COVID-19 “did not affect stroke care quality or outcomes” in largest US healthcare system

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In one of the first studies to investigate the overall quality of care and outcomes of stroke care for non-COVID-19 hospitalised patients during the pandemic from a US perspective, researchers have reported no decline in overall quality of care nor outcomes, after risk adjustment, when comparing patients with stroke and ministrokes from prior to the pandemic (March to September 2019) to the same months during the pandemic (March to September 2020).

Researchers from the US Department of Veterans Affairs (VA), and the Regenstrief Institute in Indianapolis, USA and Monash University in Melbourne, Australia, assessed patients with strokes or ministrokes (transient ischaemic attacks [TIAs]) in 128 hospitals across the USA within the VA’s health system—which claims to be the nation’s largest integrated healthcare system.

As with other non-COVID-19 conditions, the number of hospitalisations for strokes and ministrokes was lower during the pandemic than before COVID-19; approximately 30% lower for ministrokes and 19% lower for strokes.

The researchers used seven standardised measures to determine that overall quality of care for stroke and ministroke did not diminish in VA facilities during the pandemic. They found that the use of statin medications continued to increase during 2020, especially among patients with stroke—a trend that had been evident for several years prior to the pandemic. However, patients with stroke or ministroke had far fewer primary care visits, delaying or deferring care during the pandemic.

During the pandemic, about 40% of stroke patients did not have a blood pressure measurement, while only 10% of stroke patients did not have a blood pressure measurement pre-pandemic. Missing blood pressure checks was associated with a six-fold increase in short-term mortality and a three-fold increase in long-term mortality, according to Dawn Bravata (Indiana University School of Medicine, Indianapolis, USA), who led the study.

She noted that a robust relationship between increasing blood pressure and stroke risk has long been known to exist. The researchers found that blood pressure, when measured during the pandemic, was not as well-controlled as it had been during the pre-pandemic period. The study also found that death rates of stroke or ministroke patients in VA hospitals were not statistically different after risk adjustment during the pre-pandemic and pandemic time periods.

“As a healthcare system that is responsible for and tracks patients after they are discharged from the hospital, the VA is well-suited to conduct this type of analysis and do the follow-up indicated—for example, helping patients control blood pressure after a stroke or ministroke,” said Bravata. “Given the widespread phenomena that people received less healthcare during the pandemic, we would expect the same decrease in primary care visits in non-VA settings. As patients return to primary care, post-stroke checkups and blood pressure control hopefully can be prioritised.”

With few exceptions, stroke and ministroke patient characteristics were similar between 2019 (pre-pandemic) and 2020. The researchers found that, during the pandemic, a slightly greater proportion of patients came to the hospital as a result of a stroke, rather than due to a ministroke (69% vs 66%). Bravata noted that individuals with transient symptoms of ministrokes may have hesitated to seek medical attention during the pandemic.

The study evaluated care for patients with stroke or ministroke from typical causes, and did not include patients who were admitted to the hospital for COVID-19 and then had a stroke or ministroke. Fewer than 2% (72 individuals) of those admitted to the 128 VA hospitals with stroke or ministroke from March to September 2020 concurrently had or subsequently developed COVID-19.

These findings are published in the Journal of Stroke and Cerebrovascular Diseases by Bravata and her colleagues.


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