Nurose Karim, MD

Yang Q, Tong X, Coleman King S, Olivari BS, Merritt RK. Stroke Hospitalizations Before and During COVID-19 Pandemic Among Medicare Beneficiaries in the United States. Stroke. 2021.

The year 2020 will be remembered as one of the most challenging years in the history of medicine due to the novel SARS COVID-19 pandemic. The “new normal” had its impact on many lives and the economy of the country.

Stroke is the fifth leading cause of death in the United States. Each year, nearly 800,000 Americans have a new or recurrent stroke (on average 15,000 strokes per week), and approximately 150,000 die, accounting for 1 in 20 deaths in the United States. Early treatment is critical for better outcome. Due to the COVID-19 pandemic, there were statewide stay-in-home orders that led to delay in seeking care for stroke victims.

The authors of this article reviewed the rate of hospitalization during the COVID-19 pandemic stay-in-home order to understand if there were any significant differences in stroke hospitalization rates, especially in patients aged ≥65 years on Medicare fee-for-service (FFS) beneficiaries. The authors conducted a trend analysis on the weekly number of stroke hospitalizations from week 1 in 2019 through week 44 in 2020 by stroke type (all-stroke, acute ischemic stroke [AIS], and hemorrhagic stroke) and by age group (65-74, 75-84 and ≥85 years), sex, and race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic and other). This is the first study to analyze the variations in the reduction of stroke hospitalizations by state as well.

The study found that there was a slight reduction in all stroke hospitalizations from week 1 in 2019 to week 9 of 2020 (WPC=-0.08%) followed by a steep decline from week 10 through week 15 in 2020 (WPC=-5.98%). This was followed by trending back to pre-COVID-19 rates (WPC of 3.09%) from weeks 15 through 23 of 2020 and remained at a lower-than-normal level from weeks 23 through 44 (WPC=0.05%). This trend was consistent by age group, sex, race/ethnicity and for all-stroke and AIS.

From March 1 to June 6, 2020, the 14 peak weeks of COVID-19, where stay-in-home orders were released by the government, all-stroke hospitalizations among FFS beneficiaries were reduced by 22.3%. A greater reduction was seen in older age (24.9% among those ≥85 years vs. 20.9% among persons 65-74 years). The trend was similar between men and women, and among race/ethnicity groups (p>0.05). For hemorrhagic stroke, there was a decline in the initial COVID-19 period (WPC=-2.68%) followed by a slight increase from weeks 15 through 44 in 2020. 

The trend varied among states as well from weeks 10 through 23. As such, there were no change in New Hampshire, but a decline of 36.2% in Montana during 2020 compared to the same time period in 2019 for all-stroke, from -6.1% in New Hampshire to 37.0% in Montana for AIS, and from -10.8% in Massachusetts to 57.4% in Maine for hemorrhagic stroke. Ten states had insignificant changes in AIS stroke hospitalizations, and 32 states had insignificant changes in hemorrhagic stroke hospitalizations comparing weeks 10 through 23 in 2019 to 2020.

Overall, this is a very thorough study focusing on the rate of hospitalization in the population and state. The bottom line is, there was a decline in hospitalization among the elderly population which could be due to social isolation leading to delay in the diagnosis and delay in seeking care in general due to the fear of coming to the hospital. Prior studies have documented significant racial-ethnic disparities in seeking emergency care and delayed arrival at ED for stroke treatment, but the results from this study were consistent across sex and race/ethnicity groups among Medicare FFS beneficiaries. Also, the difference among different states could be due to variation in the starting dates, duration, and type of stay-at-home orders.

To summarize, stroke is a time-sensitive condition that requires prompt emergency care to avoid serious complications, long-term disability, or death regardless of the COVID-19 pandemic status.