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BackgroundThe most recent time trends on intravenous thrombolysis (IVT) utilization for acute ischemic stroke was reported in 2011 using the Get with the Guidelines. Our objectives are to assess and validate the change in IVT utilization through 2014 in a national sample of Medicare beneficiaries and to examine the effect of patient, stroke center designation, and geography on IVT utilization.MethodsWe built a comprehensive national stroke registry by combining patient-level, stroke center status, and geographical characteristics, using multiple data sources. Using multiple national administrative databases from 2007 to 2014, we generated a mixed-effect logistic regression model to characterize the independent associations of patient, hospital, and geographical characteristics with IVT in 2014.ResultsUse of IVT increased consistently from 2.8% in 2007 to 7.7% in 2014, P < 0.001. Between group differences persisted, with lower odds of use in patients who were ≥86 years (aOR 0.74, 95% CI 0.65–0.83), Black (aOR 0.73, 95% CI 0.61–0.87), or treated at a rural hospital (aOR 0.88, 95% CI 0.77–1.00). Higher odds of use were observed in patients who arrived by ambulance (aOR 2.67, 95% CI 2.38–3.00), were treated at a hospital certified as a stroke center (aOR 1.96, 95% CI 1.68–2.29), or were treated at hospitals located in the most socioeconomically advantaged areas (aOR 1.27, 95% CI 1.05–1.54).ConclusionsBetween 2007 and 2014, the frequency of IVT for patients with acute ischemic stroke increased substantially, though differences persisted in the form of less frequent treatment associated with certain characteristics. These findings can inform ongoing efforts to optimize the delivery of IVT to all AIS patients nationwide.

Introduction: Patients who require invasive mechanical ventilation (IMV) often represent a sequence of care between the emergency department (ED) and intensive care unit (ICU). Despite being the most populous state, little information exists to define patterns of IMV use within the state of California. Methods: We examined data from the masked Patient Discharge Database of California’s Office of Statewide Health Planning and Development from 2000-2009. Adult patients who received IMV during their stay were identified using the International Classification of Diseases 9th Revision and Clinical Modification procedure codes (96.70, 96.71, 96.72). Patients were divided into age strata (18-34yr, 35-64yr, and >65yr). Using descriptive statistics and regression analyses, for IMV discharges during the study period, we quantified the number of ED vs. non-ED based admissions; changes in patient characteristics and clinical outcome; evaluated the marginal costs for IMV; determined predictors for prolonged acute mechanical ventilation (PAMV, i.e. IMV>96hr); and projected the number of IMV discharges and ED-based admissions by year 2020. Results: There were 696,634 IMV discharges available for analysis. From 2000–2009, IMV discharges increased by 2.8%/year: n=60,933 (293/100,000 persons) in 2000 to n=79,868 (328/100,000 persons) in 2009. While ED-based admissions grew by 3.8%/year, non-ED-based admissions remained stable (0%). During 2000-2009, fastest growth was noted for 1) the 35–64 year age strata; 2) Hispanics; 3) patients with non-Medicare public insurance; and 4) patients requiring PAMV. Average total patient cost-adjusted charges per hospital discharge increased by 29% from 2000 (from $42,528 to $60,215 in 2014 dollars) along with increases in the number of patients discharged to home and skilled nursing facilities. Higher marginal costs were noted for younger patients (ages 18-34yr), non-whites, and publicly insured patients. Some of the strongest predictors for PAMV were age 35-64 years (OR=1.12; 95% CI [1.09-1.14], p

Background The internet can contribute to improved access to information and services among underserved populations. Little is known about veterans' use of the internet for health, and how it is affected by socio-demographic characteristics. This knowledge gap is acute given the US Department of Veterans Affairs' (VA's) deployment of a major patient portal/personal health record system. Objectives To assess the frequency and correlates of veterans' use of the internet and identify personal characteristics impeding veterans' health-related internet use. Methods Survey of 12 878 randomly selected adults from a panel of 60 000 US households. Veterans were oversampled. Results Of the 3408 veterans responding, 54% had used the internet and 29% had used the internet specifically for health. In multi-variable analyses, general internet use was positively associated with younger age (OR = 0.03, CI = 0.01_0.06, oldest versus youngest group), higher income (OR = 3.12, CI = 2.10_4.63, _$75 000 versus Conclusions In the first large, systematic survey of veterans' internet usewe found that more education and urban location were strongly, and positively, associated with veterans' health-related internet use, even after controlling for multiple socio-demographic characteristics. Interventions may be needed for less educated and rural veterans, e.g. by providers discussing internet use with their patients, or by the VA training veterans in health-related internet use.