J Stroke Search

CLOSE


J Stroke > Volume 22(3); 2020 > Article
Chen, Liu, Chi, Sung, Hsieh, Lee, Tang, Jeng, and on Behalf of the Taiwan Stroke Society Investigators: Maintenance of Stroke Care Quality amid the Coronavirus Disease 2019 Outbreak in Taiwan
Dear Sir:
It is well known that the implementation of evidence-based stroke care guidelines can effectively improve outcomes and prevent recurrence in patients with stroke [1]. In 2010, Taiwan implemented a nationwide collaborative model called the Breakthrough Series (BTS)-Stroke activity, adapted from the Get With The Guideline-Stroke program; this significantly improved outcomes on quality measures of acute ischemic stroke (AIS) care [2].
During the coronavirus disease 2019 (COVID-19) pandemic, routine care of stroke may be compromised because of reallocation of medical resources. In Taiwan, the first confirmed COVID-19 case was reported on January 21, 2020. Because of the Taiwanese government’s aggressive containment efforts [3], the cumulative number of COVID-19 cases, as of May 2020, was as low as 442. Whether the number of daily admissions and quality metrics for stroke care changed during the COVID-19 pandemic period warrants investigation.
We retrospectively analyzed registry-based data from 18 hospitals in Taiwan, including seven medical centers and 11 community hospitals. The 18 hospitals were distributed in Taiwan’s different administrative districts and contained >65% of the total population (Supplementary Table 1). All the hospitals had participated in the BTS-Stroke activity [2]. The performance measures and safety indicators were modified from the original BTS-Stroke quality metrics established in 2010 (Supplementary Table 2) and were reviewed monthly. Individual patient-level information was de-identified before analysis. Number of monthly admissions of stroke (including ischemic and hemorrhagic stroke) and 15 quality-of-care metrics were compared between the main outbreak (March 2020), early outbreak (January and February 2020), and control (January to March 2019) phases, respectively. Since the BTS-Stroke activity mainly focused on the AIS-related quality metrics, number of AIS admission were further recorded. Detailed methods and statistical analyses are presented in the Supplementary methods.
As the cumulative number of COVID-19 cases increased, there was a significant decrease in mean daily stroke admissions in the first quarter of 2020 (β=−0.07, P<0.001), which was not observed in 2019 (β=−0.03, P=0.13) (Figure 1A). Similar trends were observed in medical centers (β=−0.07, P=0.007) and community hospitals (β=−0.07, P=0.02) (Figure 1B).
The comparison between the first quarter of 2019 and 2020 was presented in Table 1. The number of daily stroke admission were decreased in 2020 compared with 2019 (41.2 vs. 44.3; incidence rate ratio [IRR], 0.93; P=0.001) as well as AIS admission (29.9 vs. 32.6; IRR, 0.93; P=0.001). The quality metrics were generally comparable, and several metrics of intravenous thrombolysis, endovascular thrombectomy, early and discharge antithrombotic use, and rehabilitation evaluation even improved in 2020.
Table 2 presents the aggregated data of stroke admissions and quality metrics across different study periods. During the main outbreak phase, the number of daily stroke admission was 37.4, which was an absolute decrease of 13% compared to the early outbreak phase (43.2; IRR, 0.87; P<0.001) and an absolute decrease of 16% compared to the control phase (44.3; IRR, 0.84; P<0.001). Compared with the early outbreak phase, quality metrics were largely comparable except for fewer patients having a door-to-computed tomography time ≤25 minutes in the main outbreak phase (76.9% vs. 84.8%; odds ratio [OR], 0.59; P=0.03). However, when compared to the control phase, the proportion of patients who arrived within 2 hours from stroke onset (18.4% vs. 14.6%; OR, 1.31; P=0.01) and those who received endovascular thrombectomy (8.5% vs. 5.4%; OR, 1.62; P=0.001) increased in the main outbreak phase. The quality metrics of rehabilitation evaluation and stroke education also improved.
We found that most stroke quality measures during the current study periods considerably improved compared to the initial BTS-Stroke activity implementation period of 2010 to 2011 [2]. More importantly, the overall quality of acute stroke care was well-maintained or even further improved for several metrics during the early and main outbreak periods, indicating that the effect of the quality improvement program persists over time.
As expected, stroke admissions in Taiwan decreased by approximately 13% to 16% in the main COVID-19 outbreak phase in the main COVID-19 outbreak phase. However, the reduction appears much less than the global average of 42% reduction reported by the World Stroke Organization [4]. During the outbreak, patients with mild stroke symptoms may be less willing or may took longer time to visit the hospital [5]. Our data showed a trend of decreasing proportion of mild stroke (National Institutes of Health Stroke Scale [NIHSS] <4; 40.2% vs. 42.6%; OR, 0.91; P=0.07) and mild to moderate stroke (NIHSS <10; 73.3% vs. 76.0%; OR, 0.87; P=0.02) in 2020 compared with 2019. Besides, the number of early arrivals was higher in 2020 than 2019; these patients most likely had considerable neurological signs and were thus sent to hospitals earlier. The proportion of patients receiving acute reperfusion therapy did not decrease in 2020, suggesting that the quality of acute intervention of stroke were still maintained during the pandemic.
When encountering an outbreak of a highly contagious disease, the performance of timely and emergent acute stroke care could be compromised. Modification of the hyperacute stroke management protocol has been advocated during this pandemic in many countries, including Taiwan [6,7]. In this study, the proportion of patients with a door-to-computed tomography time ≤25 minutes was lower in the main outbreak phase, which would have resulted in delaying hyperacute stroke management [8]. Nevertheless, the proportion of patients with a door-to-needle time ≤60 minutes in our study was not affected, suggesting that the participating hospitals made their best effort to adhere to hyperacute stroke protocols.
The main limitation of our study was that we were able to use month-based hospital-level data only, and detailed individual patient-level data such as demographic profiles and stroke severities could not be analyzed. In addition, Taiwan was far less severely affected by the pandemic compared with other countries, hence the generalizability of our results should be taken into consideration.
In conclusion, we showed that the collateral adverse effect on stroke admission even in a country less affected by COVID-19. Well-implemented performance improvement program could lead to a fair maintenance of stroke care quality even during the public health crises.

Supplementary materials

Supplementary materials related to this article can be found online at https://doi.org/10.5853/jos.2020.02292.
Supplementary methods
jos-2020-02292-suppl1.pdf
Supplementary Table 1.
List of the participating hospitals and team members of the Taiwan Stroke Society Investigators
jos-2020-02292-suppl2.pdf
Supplementary Table 2.
List of the quality metrics of stroke care
jos-2020-02292-suppl3.pdf

Conflicts of Interest

The authors have no financial conflicts of interest.

Figure 1.
Trends of mean daily admissions of stroke between the first quarters of 2019 and 2020. (A) The rates of stroke and acute ischemic stroke (AIS) admissions decreased substantially over the first 3 months of 2020 (P<0.001 and P=0.03, respectively), but not in 2019 (P=0.13 and P=0.35, respectively). (B) The decrease of stroke admission rate in 2020 were consistently found in medical centers (P=0.007) and community hospitals (P=0.02). COVID-19, coronavirus disease 2019.
jos-2020-02292f1.jpg
Table 1.
Comparison of the stroke admissions and quality metrics between the first quarter of 2020 and 2019
Study periods Jan to Mar 2020 Jan to Mar 2019 Effect size, OR (95% CI)* P
Mean daily admissions, total (day average)
 All stroke 3,748 (41.19) 3,986 (44.29) 0.93 (0.89-0.97) 0.001
 AIS 2,734 (30.04) 2,916 (32.40) 0.93 (0.88-0.98) 0.001
 AIS, medical centers 1,464 (16.09) 1,565 (17.39) 0.93 (0.86-0.99) 0.03
 AIS, community hospitals 1,270 (13.96) 1,351 (15.01) 0.93 (0.86-1.00) 0.06
 Early arrival (<2 hr) of AIS 18.1% (496/2,734) 14.6% (427/2,916) 1.29 (1.12-1.49) <0.001
Stroke severity by NIHSS score
 <4/4-10/11-20/>20 1,060/874/424/282 1,237/972/421/277 0.11
 Mild stroke (NIHSS <4) 40.2% (1,060/2,640) 42.6% (1,237/2,907) 0.91 (0.81-1.01) 0.07
Quality metrics, % (numerator/denominator)
 Door-to-CT ≤25 min 82.3% (408/496) 83.6% (357/427) 0.91 (0.65-1.28) 0.59
 IV-tPA for early arrival 96.6% (198/205) 97.4% (151/155) 0.79 (0.24-2.59) 0.69
 IV-tPA percentage 8.8% (238/2,696) 6.3% (183/2,900) 1.44 (1.18-1.76) <0.001
 Door-to-needle ≤60 min 66.4% (148/223) 66.9% (119/178) 0.98 (0.65-1.49) 0.92
 Symptomatic ICH after IV-tPA 3.8% (9/237) 3.3% (6/182) 1.13 (0.41-3.13) 0.82
 EVT percentage 8.0% (216/2,692) 5.4% (158/2,912) 1.46 (1.18-1.81) <0.001
 Symptomatic ICH after EVT 10.2% (22/216) 7.6% (12/158) 1.36 (0.66-2.80) 0.41
 Dysphagia screening 96.6% (2,091/2,171) 95.7% (2,332/2,438) 1.19 (0.88-1.59) 0.26
 Early antithrombotics use 98.6% (2,245/2,277) 97.6% (2,504/2,566) 1.72 (1.12-2.65) 0.01
 Anticoagulants for AF 92.6% (349/377) 89.5% (323/361) 1.46 (0.88-2.43) 0.14
 Lipid-lowering drugs use 94.3% (1,183/1,255) 93.9% (1,289/1,373) 1.07 (0.77-1.48) 0.68
 Antithrombotics use at discharge 97.0% (2,181/2,248) 96.0% (2,394/2,495) 1.37 (1.00-1.87) 0.049
 Rehabilitation evaluation 91.1% (2,044/2,243) 87.6% (2,190/2,501) 1.46 (1.21-1.76) <0.001
 Stroke education 97.3% (2,116/2,174) 96.5% (2,330/2,414) 1.31 (0.94-1.84) 0.12
 30-day mortality 5.6% (129/2,318) 6.8% (174/2,559) 0.81 (0.64-1.02) 0.08
OR, odds ratio; CI, confidence interval; AIS, acute ischemic stroke; NIHSS, National Institutes of Health Stroke Scale; CT, computed tomography; IV-tPA, intravenous tissue plasminogen activator; ICH, intracerebral hemorrhage; EVT, endovascular thrombectomy; AF, atrial fibrillation.
* For rate data (case per day), the effect size was incidence rate ratio.
Table 2.
Comparison of the stroke admissions and quality metrics across the main outbreak phase, early outbreak, and control periods
Study periods Main outbreak (Mar 2020) Early outbreak (Jan to Feb 2020) Effect size (compared with Mar 2020), OR (95% CI)* P Control (Jan to Mar 2019) Effect size (compared with Mar 2020), OR (95% CI) P
Mean daily admissions, total (day average)
All stroke 1,158 (37.35) 2,590 (43.17) 0.87 (0.81-0.93) <0.001 3,986 (44.29) 0.84 (0.79-0.90) <0.001
AIS 870 (28.06) 1,864 (31.07) 0.90 (0.83-0.98) 0.01 2,916 (32.40) 0.87 (0.80-0.93) <0.001
AIS, medical centers 467 (15.06) 997 (16.62) 0.91 (0.81-1.01) 0.08 1,565 (17.39) 0.87 (0.78-0.96) 0.01
AIS, community hospitals 403 (13.00) 867 (14.45) 0.90 (0.80-1.01) 0.08 1,351 (15.01) 0.87 (0.77-0.97) 0.01
Early arrival (<2 hr) of AIS 18.4% (160/870) 18.0% (336/1,864) 1.03 (0.83-1.26) 0.82 14.6% (427/2,916) 1.31 (1.08-1.60) 0.01
Stroke severity by NIHSS score
<4/4-10/11-20/>20 348/266/140/86 712/608/284/196 0.62 1,237/972/421/277 0.36
Mild stroke (NIHSS <4) 41.4% (348/840) 39.6% (712/1,800) 1.08 (0.92-1.28) 0.36 42.6% (1,237/2,907) 0.96 (0.82-1.12) 0.56
Quality metrics, % (numerator/denominator)
Door-to-CT ≤25 min 76.9% (123/160) 84.8% (285/336) 0.59 (0.37-0.95) 0.03 83.6% (357/427) 0.65 (0.42-1.02) 0.06
IV-tPA for early arrival 96.6% (56/58) 96.6% (142/147) 0.87 (0.19-4.06) 0.86 97.4% (151/155) 0.67 (0.14-3.28) 0.62
IV-tPA percentage 7.4% (63/853) 9.5% (175/1,843) 0.76 (0.57-1.03) 0.08 6.3% (183/2,900) 1.19 (0.89-1.60) 0.25
Door-to-needle ≤60 min 64.9% (37/57) 66.9% (111/166) 0.91 (0.48-1.71) 0.77 66.9% (119/178) 0.91 (0.49-1.70) 0.77
Symptomatic ICH after IV-tPA 6.3% (4/63) 2.9% (5/174) 2.33 (0.64-8.45) 0.20 3.3% (6/182) 2.05 (0.59-7.13) 0.26
EVT percentage 8.5% (73/859) 7.8% (143/1,833) 1.10 (0.82-1.48) 0.52 5.4% (158/2,912) 1.62 (1.22-2.17) 0.001
Symptomatic ICH after EVT 12.3% (9/73) 9.1% (13/143) 1.42 (0.59-3.46) 0.43 7.6% (12/158) 1.73 (0.70-4.24) 0.23
Dysphagia screening 97.4% (608/624) 96.3% (1,489/1,547) 1.45 (0.83-2.52) 0.19 95.7% (2,332/2,438) 1.68 (0.995-2.85) 0.05
Early antithrombotics use 98.8% (666/674) 98.5% (1,579/1,603) 1.22 (0.55-2.67) 0.63 97.6% (2,504/2,566) 1.96 (0.95-4.03) 0.07
Anticoagulants for AF 89.0% (97/109) 94.0% (252/268) 0.51 (0.24-1.11) 0.09 89.5% (323/361) 0.93 (0.47-1.83) 0.83
Lipid-lowering drugs use 92.7% (354/382) 95.0% (829/873) 0.67 (0.41-1.09) 0.10 93.9% (1,289/1,373) 0.82 (0.52-1.27) 0.36
Antithrombotics use at discharge 96.1% (647/673) 97.4% (1,534/1,575) 0.66 (0.40-1.09) 0.10 96.0% (2,394/2,495) 1.04 (0.67-1.60) 0.88
Rehabilitation evaluation 91.1% (617/677) 91.1% (1,427/1,566) 1.00 (0.73-1.37) 0.99 87.6% (2,190/2,501) 1.45 (1.09-1.94) 0.01
Stroke education 98.7% (628/636) 96.7% (1,488/1,538) 2.51 (1.21-5.22) 0.01 96.5% (2,330/2,414) 2.68 (1.32-5.46) 0.01
30-day mortality 5.3% (40/750) 5.7% (89/1,568) 0.94 (0.64-1.38) 0.76 6.8% (174/2,559) 0.78 (0.55-1.11) 0.17
OR, odds ratio; CI, confidence interval; AIS, acute ischemic stroke; NIHSS, National Institutes of Health Stroke Scale; CT, computed tomography; IV-tPA, intravenous tissue plasminogen activator; ICH, intracerebral hemorrhage; EVT, endovascular thrombectomy; AF, atrial fibrillation.
* The effect size was the result of the early outbreak phase (Jan to Feb 2020) compared with the main outbreak phase (Mar 2020): incidence rate ratio for rate data (case per day) and OR for percentage data;
The effect size was the result of the control phase (Jan to Mar 2019) compared with the main outbreak phase (Mar 2020): incidence rate ratio for rate data (case per day) and OR for percentage data.

References

1. Schwamm LH, Fonarow GC, Reeves MJ, Pan W, Frankel MR, Smith EE, et al. Get With The Guidelines-Stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack. Circulation 2009;119:107-115.
crossref pmid
2. Hsieh FI, Jeng JS, Chern CM, Lee TH, Tang SC, Tsai LK, et al. Quality improvement in acute ischemic stroke care in Taiwan: the breakthrough collaborative in stroke. PLoS One 2016;11:e0160426.
crossref
3. Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan: big data analytics, new technology, and proactive testing. JAMA 2020;323:1341-1342.
crossref pmid pdf
4. Liu R, Zhao J, Fisher M. The global impact of COVID-19 on acute stroke care. CNS Neurosci Ther 2020;26:1103-1105.
crossref pmc
5. Teo KC, Leung WCY, Wong YK, Liu RKC, Chan AHY, Choi OMY, et al. Delays in stroke onset to hospital arrival time during COVID-19. Stroke 2020;51:2228-2231.
crossref pmid
6. Khosravani H, Rajendram P, Notario L, Chapman MG, Menon BK. Protected code stroke: hyperacute stroke management during the coronavirus disease 2019 (COVID-19) pandemic. Stroke 2020;51:1891-1895.
crossref pmid pmc
7. Lin PY, Chang YM, Huang CY, Lin CH, Chuang MT, Chen PL, et al. Management of hyperacute stroke during the coronavirus disease of 2019 pandemic: the modified code stroke in a medical center in Taiwan. J Stroke 2020;22:278-281.
crossref pmid pmc pdf
8. Kerleroux B, Fabacher T, Bricout N, Moïse M, Testud B, Vingadassalom S, et al. Mechanical thrombectomy for acute ischemic stroke amid the COVID-19 outbreak: decreased activity, and increased care delays. Stroke 2020;51:2012-2017.
crossref pmid


ABOUT JoS
AUTHOR INFORMATION
ARTICLE CATEGORY

Browse all articles >

BROWSE ARTICLES
Editorial Office
Department of Neurology, Asan Medical Center,Ulsan University College of Medicine
88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
Submission, status and progress, etc ⟫ E-mail: editor@j-stroke.org
Website and system ⟫ E-mail: journal@m2community.co.kr
Publishing company ⟫ E-mail: jin@ijpnc.com
Developed in M2community
Copyright © 2020 by Korean Stroke Society. All rights reserved.
Close layer
prev next