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What were the hospital discharge rates, demographic factors, and outcomes of hospitalization associated with the COVID-19 pandemic among US patients with ischemic stroke (IS) in 2020?
In this cohort study of 478 US hospitals with 324 013 patients with IS, substantial decreases in the number of patients discharged with IS were observed at the beginning of the pandemic in February 2020, but these rates returned to prepandemic levels by July 2020. Compared with patients with IS in 2019, those with IS and comorbid COVID-19 in 2020 were less likely to have conventional vascular risk factors or stroke at hospital admission and were more likely to be Black or Hispanic and to experience medical complications and in-hospital death.
Among patients with IS in 2020, comorbid COVID-19 was common, especially in Black and Hispanic populations, and in-hospital morbidity and mortality rates were high.
After the emergence of COVID-19, studies reported a decrease in hospitalizations of patients with ischemic stroke (IS), but there are little to no data regarding hospitalizations for the remainder of 2020, including outcome data from a large cohort of patients with IS and comorbid COVID-19.
To assess hospital discharge rates, demographic factors, and outcomes of hospitalization associated with the COVID-19 pandemic among US patients with IS before vs during the COVID-19 pandemic.
Design, Setting, and Participants
This retrospective cohort study used data from the Vizient Clinical Data Base on 324 013 patients with IS at 478 nonfederal hospitals in 43 US states between January 1, 2019, and December 31, 2020. Patients were eligible if they were admitted to the hospital on a nonelective basis and were not receiving hospice care at the time of admission. A total of 41 166 discharged between January and March 2020 were excluded from the analysis because they had unreliable data on COVID-19 status, leaving 282 847 patients for the study.
Ischemic stroke and laboratory-confirmed COVID-19.
Main Outcomes and Measures
Monthly counts of discharges among patients with IS in 2020. Demographic characteristics and outcomes, including in-hospital death, among patients with IS who were discharged in 2019 (control group) were compared with those of patients with IS with or without comorbid COVID-19 (COVID-19 and non–COVID-19 groups, respectively) who were discharged between April and December 2020.
Of the 282 847 patients included in the study, 165 912 (50.7% male; 63.4% White; 26.3% aged ≥80 years) were allocated to the control group; 111 418 of 116 935 patients (95.3%; 51.9% male; 62.8% White; 24.6% aged ≥80 years) were allocated to the non–COVID-19 group and 5517 of 116 935 patients (4.7%; 58.0% male; 42.5% White; 21.3% aged ≥80 years) to the COVID-19 group. A mean (SD) of 13 846 (553) discharges per month among patients with IS was reported in 2019. Discharges began decreasing in February 2020, reaching a low of 10 846 patients in April 2020 before returning to a prepandemic level of 13 639 patients by July 2020. A mean (SD) of 13 492 (554) discharges per month was recorded for the remainder of 2020. Black and Hispanic patients accounted for 21.4% and 7.0% of IS discharges in 2019, respectively, but accounted for 27.5% and 16.0% of those discharged with IS and comorbid COVID-19 in 2020. Compared with patients in the control and non–COVID-19 groups, those in the COVID-19 group were less likely to smoke (16.0% vs 17.2% vs 6.4%, respectively) and to have hypertension (73.0% vs 73.1% vs 68.2%) or dyslipidemia (61.2% vs 63.2% vs 56.6%) but were more likely to have diabetes (39.8% vs 40.5% vs 53.0%), obesity (16.2% vs 18.4% vs 24.5%), acute coronary syndrome (8.0% vs 9.2% vs 15.8%), or pulmonary embolus (1.9% vs 2.4% vs 6.8%) and to require intubation (11.3% vs 12.3% vs 37.6%). After adjusting for baseline factors, patients with IS and COVID-19 were more likely to die in the hospital than were patients with IS in 2019 (adjusted odds ratio, 5.17; 95% CI, 4.83-5.53; National Institutes of Health Stroke Scale adjusted odds ratio, 3.57; 95% CI, 3.15-4.05).
Conclusions and Relevance
In this cohort study, after the emergence of COVID-19, hospital discharges of patients with IS decreased in the US but returned to prepandemic levels by July 2020. Among patients with IS between April and December 2020, comorbid COVID-19 was relatively common, particularly among Black and Hispanic populations, and morbidity was high.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Accepted for Publication: March 18, 2021.
Published: May 17, 2021. doi:10.1001/jamanetworkopen.2021.10314
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 de Havenon A et al. JAMA Network Open.
Corresponding Author: Adam de Havenon, MD, Department of Neurology, University of Utah, 175 N Medical Dr, Salt Lake City, UT 84132 (firstname.lastname@example.org).
Author Contributions: Dr de Havenon had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: de Havenon, Ney, Hohmann, Anadani, Majersik.
Acquisition, analysis, or interpretation of data: de Havenon, Callaghan, Hohmann, Shippey, Yaghi.
Drafting of the manuscript: de Havenon.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: de Havenon, Shippey.
Administrative, technical, or material support: Shippey.
Conflict of Interest Disclosures: Dr de Havenon reported receiving investigator-initiated funding from AMAG Pharmaceuticals and Regeneron Pharmaceuticals outside the submitted work. Dr Callaghan reported serving as a consultant for a Patient-Centered Outcomes Research Institute grant from DynaMed and performing medicolegal consultations, including consultations for the National Vaccine Injury Compensation Program, outside the submitted work. Dr Majersik reported receiving grants from the National Institute of Neurological Disorders and Stroke, National Institutes of Health; receiving personal fees from the American Heart Association and Foldax; and being an associate editor of Stroke and an editorial board member of Neurology outside the submitted work. No other disclosures were reported.
Funding/Support: This work was supported by grant K23NS105924 from the National Institute of Neurological Disorders and Stroke, National Institutes of Health (Dr de Havenon).
Role of the Funder/Sponsor: The National Institute of Neurological Disorders and Stroke and the National Institutes of Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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