后期LKWA为>4.5小时组的人数有显著上升趋势。观察到社会经济差异，新冠疫情后LKWA为>4.5小时组的非白人患者持续上升。这些发现凸显了实施针对性措施以改善AIS患者LKWA时间差异的必要性。
