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Hospital admission for stroke or transient ischemic attack among First Nations people with diabetes in Ontario: a population-based cohort study.

ABSTRACT: BACKGROUND:First Nations people have high rates of diabetes mellitus, which is a risk factor for stroke. We studied the rates of hospital admission, processes of care and outcomes of stroke and transient ischemic attack (TIA) in First Nations people in Ontario. METHODS:Using linked administrative databases, we identified annual cohorts of people aged 20-105 years in Ontario with prevalent diabetes between Apr. 1, 1995, and Mar. 31, 2015. We identified Status First Nations people in Ontario from the Indian Register. We compared age- and sex-standardized rates of hospital admission for stroke or TIA, processes of care and case fatality among First Nations versus other people in Ontario with diabetes. RESULTS:Overall, 28 874 people with diabetes (of whom 536 were First Nations people) were admitted to hospital with a stroke or TIA between Apr. 1, 2011, and Mar. 31, 2016. Admission rates for stroke or TIA declined over the study period but were higher among First Nations people than other Ontarians in most years after 2005/06. First Nations people admitted with stroke or TIA were as likely as other Ontarians to undergo neuroimaging within 24 hours (94.6% v. 96.0%), be discharged to inpatient rehabilitation (31.8% v. 34.8%) and receive carotid revascularization (1.4% v. 2.7%), but were less likely to receive thrombolysis (6.3% v. 11.0%). Age- and sex-standardized stroke case fatality was similar in First Nations people and other Ontarians at 7 days (12.0% v. 8.5%), 30 days (19.2% v. 16.0%) and 1 year (33.8% v. 28.1%). INTERPRETATION:Rates of hospital admission for stroke or TIA were higher among First Nations people than other people with diabetes in Ontario. Future work should focus on determining Indigenous-specific determinants of health related to this disparity and implementing appropriate interventions to mitigate the risks and sequelae of stroke in First Nations people.

SUBMITTER: Kapral MK

PROVIDER: S-EPMC7082109 | biostudies-literature | 2020 Jan-Mar

REPOSITORIES: biostudies-literature

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Hospital admission for stroke or transient ischemic attack among First Nations people with diabetes in Ontario: a population-based cohort study.

Kapral Moira K MK Shah Baiju R BR Green Michael E ME Porter Joan J Griffiths Rebecca R Frymire Eliot E Slater Morgan M Jacklin Kristen K Sutherland Roseanne R Walker Jennifer D JD

CMAJ open 20200101 1

<h4>Background</h4>First Nations people have high rates of diabetes mellitus, which is a risk factor for stroke. We studied the rates of hospital admission, processes of care and outcomes of stroke and transient ischemic attack (TIA) in First Nations people in Ontario.<h4>Methods</h4>Using linked administrative databases, we identified annual cohorts of people aged 20-105 years in Ontario with prevalent diabetes between Apr. 1, 1995, and Mar. 31, 2015. We identified Status First Nations people i ...[more]

PMID: 32184279

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Project description:BackgroundPatients with ischemic stroke or transient ischemic attack (TIA) are at increased risk for future cardiovascular events despite current preventive therapies. The identification of insulin resistance as a risk factor for stroke and myocardial infarction raised the possibility that pioglitazone, which improves insulin sensitivity, might benefit patients with cerebrovascular disease.MethodsIn this multicenter, double-blind trial, we randomly assigned 3876 patients who had had a recent ischemic stroke or TIA to receive either pioglitazone (target dose, 45 mg daily) or placebo. Eligible patients did not have diabetes but were found to have insulin resistance on the basis of a score of more than 3.0 on the homeostasis model assessment of insulin resistance (HOMA-IR) index. The primary outcome was fatal or nonfatal stroke or myocardial infarction.ResultsBy 4.8 years, a primary outcome had occurred in 175 of 1939 patients (9.0%) in the pioglitazone group and in 228 of 1937 (11.8%) in the placebo group (hazard ratio in the pioglitazone group, 0.76; 95% confidence interval [CI], 0.62 to 0.93; P=0.007). Diabetes developed in 73 patients (3.8%) and 149 patients (7.7%), respectively (hazard ratio, 0.48; 95% CI, 0.33 to 0.69; P<0.001). There was no significant between-group difference in all-cause mortality (hazard ratio, 0.93; 95% CI, 0.73 to 1.17; P=0.52). Pioglitazone was associated with a greater frequency of weight gain exceeding 4.5 kg than was placebo (52.2% vs. 33.7%, P<0.001), edema (35.6% vs. 24.9%, P<0.001), and bone fracture requiring surgery or hospitalization (5.1% vs. 3.2%, P=0.003).ConclusionsIn this trial involving patients without diabetes who had insulin resistance along with a recent history of ischemic stroke or TIA, the risk of stroke or myocardial infarction was lower among patients who received pioglitazone than among those who received placebo. Pioglitazone was also associated with a lower risk of diabetes but with higher risks of weight gain, edema, and fracture. (Funded by the National Institute of Neurological Disorders and Stroke; ClinicalTrials.gov number, NCT00091949.).

Project description:Background and purposeWe determined the association between hospital factors, performance on transient ischemic attack (TIA) process measures, and 90-day ischemic stroke incidence.MethodsLongitudinal analysis of retrospectively obtained data on 9168 veterans ≥18 years with TIA presenting to the emergency department or inpatient unit at 69 Veterans Affairs hospitals with ≥10 eligible patients per year in fiscal years 2015 to 2018. Process measures were high/moderate potency statin within 7 days of discharge, antithrombotic by day 2, and hypertension control (<140/90 mm Hg) at 90 days. The outcome was 90-day stroke incidence.ResultsDuring the 4-year study period, hospitals significantly increased statin use (adjusted odds ratio [aOR] per 1-year increase, 1.24 [95% CI, 1.17–1.32]; P<0.001), whereas neither hypertension control (P=0.44) nor antithrombotic use (P=0.82) improved over time. Hospitals that admitted a higher proportion of TIA patients versus emergency department discharge had significantly greater use of statins (aOR per 10-percentage point increase in the proportion of TIA patients admitted, 1.09 [1.03–1.16]; P=0.003) and antithrombotics (aOR per 10-percentage point increase in TIA patients admitted, 1.14 [1.06–1.23]; P<0.001). Hospitals with higher emergency physician staffing and lower TIA patient volume had greater use of antithrombotics (aOR per 1 full-time physician increase, 1.05 [1.01–1.08]; P=0.008 and aOR per 10-patient decrease in volume, 1.09 [1.01–1.16]; P=0.02). Higher emergency physician staffing was associated with lower 90-day stroke incidence (aOR per 1 full-time physician increase, 0.96 [0.92–0.99]; P=0.02) but other hospital factors were not.ConclusionsHospitals admitting higher percentages of TIA patients and having higher emergency physician staffing have greater performance on select guideline-concordant process measures for TIA. Higher emergency physician staffing was associated with improved outcomes 90 days after TIA.

Project description:ImportanceStroke represents a significant burden on the health care system of China. The Chinese Stroke Center Alliance was launched in 2015 to monitor and improve care quality and outcomes for patients with acute stroke and transient ischemic attack (TIA).ObjectiveTo evaluate the clinical characteristics, management, and in-hospital clinical outcomes and complications among patients with stroke or TIA in China.Design, setting, and participantsThis quality improvement study assessed stroke or TIA admissions to 1476 participating hospitals in the Chinese Stroke Center Alliance between August 1, 2015, and July 31, 2019.ExposuresStroke types and calendar year.Main outcomes and measuresEleven guideline-based admission or discharge management measures and 2 summary measures: an all-or-none binary outcome and a composite score (range, 0 [nonadherence] to 1 [perfect adherence]) for adherence to evidence-based stroke and TIA care and in-hospital clinical outcomes, including death or discharge against medical advice (DAMA), major adverse cardiovascular events (MACEs), including ischemic stroke, hemorrhagic stroke, TIA, or myocardial infarction; and in-hospital complications.ResultsOf 1 006 798 patients with stroke or TIA (mean [SD] age, 65.7 [12.2] years; 383 500 [38.1%] female), 838 229 (83.3%) had an ischemic stroke, 64 929 (6.4%) had TIA, 85 705 (8.5%) had intracerebral hemorrhage (ICH), and 11 241 (1.1%) had subarachnoid hemorrhage (SAH). Management measures varied by cerebrovascular event type, with the mean (SD) composite score ranging from 0.57 (0.31) in SAH to 0.83 (0.24) in TIA. Poor outcomes and complications were highest among patients with SAH (21.9%; 95% CI, 21.0%-22.8% in-hospital death or DAMA; 9.6%; 95% CI, 9.1%-10.2% MACEs; and 31.4%; 95% CI, 30.6%-32.3% in-hospital complications) and patients with ICH (17.2%; 95% CI, 16.9%-17.5% in-hospital death or DAMA; 9.3%; 95% CI, 9.1%-9.5% MACEs; and 31.3%; 95% CI, 31.0%-31.6% in-hospital complications), followed by patients with ischemic stroke (6.1%; 95% CI, 6.0%-6.1% in-hospital death or DAMA; 6.3%; 95% CI, 6.3%-6.4% MACEs; and 12.8%; 95% CI, 12.7%-12.9% in-hospital complications), and lowest in patients with TIA (5.0%; 95% CI, 4.8%-5.2% in-hospital death or DAMA; 2.4%; 95% CI, 2.3%-2.5% MACEs; and 0.8%; 95% CI, 0.7%-0.8% in-hospital complications). Temporal improvements in management measures were observed from 2015 to 2019, especially in administration of intravenous recombinant tissue plasminogen activator (+60.3% relatively; 95% CI, 52.9%-70.5%), dysphagia screening (+14.7% relatively; 95% CI, 14.0%-15.6%), and use of anticoagulants for atrial fibrillation (+31.4% relatively; 95% CI, 25.7%-37.3%). Temporal improvements in in-hospital death or DAMA (-9.7% relatively; 95% CI, -9.6% to -8.5%) and complications (-27.1% relatively; 95% CI, -28.6% to -25.3) were also observed.Conclusions and relevanceIn this quality improvement study, performance measure adherence and poor outcomes and complications varied by cerebrovascular event type; although there were substantial improvements over time, these results suggest that support for the use of evidence-based practices is needed.

Project description:Background and Purpose- The role of aspirin plus clopidogrel (A+C) therapy compared with aspirin monotherapy in patients presenting with acute ischemic stroke (IS) or transient ischemic attack remains uncertain. We conducted this study to determine the optimal period of efficacy and safety of A+C compared with aspirin monotherapy. Methods- Ten randomized controlled trials (15 434 patients) were selected using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) (inception June 2018) comparing A+C with aspirin monotherapy in patients with transient ischemic attack or IS. The primary efficacy outcome was recurrent IS, and the primary safety outcome was major bleeding. The secondary outcomes were major adverse cardiovascular events (composite of stroke, myocardial infarction, and cardiovascular mortality) and all-cause mortality. We stratified analysis based on the short- (≤1 month), intermediate- (≤3 month), and long-term (>3 month) A+C therapy. Effects were estimated as relative risk (RR) with 95% CI. Results- A+C significantly reduced the risk of recurrent IS at short-term (RR, 0.53; 95% CI, 0.37-0.78) and intermediate-term (RR, 0.72; 95% CI, 0.58-0.90) durations. Similarly, major adverse cardiovascular event was significantly reduced by short-term (RR, 0.68; 95% CI, 0.60-0.78) and intermediate-term (RR, 0.76; 95% CI, 0.61-0.94) A+C therapy. However, long-term A+C did not yield beneficial effect in terms of recurrent IS (RR, 0.81; 95% CI, 0.63-1.04) and major adverse cardiovascular events (RR, 0.87; 95% CI, 0.71-1.07). Intermediate-term (RR, 2.58; 95% CI, 1.19-5.60) and long-term (RR, 1.87; 95% CI, 1.36-2.56) A+C regimens significantly increased the risk of major bleeding as opposed to short-term A+C (RR, 1.82; 95% CI, 0.91-3.62). Excessive all-cause mortality was limited to long-term A+C (RR, 1.45; 95% CI, 1.10-1.93). Conclusions- Short-term A+C is more effective and equally safe in comparison to aspirin alone in patients with acute IS or transient ischemic attack.

Dataset Information

Hospital admission for stroke or transient ischemic attack among First Nations people with diabetes in Ontario: a population-based cohort study.

Publications

Hospital admission for stroke or transient ischemic attack among First Nations people with diabetes in Ontario: a population-based cohort study.

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