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Objective: Initial stroke severity is a potent modifier of stroke outcomes but this information is difficult to obtain from electronic health record (EHR) data. This limits the ability to risk-adjust for evaluations of stroke care and outcomes at a population level. The purpose of this analysis was to develop and validate a predictive model of initial stroke severity using EHR data elements., Methods: This observational cohort included individuals admitted to a US Department of Veterans Affairs hospital with an ischemic stroke. We extracted 65 independent predictors from the EHR. The primary analysis modeled mild (NIHSS score 0-3) versus moderate/severe stroke (NIHSS score ≥4) using multiple logistic regression. Model validation included: (1) splitting the cohort into derivation (65%) and validation (35%) samples and (2) evaluating how the predicted stroke severity performed in regard to 30-day mortality risk stratification., Results: The sample comprised 15,346 individuals with ischemic stroke (n = 10,000 derivation; n = 5,346 validation). The final model included 15 variables and correctly classified 70.4% derivation sample patients and 69.4% validation sample patients. The areas under the curve (AUC) were 0.76 (derivation) and 0.76 (validation). In the validation sample, the model performed similarly to the observed NIHSS in terms of the association with 30-day mortality (AUC: 0.72 observed NIHSS, 0.70 predicted NIHSS)., Conclusions: EHR data can be used to construct a surrogate measure of initial stroke severity. Further research is needed to better differentiate moderate and severe strokes, enhance stroke severity classification, and how to incorporate these measures in evaluations of stroke care and outcomes., Competing Interests: Declaration of Competing Interest The authors have no disclosures to report., (Published by Elsevier Inc.)

Objective: To study factors associated with systolic blood pressure(SBP) control for patients post-discharge from an ischemic stroke or transient ischemic attack(TIA) during the early months of the COVID-19 pandemic compared to pre-pandemic periods within the Veterans Health Administration(VHA)., Materials and Methods: We analyzed retrospective data from patients discharged from Emergency Departments or inpatient admissions after an ischemic stroke or TIA. Cohorts consisted of 2,816 patients during March-September 2020 and 11,900 during the same months in 2017-2019. Outcomes included primary care or neurology clinic visits, recorded blood pressure readings and average blood pressure control in the 90-days post-discharge. Random effect logit models were used to compare clinical characteristics of the cohorts and relationships between patient characteristics and outcomes., Results: The majority (73%) of patients with recorded readings during the COVID-19 period had a mean post-discharge SBP within goal (<140 mmHg); this was slightly lower than the pre-COVID-19 period (78%; p=0.001). Only 38% of the COVID-19 cohort had a recorded SBP in the 90-days post-discharge compared with 83% of patients during the pre-pandemic period (p=0.001). During the pandemic period, 29% did not have follow-up primary care or neurologist visits, and 33% had a phone or video visit without a recorded SBP reading., Conclusions: Patients with an acute cerebrovascular event during the initial COVID-19 period were less likely to have outpatient visits or blood pressure measurements than during the pre-pandemic period; patients with uncontrolled SBP should be targeted for follow-up hypertension management., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests, (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Hospitalizations for acute ischemic stroke (AIS) and transient ischemic attack (TIA) decreased during the COVID-19 pandemic. We compared the quality of care and outcomes for patients with AIS/TIA before vs. during the COVID-19 pandemic across the United States Department of Veterans Affairs healthcare system., Methods: This retrospective cohort study compared AIS/TIA care quality before (March-September 2019) vs. during (March-September 2020) the pandemic. Electronic health record data were used to identify patient characteristics, quality of care and outcomes. The without-fail rate was a composite measure summarizing whether an individual patient received all of the seven processes for which they were eligible. Mixed effects logistic regression modeling was used to assess differences between the two periods., Results: A decrease in presentations occurred during the pandemic (N = 4360 vs. N = 5636 patients; p = 0.003) and was greater for patients with TIA (-30.4%) than for AIS (-18.7%). The without-fail rate improved during the pandemic (56.2 vs. before 50.1%). The use of high/moderate potency statins increased among AIS patients (OR 1.26 [1.06-1.48]) and remained unchanged among those with TIA (OR 1.04 [0.83,1.29]). Blood pressure measurement within 90-days of discharge was less frequent during the pandemic (57.8 vs. 89.2%, p < 0.001). Hypertension control decreased among patients with AIS (OR 0.73 [0.60-0.90]) and TIA (OR 0.72 [0.54-0.96]). The average systolic and diastolic blood pressure was 1.9/1.4 mmHg higher during the pandemic than before (p < 0.001). Compared to before, during the pandemic fewer AIS patients had a primary care visit (52.5% vs. 79.8%; p = 0.0001) or a neurology visit (27.9 vs. 41.1%; p = 0.085). Both 30- and 90-day unadjusted all-cause mortality rates were higher in 2020 (3.6% and 6.7%) vs. 2019 (2.9, 5.4%; p = 0.041 and p = 0.006); but these differences were not statistically significant after risk adjustment., Conclusions: Overall quality of care for patients with AIS/TIA did not decline during the COVID-19 pandemic., Competing Interests: Declaration of Competing Interest None., (Published by Elsevier Inc.)

Objectives: To determine the impact of admission among transient ischemic attack (TIA) patients in the emergency department (ED)., Study Design: Retrospective cohort study using national Veterans Health Administration data (2008)., Methods: We first analyzed whether admitted patients were discharged from the hospital with a diagnosis of TIA. We then analyzed whether admission was associated with a composite outcome (new stroke, new myocardial infarction, or death in the year after TIA) using multivariate logistic regression modeling with propensity score matching., Results: Among 3623 patients assigned a diagnosis of TIA in the ED, 2118 (58%) were admitted to the hospital or placed in observation compared with 1505 (42%) who were discharged from the ED. Among the 2118 patients who were admitted, 903 (43% of admitted group) were discharged from the hospital with a diagnosis of TIA, and 548 (26% of admitted group) were discharged with a diagnosis of stroke. Admitted patients were more likely than nonadmitted patients to receive processes of care (i.e., brain imaging, carotid imaging, echocardiography). In matched analyses using propensity scores, the 1-year composite outcome in the admitted group (15.3%) was not lower than the discharged group (13.3%, OR 1.17 [.94-1.46], P = .17)., Conclusions: Less than half of patients admitted with a diagnosis of TIA retained that diagnosis at hospital discharge. Although admitted patients were more likely to receive diagnostic procedures, we did not identify improvements in outcomes among admitted patients; however, evaluating care for patients with TIA is limited by the reliability of secondary data analysis., (Copyright © 2017 National Stroke Association. All rights reserved.)

Background: Screening instruments for obstructive sleep apnea (OSA), as used routinely to guide clinicians regarding patient referral for polysomnography (PSG), rely heavily on symptomatology. We sought to develop and validate a cerebrovascular disease-specific OSA prediction model less reliant on symptomatology, and to compare its performance with commonly used screening instruments within a population with ischemic stroke or transient ischemic attack (TIA)., Methods: Using data on demographic factors, anthropometric measurements, medical history, stroke severity, sleep questionnaires, and PSG from 2 independently derived, multisite, randomized trials that enrolled patients with stroke or TIA, we developed and validated a model to predict the presence of OSA (i.e., Apnea-Hypopnea Index ≥5 events per hour). Model performance was compared with that of the Berlin Questionnaire, Epworth Sleepiness Scale (ESS), the Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, and Gender instrument, and the Sleep Apnea Clinical Score., Results: The new SLEEP Inventory (Sex, Left heart failure, ESS, Enlarged neck, weight [in Pounds], Insulin resistance/diabetes, and National Institutes of Health Stroke Scale) performed modestly better than other instruments in identifying patients with OSA, showing reasonable discrimination in the development (c-statistic .732) and validation (c-statistic .731) study populations, and having the highest negative predictive value of all in struments., Conclusions: Clinicians should be aware of these limitations in OSA screening instruments when making decisions about referral for PSG. The high negative predictive value of the SLEEP INventory may be useful in determining and prioritizing patients with stroke or TIA least in need of overnight PSG., (Published by Elsevier Inc.)

Background: Risk-adjusted poststroke mortality has been proposed for use as a measure of stroke care quality. Although valid measures of stroke severity (e.g., the National Institutes of Health Stroke Scale [NIHSS]) are not typically available in administrative datasets, radiology reports are often available within electronic health records. We sought to examine whether admission head computed tomography data could be used to estimate stroke severity., Materials and Methods: Using chart review data from a cohort of acute ischemic stroke patients (1998-2003), we developed a radiographic measure ([BIS]) of stroke severity in a two-third development set and assessed in a one-third validation set. The retrospective NIHSS was dichotomized as mild/moderate (<10) and severe (≥10). We compared the association of this radiographic score with NIHSS and in-hospital mortality at the patient level., Results: Among 1348 stroke patients, 86.5% had abnormal findings on initial head computed tomography. The c-statistic for the BIS for modeling severe stroke (development, .581; validation, .579) and in-hospital mortality (development, .623; validation, .678) were generated., Conclusions: Although the c-statistics were only moderate, the BIS provided significant risk stratification information with a 2-variable score. Until administrative data routinely includes a valid measure of stroke severity, radiographic data may provide information for use in risk adjustment., (Published by Elsevier Inc.)

Background: Rapid brain imaging for ischemic stroke is important for patient outcomes. We sought to determine the proportion of ischemic stroke patients receiving brain imaging within the guideline-recommended 24 hours, and predictors of faster imaging among patients with acute symptoms., Methods: Retrospective analysis of Veterans Health Administration (VHA) Office of Performance Measurement Stroke Special Project data. Of 3000 ischemic stroke patients, secondary samples included 649 presenting within 6 hours of onset, and 217 potentially tissue plasminogen activator (tPA)-eligible patients (onset-to-arrival time <3 hours, National Institutes of Health Stroke Scale >2). Two linear regression models examined the association between door-to-imaging time and predictors among secondary samples, accounting for clustering within hospital., Results: Of the 3000 ischemic stroke patients, 97.1% had brain imaging within 24 hours. Among patients presenting within 6 hours of onset, median door-to-imaging time was 59 minutes (interquartile range [IQR], 33-109). Predictors of faster door-to-imaging time included elevated arrival blood pressure and stroke center presentation. Among the potentially tPA-eligible patients, median door-to-imaging time was 52 minutes (IQR, 31-105); no significant predictors were identified., Conclusions: Nearly all ischemic stroke patients at VHA hospitals have door-to-imaging time within 24 hours. There remains room for improvement for timely brain imaging among patients with acute symptom onset., (Copyright © 2015 National Stroke Association. All rights reserved.)

Background: Thrombocytopenia has been associated with increased mortality in nonstroke conditions. Because its role in acute ischemic stroke is less well understood, we sought to determine whether thrombocytopenia at admission for acute ischemic stroke was associated with in-hospital mortality., Methods: We used data from a retrospective cohort of stroke patients (1998-2003) at 5 U.S. hospitals. Risk factors considered included conditions that can lead to thrombocytopenia (e.g., liver disease), increase bleeding risk (e.g., hemophilia), medications with antiplatelet effects (e.g., aspirin), and known predictors of mortality (e.g., National Institutes of Health Stroke Scale and Charlson Comorbidity Index scores). Logistic regression modeling evaluated the adjusted association between thrombocytopenia, defined as platelets <100,000/μL, and in-hospital mortality., Results: Among 1233 acute ischemic stroke patients, thrombocytopenia was present in 2.3% (n = 28). A total of 6.1% (n = 75) of patients died in the hospital. In unadjusted analyses, thrombocytopenia was associated with higher mortality (8/28 [28.6%] v 67/1205 [5.6%]; P < .0001). Thrombocytopenia was also independently associated with in-hospital mortality after adjustment for National Institutes of Health Stroke Scale score and comorbidities, with an odds ratio of 6.6 (95% confidence interval 2.3-18.6)., Conclusions: Admission thrombocytopenia among patients presenting with acute ischemic stroke predicts in-hospital mortality., (Published by Elsevier Inc.)

Anemia is a known predictor of in-hospital mortality among patients with such vascular conditions as acute myocardial infarction, congestive heart failure, and chronic kidney disease. The role of anemia in patients with acute ischemic stroke is less well understood. We sought to examine the association between anemia at hospital admission and the combined outcome of in-hospital mortality and discharge to hospice in patients with acute ischemic stroke. We evaluated data from a retrospective cohort of consecutive ischemic stroke patients presenting within 48 hours of symptom onset at 5 hospitals between 1998 and 2003. Anemia was defined as an admission hematocrit value of <30%. Less severe stroke was defined as an admission National Institutes of Health Stroke Scale score of <10. The outcome was the combined endpoint of in-hospital mortality or discharge to hospice. Among 1306 patients with stroke, anemia was present on admission in 6.4%, and the combined outcome of death or discharge to hospice was present in 10.1%. Anemia was not associated with outcome in patients with severe stroke (anemia, 17.2% [5 of 29] vs no anemia, 28,4% [98 of 345]; P = .20), but was associated with outcome in patients with less severe stroke (anemia, 13.0% [7 of 54] vs no anemia, 2.5% [22 of 878]; P < .0001). After adjustment for stroke severity, admission anemia was independently associated with outcome in patients with less severe stroke (adjusted odds ratio, 4.17; 95% confidence interval, 1.47-11.90), but not in patients with more severe strokes (adjusted odds ratio, 0.82; 95% confidence interval, 0.30-2.22). Our data indicate that anemia is associated with in-hospital mortality or discharge to hospice in patients with less severe ischemic stroke., (Published by Elsevier Inc.)

Background: Some studies have found that older individuals are not as likely as their younger counterparts to be treated with some guideline-based stroke therapies. We examined whether age-related differences in inpatient quality of care exist among US veterans with ischemic stroke., Methods: This was a retrospective study of a national sample of veterans admitted to 129 Veterans Affairs medical centers for ischemic stroke during fiscal year 2007. Inpatient stroke care quality was examined across 14 inpatient processes of care, including dysphagia screening, National Institutes of Health Stroke Scale (NIHSS) score documentation, thrombolysis, deep venous thrombosis prophylaxis, antithrombotic therapy by hospital day 2 and at discharge, early ambulation, fall risk assessment, pressure ulcer risk assessment, rehabilitation needs assessment, atrial fibrillation management, lipid management, smoking cessation counseling, and stroke education., Results: Among the 3939 veterans with ischemic stroke, the mean age was 67.8 years (standard deviation, 11.5). The overall performance rate was >70% for 10 of the 14 quality indicators. In unadjusted analyses, older patients were less likely to receive lipid management, smoking cessation, NIHSS documentation, and early ambulation compared with younger patients; conversely, older patients were more likely to receive dysphagia screening and stroke education. After adjusting for demographic, clinical, and hospital level characteristics, the age-related differences in processes of care were less consistent; however, the youngest patients were more likely to receive smoking cessation counseling and the oldest patients were less likely to receive lipid management., Conclusions: Risk-adjusted inpatient stroke care quality varies little with age for veterans admitted to a Veterans Affairs medical center for acute ischemic stroke., (Published by Elsevier Inc.)

Previous research on echocardiography in patients with acute stroke has focused on identifying possible cardioembolic etiologies of the stroke, but physicians might also obtain echocardiography to guide the management of heart disease in stroke patients. The objectives of this study were to determine how frequently echocardiography is used in acute ischemic stroke patients, and to evaluate if receiving echocardiography is associated with new prescriptions for anticoagulant or cardiac medications. This secondary data analysis of a previous cohort study included medical records of acute ischemic stroke patients admitted to 1 of 10 acute-care hospitals in Connecticut from 1996 to 1998. A total of 58 of 119 (49%) acute ischemic stroke patients received echocardiography. Among these 58 patients, 43 (74%) received either a new prescription for anticoagulation or a new cardiac medication prescription (10 of 58 [17%] new anticoagulation only, 22 of 58 [38%] new cardiac medication only, and 11 of 58 [19%] both). New anticoagulant medications were prescribed more often in patients receiving echocardiography (21 of 58; 36%), than in patients not receiving echocardiography (10 of 61; 16%) (P = .014). In addition, new cardiac medications were prescribed more often in patients receiving echocardiography (34 of 58; 59%), than in patients not receiving echocardiography (24 of 61; 39%) (P = .035). Echocardiography is commonly obtained in patients with acute stroke, and its use is associated with both the prescription of new anticoagulation and new cardiac medications. Although previous research about the use of echocardiography in acute stroke has focused on its role in identifying stroke etiologies, future research should include an assessment of it use in treating concomitant heart disease.