Impact of the COVID-19 Pandemic on Acute Stroke Care, Time Metrics, Outcomes, and Racial Disparities in a Southeast Michigan Health System

Abstract

Background COVID-19 has impacted acute stroke care with several reports showing worldwide drops in stroke caseload during the pandemic. We studied the impact of COVID-19 on acute stroke care in our health system serving Southeast Michigan as we rolled out a policy to limit admissions and transfers. Methods in this retrospective study conducted at two stroke centers, we included consecutive patients presenting to the ED for whom a stroke alert was activated during the period extending from 3/20/20 to 5/20/20 and a similar period in 2019. We compared demographics, time metrics, and discharge outcomes between the two groups. Results of 385 patients presented to the ED during the two time periods, 58% were African American. There was a significant decrease in the number of stroke patients presenting to the ED and admitted to the hospital between the two periods ( p <0.001). In 2020, patients had higher presenting NIHSS (median: 2 vs 5, p = 0.012), discharge NIHSS (median: 2 vs 3, p = 0.004), and longer times from LKW to ED arrival (4.8 vs 9.4 h, p = 0.031) and stroke team activation (median: 10 vs 15 min, p = 0.006). In 2020, stroke mimics rates were lower among African Americans. There were fewer hospitalizations ( p <0.001), and transfers from outside facilities ( p = 0.015). Conclusion a trend toward faster stroke care in the ED was observed during the pandemic along with dramatically reduced numbers of ED visits, hospitalizations and stroke mimics. Delayed ED presentations and higher stroke severity characterized the African American population, highlighting deepening of racial disparities during the pandemic.

Trends in Stroke Presentations before and during the COVID-19 Pandemic: A Meta-Analysis

“…This may be related to possible delayed hospital arrival and an overall decrease in the absolute number of patients with mild and moderate stroke seeking medical care. 21,29,30,46,54,55,59,60,62,70 However, the likelihood of being treated with IVT did not differ between two periods in comprehensive stroke centers and that of being treated with EVT increased during the pandemic, which might be due to adequate changes made in workflow of acute stroke care in comprehensive stroke centers. 71 Higher likelihood of being treated with EVT might also have been caused by higher likelihood of large vessel occlusions due to prothrombotic state driven by COVID-19 virus, as reported by multiple studies.…”

“…8, Twenty-four studies met criteria for 'good' quality and 13 met criteria for 'fair' quality (Supplemetary Tables 2-4). Most studies compared the pandemic period (ranging from January to June 2020) to a similar period in the preceding year (range January to June 2019) [28][29][30][31]33,35,39,[41][42][43]45,46,[48][49][50]52,[54][55][56][57][58]60 or the months preceding the pandemic (range September 2019 to December 2019). 8,32,34,[36][37][38]40,44,47,51,53,59,[61][62][63]…”

“…The onset-to-door time was reported in 14/37 studies. 29,30,44,46,48,49,52,54,55,[57][58][59]61,63 There was no difference in mean onset-to-door time during pandemic when compared to pre-pandemic period (standardized mean difference=-0.2; 95% CI, -0.8 to 0.3).…”

Three-month functional outcomes following endovascular thrombectomy during the first wave of the COVID-19 pandemic: a Canadian single-center cohort study

“…Some studies conducted in the USA have highlighted that the pandemic has worsened disparities in healthcare access and outcomes following acute stroke, although these findings may perhaps be less applicable to countries such as Canada with universal public healthcare coverage. 20 21 …”

The American Society of Neuroradiology: Cultivating a Diverse and Inclusive Culture to Build a Stronger Organization

“…8 Disparities have also been shown in a number of disease processes in which neuroradiologists directly or indirectly provide clinical care, including stroke, 9,10 dementia, 11 pain management including osteoporotic compression fracture, 12,13 and head and neck cancer. 14 Furthermore, pre-existing disparities have been further exacerbated by the coronavirus disease 2019 (COVID-19) pandemic, [15][16][17][18] particularly in impoverished communities and communities of color. Although the root causes of health disparities are complex, they can be grouped into health system, patient, and provider factors.…”