ABSTRACT
Background: Pandemics may promote hospital avoidance among patients with emergencies, and added precautions may exacerbate treatment delays. Methods: We used linked administrative data and data from the Quality Improvement and Clinical Research Alberta Stroke Program – a registry capturing stroke-related data on the entire Albertan population(4.3 million) – to identify all patients hospitalized with stroke in the pre-pandemic(01/01/2016-27/02/2020) and COVID-19 pandemic(28/02/2020-30/08/2020) periods. We examined changes in stroke presentation rates and use of thrombolysis and endovascular therapy(EVT), adjusted for age, sex, comorbidities, and pre-admission care needs;and in workflow, stroke severity(National Institutes of Health Stroke Scale/NIHSS), and in-hospital outcomes. Results: We analyzed 19,531 patients with ischemic stroke pre-pandemic versus 2,255 during the pandemic. Hospitalizations/presentations dropped(weekly adjusted-incidence-rate-ratio[aIRR]:0.48,95%CI:0.46-0.50), as did population-level incidence of thrombolysis(aIRR:0.49,0.44-0.56) or EVT(aIRR:0.59,0.49-0.69). However, proportions of presenting patients receiving thrombolysis/EVT did not decline (thrombolysis:11.7% pre-pandemic vs 13.1% during-pandemic, aOR:1.02,0.75-1.38). For out-of-hospital strokes, onset-to-door times were prolonged(adjusted-coefficient:37.0-minutes, 95%CI:16.5-57.5), and EVT recipients experienced greater door-to-reperfusion delays(adjusted-coefficient:18.7-minutes,1.45-36.0). NIHSS scores and in-hospital mortality did not differ. Conclusions: The first COVID-19 wave was associated with a halving of presentations and acute therapy utilization for ischemic stroke at a population level, and greater pre-/in-hospital treatment delays. Our data can inform public health messaging and stroke care in future pandemic waves.
ABSTRACT
Background: Pandemics may promote hospital avoidance among patients with emergencies, and added precautions may exacerbate treatment delays. Methods: We used linked administrative data and data from the Quality Improvement and Clinical Research Alberta Stroke Program - a registry capturing stroke related data on the entire Albertan population (4.3 million) - to identify all patients hospitalized with stroke in the pre-pandemic (01/01/2016-27/02/2020) and COVID-19 pandemic (28/02/ 2020-30/08/2020) periods. We examined changes in stroke presentation rates and use of thrombolysis and endovascular therapy (EVT), adjusted for age, sex, comorbidities, and preadmission care needs;and in workflow, stroke severity (National Institutes of Health Stroke Scale/NIHSS), and in-hospital outcomes. Results: We analyzed 19,531 patients with ischemic stroke pre-pandemic versus 2,255 during the pandemic. Hospitalizations/presentations dropped (weekly adjusted-incidencerate-ratio[aIRR]:0.48,95%CI:0.46-0.50), as did population-level incidence of thrombolysis (aIRR:0.49,0.44-0.56) or EVT (aIRR:0.59,0.49-0.69). However, proportions of presenting patients receiving thrombolysis/EVT did not decline (thrombolysis:11.7% pre-pandemic vs 13.1% during-pandemic, aOR:1.02, 0.75-1.38). For out-of-hospital strokes, onset-to-door times were prolonged(adjusted-coefficient:37.0-minutes, 95%CI:16.5-57.5), and EVT recipients experienced greater door-to-reperfusion delays (adjusted-coefficient:18.7-minutes,1.45-36.0). NIHSS scores and in-hospital mortality did not differ. Conclusions: The first COVID-19 wave was associated with a halving of presentations and acute therapy utilization for ischemic stroke at a population level, and greater pre-/in-hospital treatment delays. Our data can inform public health messaging and stroke care in future pandemic waves.
ABSTRACT
Objective: To understand the effect of the COVID-19 pandemic on the presentation and treatment of acute ischemic stroke. Background: Pandemics may result in hospital avoidance among patients with emergencies, and the added demands of precautions during stroke codes may exacerbate treatment delays. There is a paucity of population-based data on these phenomena. Design/Methods: We extracted data from the Quality Improvement and Clinical Research(QuICR) Alberta Stroke Program, a Canadian population-based stroke registry capturing stroke-related data on the entire population of Alberta, Canada. We used linked administrative data to identify all patients hospitalized with stroke pre-COVID-19(1-January- 2016 to 27-February-2020) and post-COVID-19 (28-February-2020 to 30-June-2020). We used Poisson regressions to evaluate changes in stroke hospitalizations and use of thrombolysis and endovascular therapy(EVT), adjusted for age, sex, comorbidities, and continuing care needs. We compared proportions receiving treatment using logistic regressions, and compared workflow metrics and stroke severity (National Institutes of Health Stroke Scale, NIHSS) using generalized linear models. Results: We analyzed 19,531 patients with ischemic stroke pre-COVID-19 versus 1,400 postCOVID-19. Hospitalizations dropped post-COVID-19 (weekly aIRR:0.49,95%CI 0.46-0.52), as did incidence of thrombolysis (aIRR:0.50,0.42-0.59) and EVT (aIRR:0.56,0.44-0.72). However, the proportions of presenting patients receiving thrombolysis and EVT among all ischemic patients were unchanged (thrombolysis 12.9% pre- and post-COVID, aOR:0.86,0.58-1.29;EVT 6.2% pre- vs 6.8% post-COVID, aOR:1.30, 0.91-1.84). Call-to-ambulance-dispatch and call-toparamedics-on-scene times were prolonged post-COVID-19 (adjusted-coefficient for call-toparamedics-on-scene:9.05min, 5.41-12.7), and EVT recipients experienced a greater delay in CT-to-groin-puncture and door-to-groin-puncture times (e.g. CT-to-groin-puncture median 53min, IQR 35-79 pre- vs 73min, 44-108 post-COVID;adjusted-coefficient: 15.33min, 95%CI 2.09-28.6). Among treated patients, there were no relevant differences in NIHSS, onset-to-call, door-to-CT, or door-to-needle times. Conclusions: The pandemic was associated with a halving of presentations for ischemic stroke and use of acute therapies at a population level, and greater pre-hospital and in-hospital workflow delays. Our results may help inform public health messaging and help optimize stroke workflow.