Ericka Teleg, MD
The COVID-19 pandemic has caused a shift in stroke systems and has changed the way stroke approach and management are put in place. The impact of this is that time is still brain. Time and stroke outcomes still matter more so during this time. From a patient’s perspective in experiencing and reporting symptoms to the way emergency room systems tackle stroke during the pandemic, remain a challenge.
The objective of this study was to analyze characteristics, evaluation, treatment, and in-hospital outcomes of patients presenting with acute ischemic stroke pre-COVID-19 and during COVID-19 time. This study is important as it allows us to be able to navigate the time-sensitive nature of stroke during COVID-19. With the COVID-19 restrictions and concern for infection and transmission, several studies have demonstrated no difference in diagnostic and treatment times pre-COVID 19 versus the COVID-19 era. On the other hand, some studies showed a decline in stroke presentations. One reason emphasized in this article is underreporting of symptoms due to fear of COVID-19 exposure in-hospital.
The Get With The Guidelines-Stroke (GWTG-S) Registry includes a database of characteristics, treatment patterns, quality metrics and in-hospital outcomes. A database such as this includes the involvement of 2000 hospitals, and its reported validity and reliability allow investigators to analyze important variables and compare stroke systems pre-COVID 19 and during COVID-19. The robustness of data with a final study cohort consisted of 81,084 patients with acute ischemic stroke time from November 1, 2019 to June 29, 2020. Importantly, the investigators explained that time immediately before the first COVID-19 registry case was chosen as a comparison group. This was chosen to optimize the chances of detecting changes in stroke care related to the pandemic.
In the investigators’ methodology, clinical characteristics were compared between two groups using the absolute standardized differences. Treatment patterns and process measures were compared between two groups using Pearson Chi-square test and Kruskal Wallis. Thereafter, the impact of time on outcomes of acute ischemic stroke, logistic regression analysis models were used to account for hospital clustering of patients. Hence, models were adjusted for demographics, patient characteristics, medical and clinical characteristics. The article has included patients’ characteristic tables; Table 2 shows the treatment patterns and process measures of the cohort stratified by pre-COVID-19 and during COVID-19 time period. In their analysis, there was a 15.3% drop in weekly acute ischemic strokes volume in the COVID-19 time when compared to 2019. Their results reported a decrease in stroke presentations in time following the COVID-19 pandemic onset. Patients’ fear was identified as a likely a reason not to seek consult. Despite this concern, other health care systems not included in the GWTG-S registry, like those in Lombardy, Italy, experienced an increase in the number of ischemic stroke consults and admissions.
This study has identified the following limitations: being retrospective and observational in nature and the validity of the accuracy of data collection. Also, incomplete data was mentioned. The authors mentioned that the chance for residual unmeasured confounding remains despite the applied logistic regression analysis adjustment for patient and hospital characteristics. Data entry lags has been identified to explain decline in observed acute ischemic patients during the pandemic. Overall, the study highlights that the quality of stroke treatment pre-COVID-19 and during COVID-19 was similar and has not deteriorated during COVID-19 in the United States.
