Does Emergency Medical Services Transportation Mitigate Post-stroke Discharge Disability? A Prospective Observational St
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Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA; 2South Carolina Department of Health and Environmental Control, Columbia, SC, USA; 3Statistics Collaborative, Inc., Washington, DC, USA; 4Department of Health, Human Services and Public Policy, California State University–Monterey Bay, Seaside, CA, USA; 5Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA; 6Bureau of Emergency Medical Services, South Carolina Department of Health and Environmental Control, Columbia, SC, USA; 7Genentech, Inc., South San Francisco, CA, USA; 8HCA Healthcare, Mission Research Institute, Asheville, NC, USA; 9Prisma Health Stroke Unit, Dept of Neurology, University of South Carolina School of Medicine, Columbia, SC, USA.
BACKGROUND: Whether emergency medical services (EMS) transport improves disability outcomes compared with other transport among acute ischemic stroke (AIS) patients is unknown. OBJECTIVE: To study severity-adjusted associations of hospital arrival mode (EMS vs. other transport) with inhospital and discharge disability outcomes. DESIGN: Prospective observational study. PARTICIPANTS: AIS patients discharged April 2016 to October 2017 from a safety-net hospital in South Carolina. MAIN MEASURES: National Institutes of Health Stroke Scale (NIHSS) change at discharge (admission NIHSS score minus discharge NIHSS, continuous variable), 24h NIHSS change (attaining high improvement, admission NIHSS minus 24-h NIHSS being 75th percentile or higher), door to neuroimaging (DTI) time, and IV alteplase receipt. NIHSS change was assessed within stroke severity groups, mild, moderate, and severe (admission NIHSS 0–5, 6–14, and ≥ 15, respectively). KEY RESULTS: Of 1168 patients, 838 were study-eligible (52% male, 52.4% Black, 72.2% EMS arrivals, 56.6% mild strokes). Severe and moderate stroke patients were more likely than mild stroke patients to use EMS (adjusted odds ratios, AOR [95% CI] 11.7 [5.0, 27.4] and 4.0 [2.6, 6.3], respectively). EMS arrival was associated with shorter DTI time (adjusted difference − 88.4 min) and higher likelihood of alteplase administration (AOR 5.3 [2.5, 11.4]), both key mediating variables in disability outcomes. High 24-h NIHSS improvement was more likely for EMS arrivals vs. other arrivals among moderate strokes (AOR 3.4 [1.1, 10.9]) and severe strokes (AOR > 999). EMS arrivals had substantially higher NIHSS improvement at discharge within the severe stroke group (adjusted NIHSS change at discharge, 5.9 points higher, p = 0.01). Alteplase recipients showed higher discharge NIHSS
Received November 18, 2019 Accepted August 5, 2020
improvement than non-recipients (by 2.8 and 1.9 points among severe and moderate strokes, respectively; p = 0.01, 0.02). CONCLUSIONS: The findings offer evidence for including stroke education as a standard of care in the primary care management of patients with stroke-risk comorbidities/ lifestyle in order to minimize post
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