Effects of Comprehensive Stroke Care Capabilities on In-Hospital Mortality of Patients with Ischemic and Hemorrhagic Stroke: J-ASPECT Study

Iihara, Koji; Nishimura, Kunihiro; Kada, Akiko; Nakagawara, Jyoji; Ogasawara, Kuniaki; Ono, Junichi; Shiokawa, Yoshiaki; Aruga, Toru; Miyachi, Shigeru; Nagata, Izumi; Toyoda, Kazunori; Matsuda, Shinya; Miyamoto, Yoshihiro; Suzuki, Akifumi; Ishikawa, Koichi; Kataoka, Hiroharu; Nakamura, Fumiaki; Kamitani, Satoru

doi:10.1371/journal.pone.0096819

Cited by 68 publications

(102 citation statements)

References 23 publications

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“…27 The present study is the first to compare outcomes for SAH patients treated with clipping and coiling via a mixed-model analysis of a large nationwide discharge database (DPC database) after adjustment for patient-level characteristics including age, sex, level of consciousness (JCS score), CCI score, and hospital-level CSC capabilities (CSC score). 14,15 Our results revealed that patients who had undergone coiling exhibited significantly higher in-hospital mortality (12.4% vs 8.7%) and shorter hospital stays (32.0 vs 37.0 days) than those in patients who had undergone clipping. The proportion of patients discharged with mRS scores of 3-6 (coiling 46.4%, clipping 42.9%) and median medical costs (thousands US$: coiling 35.7, clipping 36.7) were not significantly different between the groups.…”

Section: Discussionmentioning

confidence: 66%

“…Therefore, international, national, and longitudinal comparisons of outcomes for patients with SAH treated using different therapeutic modalities should be discussed in light of socioeconomic indicators, acute stroke care capabilities at the specific time, 13,14,26,28,31 and patient-level characteristics such as SAH severity. 27 The present study is the first to compare outcomes for SAH patients treated with clipping and coiling via a mixed-model analysis of a large nationwide discharge database (DPC database) after adjustment for patient-level characteristics including age, sex, level of consciousness (JCS score), CCI score, and hospital-level CSC capabilities (CSC score).…”

Section: Discussionmentioning

confidence: 99%

“…4 The JCS is the most widely used grading scale for assessing impaired consciousness in Japan (Supplementary Table S1). 14,29 This scale represented levels of consciousness upon admission regardless of whether patients had subsequently undergone ventriculostomy or CSF shunt placement.…”

Section: Sampling Strategymentioning

confidence: 99%

“…Although McDonald et al performed propensity score analysis to minimize potential selection bias, SAH severity was not included in the patient variables used to generate propensity scores, making interpretation of the results difficult. 17 On the other hand, SAH severity was adjusted by the JCS score 14,25,29 in the present study, minimizing its confounding effects. Notably, the importance of the JCS, first developed in 1974 for the prediction of stroke outcomes, has recently been validated.…”

Section: Unmeasured Confoundersmentioning

confidence: 99%

“…Given recently established evidence for the efficacy of mechanical thrombectomy in patients with acute ischemic stroke, a task force headed by the Japan Stroke Society and the Japan Neurosurgical Society has initiated an active discussion regarding the recommended items and criteria for the designation of primary stroke centers and CSCs in Japan, such as the CSC score. 14 …”

Section: Unmeasured Confoundersmentioning

confidence: 99%

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Effect of treatment modality on in-hospital outcome in patients with subarachnoid hemorrhage: a nationwide study in Japan (J-ASPECT Study)

Kurogi

Kada

Nishimura

et al. 2018

Journal of Neurosurgery

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ABBREVIATIONS BRAT = Barrow Ruptured Aneurysm Trial; CCI = Charlson Comorbidity Index; CSC = comprehensive stroke center; DPC = Diagnosis Procedure Combination; HAC = hospital-acquired condition; ISAT = International Subarachnoid Aneurysm Trial; JCS = Japan Coma Scale; mRS = modified Rankin Scale; PPV = positive predictive value; PSI = patient safety indicator; RCT = randomized controlled trial; SAH = subarachnoid hemorrhage. OBJECTIVE Although heterogeneity in patient outcomes following subarachnoid hemorrhage (SAH) has been observed across different centers, the relative merits of clipping and coiling for SAH remain unknown. The authors sought to compare the patient outcomes between these therapeutic modalities using a large nationwide discharge database encompassing hospitals with different comprehensive stroke center (CSC) capabilities. METHODS They analyzed data from 5214 patients with SAH (clipping 3624, coiling 1590) who had been urgently hospitalized at 393 institutions in Japan in the period from April 2012 to March 2013. In-hospital mortality, modified Rankin Scale (mRS) score, cerebral infarction, complications, hospital length of stay, and medical costs were compared between the clipping and coiling groups after adjustment for patient-level and hospital-level characteristics by using mixedmodel analysis. RESULTS Patients who had undergone coiling had significantly higher in-hospital mortality (12.4% vs 8.7%, OR 1.3) and a shorter median hospital stay (32.0 vs 37.0 days, p < 0.001) than those who had undergone clipping. The respective proportions of patients discharged with mRS scores of 3-6 (46.4% and 42.9%) and median medical costs (thousands US$, 35.7 and 36.7) were not significantly different between the groups. These results remained robust after further adjustment for CSC capabilities as a hospital-related covariate. SUBMITTED

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Section: Discussionmentioning

confidence: 66%

Section: Discussionmentioning

confidence: 99%

Section: Sampling Strategymentioning

confidence: 99%

Section: Unmeasured Confoundersmentioning

confidence: 99%

Section: Unmeasured Confoundersmentioning

confidence: 99%

See 3 more Smart Citations

Effect of treatment modality on in-hospital outcome in patients with subarachnoid hemorrhage: a nationwide study in Japan (J-ASPECT Study)

Kurogi

Kada

Nishimura

et al. 2018

Journal of Neurosurgery

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Effect of Bypassing the Closest Stroke Center in Patients with Intracerebral Hemorrhage

Ramos-Pachón,

Rodríguez-Luna,

Martí-Fàbregas

et al. 2023

JAMA Neurol

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ImportancePrehospital transfer protocols are based on rapid access to reperfusion therapies for patients with ischemic stroke. The effect of different protocols among patients receiving a final diagnosis of intracerebral hemorrhage (ICH) is unknown.ObjectiveTo determine the effect of direct transport to an endovascular treatment (EVT)–capable stroke center vs transport to the nearest local stroke center.Design, Setting, and ParticipantsThis was a prespecified secondary analysis of RACECAT, a multicenter, population-based, cluster-randomized clinical trial conducted from March 2017 to June 2020 in Catalonia, Spain. Patients were evaluated by a blinded end point assessment. All consecutive patients suspected of experiencing a large vessel occlusion stroke (Rapid Arterial Occlusion Evaluation Scale [RACE] score in the field &gt;4 on a scale of 0 to 9, with lower to higher stroke severity) with final diagnosis of ICH were included. A total of 1401 patients were enrolled in RACECAT with suspicion of large vessel occlusion stroke. The current analysis was conducted in October 2022.InterventionDirect transport to an EVT-capable stroke center (n = 137) or to the closest local stroke center (n = 165).Main Outcomes and MeasuresThe primary outcome was tested using cumulative ordinal logistic regression to estimate the common odds ratio (OR) and 95% CI of the shift analysis of disability at 90 days as assessed by the modified Rankin Scale (mRS) score (range, 0 [no symptoms] to 6 [death]) in the intention-to-treat population. Secondary outcomes, included 90-day mortality, death or severe functional dependency, early neurological deterioration, early mortality, ICH volume and enlargement, rate of neurosurgical treatment, rate of clinical complications during initial transport, and rate of adverse events until day 5.ResultsOf 1401 patients enrolled, 1099 were excluded from this analysis (32 rejected informed consent, 920 had ischemic stroke, 29 had transient ischemic attack, 12 had subarachnoid hemorrhage, and 106 had stroke mimic). Thus, 302 patients were included (204 [67.5%] men; mean [SD] age 71.7 [12.8] years; and median [IQR] RACE score, 7 [6-8]). For the primary outcome, direct transfer to an EVT-capable stroke center (mean [SD] mRS score, 4.93 [1.38]) resulted in worse functional outcome at 90 days compared with transfer to the nearest local stroke center (mean [SD] mRS score, 4.66 [1.39]; adjusted common OR, 0.63; 95% CI, 0.41-0.96). Direct transfer to an EVT-capable stroke center also suggested potentially higher 90-day mortality compared with transfer to the nearest local stroke center (67 of 137 [48.9%] vs 62 of 165 [37.6%]; adjusted hazard ratio, 1.40; 95% CI, 0.99-1.99). The rates of medical complications during the initial transfer (30 of 137 [22.6%] vs 9 of 165 patients [5.6%]; adjusted OR, 5.29; 95% CI, 2.38-11.73) and in-hospital pneumonia (49 of 137 patients [35.8%] vs 29 of 165 patients [17.6%]; OR, 2.61; 95% CI, 1.53-4.44) were higher in the EVT-capable stroke center group.Conclusions and RelevanceIn this secondary analysis of the RACECAT randomized clinical trial, bypassing the closest stroke center resulted in reduced chances of functional independence at 90 days for patients who received a final diagnosis of ICH.Trial RegistrationClinicalTrials.gov Identifier: NCT02795962

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Prevalence of delayed diagnosis of acute ischemic stroke in an acute care hospital: A single‐center cross‐sectional study in Japan

Takarada

Komagamine

Mito

2021

J of Gen and Family Med

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Backgrounds Given the short therapeutic window for evidence‐based therapies such as thrombolysis and endovascular treatment, it is important to immediately diagnose ischemic stroke. We investigated the prevalence of missed ischemic stroke diagnoses at initial contact and the proportion of potentially treatable patients without a delayed diagnosis. Methods A cross‐sectional study was conducted. A total of 408 consecutive patients hospitalized due to acute ischemic stroke were included. The primary outcome was a delayed diagnosis of ischemic stroke at initial contact. A diagnosis of stroke was judged to be delayed unless physicians made a diagnosis and initiated treatment for ischemic stroke during the initial contact. The secondary outcome was ischemic stroke with a missed therapeutic window for effective treatment due to delayed diagnosis. Results The median patient age was 78 years old, and the median time from onset to presentation was nine hours. A diagnosis of stroke was deemed delayed in 49 (12.0%) patients. In the multivariable analysis, presentation 48 hours or more after stroke onset (OR 2.45) and the improvement of neurological symptoms prior to presentation (OR 3.11) were independently associated with delayed diagnosis of ischemic stroke. Opportunities for effective treatment were missed in 18 (36.7%) of the 49 delayed diagnosis cases, although no patients missed opportunities for thrombectomy due to delayed diagnosis. Conclusions Even in the modern era, one out of every eight ischemic stroke cases was missed at the initial visit, and one‐third of missed stroke cases might be candidates for effective treatment without diagnostic delay.

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Effects of Comprehensive Stroke Care Capabilities on In-Hospital Mortality of Patients with Ischemic and Hemorrhagic Stroke: J-ASPECT Study

Cited by 68 publications

References 23 publications

Effect of treatment modality on in-hospital outcome in patients with subarachnoid hemorrhage: a nationwide study in Japan (J-ASPECT Study)

Effect of treatment modality on in-hospital outcome in patients with subarachnoid hemorrhage: a nationwide study in Japan (J-ASPECT Study)

Effect of Bypassing the Closest Stroke Center in Patients with Intracerebral Hemorrhage

Prevalence of delayed diagnosis of acute ischemic stroke in an acute care hospital: A single‐center cross‐sectional study in Japan

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