Maintenance of Stroke Care Quality amid the Coronavirus Disease 2019 Outbreak in Taiwan

Article information

J Stroke. 2020;22(3):407-411

Publication date (electronic) : 2020 September 29

doi : https://doi.org/10.5853/jos.2020.02292

Chih-Hao Chen^a, Chi-Hung Liu^b, Nai-Fang Chi^c, Pi-Shan Sung^d, Cheng-Yang Hsieh^e, Meng Lee^f, Sung-Chun Tang^,a, Jiann-Shing Jeng^a, on Behalf of the Taiwan Stroke Society Investigators

^aDepartment of Neurology, National Taiwan University Hospital, Taipei, Taiwan

^bDepartment of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan

^cDepartment of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan

^dDepartment of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan

^eDepartment of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan

^fDepartment of Neurology, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan

Correspondence: Sung-Chun Tang Department of Neurology, National Taiwan University Hospital, No. 7, ChungShan South Road, Taipei 100, Taiwan Tel: +886-2-23562144 Fax: +886-2-23418395 E-mail: sctang@ntuh.gov.tw

Received 2020 June 12; Revised 2020 July 31; Accepted 2020 August 3.

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).

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.

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 1.

Comparison of the stroke admissions and quality metrics between the first quarter of 2020 and 2019

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.

Table 2.

Comparison of the stroke admissions and quality metrics across the main outbreak phase, early outbreak, and control periods

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.