Temporal trends and rural-urban disparities in cerebrovascular risk factors,in-hospital management and outcomes in ischaemic strokes in China from 2005 to 2015:a nationwide serial cross-sectional survey

Background Stroke is the leading cause of mortality in China,with limited evidence of in-hospital burden obtained from nationwide surveys.We aimed to monitor and track the temporal trends and rural-urban disparities in cerebrovascular risk factors,management and outcomes from 2005 to 2015.Methods We used a two-stage random sampling survey to create a nationally representative sample of patients admitted for ischaemic stroke in 2005,2010 and 2015.We sampled participating hospitals with an economic-geographical region-stratified random-sampling approach first and then obtained patients with a systematic sampling approach.We weighed our survey data to estimate the national-level results and assess changes from 2005 to 2015.Results We analysed 28277 ischaemic stroke admissions from 189 participating hospitals.From 2005 to 2015,the estimated national hospital admission rate for ischaemic stroke per 100000 people increased(from 75.9 to 402.7,Ptrend<0.001),and the prevalence of risk factors,including hypertension,diabetes,dyslipidaemia and current smoking,increased.The composite score of diagnostic tests for stroke aetiology assessment(from 0.22 to 0.36,Ptrend<0.001)and secondary prevention treatments(from 0.46 to 0.70,Ptrend<0.001)were improved.A temporal decrease was found in discharge against medical advice(DAMA)(from 15.2%(95%CI 13.7%to 16.7%)to 8.6%(8.1%to 9.0%);adjusted Ptrend=0.046),and decreases in in-hospital mortality(0.7%in 2015 vs 1.8%in 2005;adjusted OR(aOR)0.52;95%CI 0.32 to 0.85)and the composite outcome of in-hospital mortality or DAMA(8.4%in 2015 vs 13.9%in 2005;aOR 0.65;95%CI 0.47 to 0.89)were observed.Disparities between rural and urban hospitals narrowed;however,disparities persisted in in-hospital management(brain MRI:rural-urban difference from−14.4%to−11.2%;cerebrovascular assessment:from−20.3%to−16.7%;clopidogrel:from−2.1%to−10.3%;anticoagulant for atrial fibrillation:from−10.9%to−8.2%)and in-hospital outcomes(DAMA:from 2.7%to 5.0%;composite outcome of in-hospital mortality or DAMA:from 2.4%to 4.6%).Conclusions From 2005 to 2015,improvements in hospital admission and in-hospital management for ischaemic stroke in China were found.A temporal improvement in DAMA and improvements in in-hospital mortality and the composite outcome of in-hospital mortality or DAMA were observed.Disparities between rural and urban hospitals generally narrowed but persisted.

The American Heart Association’s Get With the Guidelines(GWTG)-Stroke development and impact on stroke care

The American Heart Association’s Get With the Guidelines(GWTG)-Stroke programme has changed stroke care delivery in the USA since its establishment in 2003.GWTG is a voluntary registry and continuous quality improvement initiative that collects data on patient characteristics,hospital adherence to guidelines and inpatient outcomes.Implementation of the programme saw increased provision of evidence-based care and improved patient outcomes.This review will describe the development of the programme and discuss the impact on stroke outcomes and transformation of stroke care delivery that followed its implementation.

Outcomes of Medicare beneficiaries hospitalised with transient ischaemic attack and stratification using the ABCD^(2) score

Background Long-term outcomes for Medicare beneficiaries hospitalised with transient ischaemic attack(TIA)and role of ABCD^(2) score in identifying high-risk individuals are not studied.Methods We identified 40825 Medicare beneficiaries hospitalised from 2011 to 2014 for a TIA to a Get With The Guidelines(GWTG)-Stroke hospital and classified them using ABCD^(2)s of mortality and rehospitalisation(all-cause,ischaemic stroke,haemorrhagic stroke,myocardial infarction,and gastrointestinal and intracranial haemorrhage)for high-risk versus low-risk groups adjusted for patient and hospital characteristics.Results Of the 40825 patients,35118(86%)were high risk(ABCD^(2)≥4)and 5707(14%)were low risk(ABCD^(2)=0-3).Overall rate of mortality during 1-year follow-up after hospital discharge for the index TIA was 11.7%,44.3% were rehospitalised for any reason and 3.6%were readmitted due to stroke.Patients with ABCD^(2) score≥4 had higher mortality at 1 year than not(adjusted HR 1.18,95%CI 1.07 to 1.30).Adjusted risks for ischaemic stroke,all-cause readmission and mortality/all-cause readmission at 1 year were also significantly higher for patients with ABCD^(2) score≥4 vs 0-3.In contrast,haemorrhagic stroke,myocardial infarction,gastrointestinal bleeding and intracranial haemorrhage risk were not significantly different by ABCD^(2) score.Conclusions This study validates the use of ABCD^(2) score for long-term risk assessment after TIA in patients aged 65 years and older.Attentive efforts for community-based follow-up care after TIA are needed for ongoing prevention in Medicare beneficiaries who were hospitalised for TIA.

Patterns of antidepressant therapy and clinical outcomes among ischaemic stroke survivors

Background and purpose Depression is common after stroke and is often treated with antidepressant medications(AD).ADs have also been hypothesised to improve stroke recovery,although recent randomised trials were neutral.We investigated the patterns of in-hospital AD initiation after ischaemic stroke and association with clinical and readmission outcomes.Methods All Medicare fee-for-service beneficiaries aged 65 or older hospitalised for ischaemic stroke in participating Get With The Guidelines-Stroke hospitals between April and December 2014 were eligible for this analysis.Outcome measures included days alive and not in a healthcare institution(home time),all-cause mortality and readmission within 1-year postdischarge.Propensity score(PS)-adjusted logistic regression models were used to evaluate the associations between AD use and each outcome measure.We also compared outcomes in patients prescribed selective serotonin reuptake inhibitors(SSRIs)AD versus those prescribed non-SSRI ADs.Results Of 21805 AD naive patients included in this analysis,1835(8.4%)were started on an AD at discharge.Patients started on an AD had higher rates of depression and prior ischaemic stroke,presented with higher admission National Institutes of Health Stroke Scale score and were less likely to be discharged home.Similarly,patients started on an SSRI had lower rates of discharge to home.Adjusting for stroke severity,patients started on an AD had worse all-cause mortality,all-cause readmission,major adverse cardiac events,readmission for depression and decreased home-time.However,AD use was also associated with an increased risk for the sepsis,a falsification endpoint,suggesting the presence of residual confounding.Conclusions Patients with ischaemic stroke initiated on AD therapy are at increased risk of poor clinical outcomes and readmission even after PS adjustment,suggesting that poststroke depression requiring medication is a poor prognostic sign.Further research is needed to explore the reasons why depression is associated with worse outcome,and whether AD treatment modifies this risk or not.