Hospitalizations for Ischemic Stroke Before vs During the COVID-19 Pandemic | Cerebrovascular Disease | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Characteristics and Outcomes Among US Patients Hospitalized for Ischemic Stroke Before vs During the COVID-19 Pandemic

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  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?

Findings  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.

Meaning  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.

Abstract

Importance  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.

Objective  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.

Exposure  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.

Results  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.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

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 (adam.dehavenon@hsc.utah.edu).

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.

Supervision: Ney.

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.

References
1.
Morelli  N , Rota  E , Terracciano  C ,  et al.  The baffling case of ischemic stroke disappearance from the casualty department in the COVID-19 era.   Eur Neurol. 2020;83(2):213-215. doi:10.1159/000507666PubMedGoogle ScholarCrossref
2.
Kansagra  AP , Goyal  MS , Hamilton  S , Albers  GW .  Collateral effect of COVID-19 on stroke evaluation in the United States.   N Engl J Med. 2020;383(4):400-401. doi:10.1056/NEJMc2014816PubMedGoogle ScholarCrossref
3.
Uchino  K , Kolikonda  MK , Brown  D ,  et al.  Decline in stroke presentations during COVID-19 surge.   Stroke. 2020;51(8):2544-2547. doi:10.1161/STROKEAHA.120.030331PubMedGoogle ScholarCrossref
4.
Lange  SJ , Ritchey  MD , Goodman  AB ,  et al.  Potential indirect effects of the COVID-19 pandemic on use of emergency departments for acute life-threatening conditions—United States, January-May 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(25):795-800. doi:10.15585/mmwr.mm6925e2 PubMedGoogle ScholarCrossref
5.
Nguyen-Huynh  MN , Tang  XN , Vinson  DR ,  et al.  Acute stroke presentation, care, and outcomes in community hospitals in northern California during the COVID-19 pandemic.   Stroke. 2020;51(10):2918-2924. doi:10.1161/STROKEAHA.120.031099PubMedGoogle ScholarCrossref
6.
Cowan  LT , Lutsey  PL , Pankow  JS , Matsushita  K , Ishigami  J , Lakshminarayan  K .  Inpatient and outpatient infection as a trigger of cardiovascular disease: the ARIC study.   J Am Heart Assoc. 2018;7(22):e009683. doi:10.1161/JAHA.118.009683 PubMedGoogle Scholar
7.
Boehme  AK , Luna  J , Kulick  ER , Kamel  H , Elkind  MSV .  Influenza-like illness as a trigger for ischemic stroke.   Ann Clin Transl Neurol. 2018;5(4):456-463. doi:10.1002/acn3.545 PubMedGoogle ScholarCrossref
8.
Abou-Ismail  MY , Diamond  A , Kapoor  S , Arafah  Y , Nayak  L .  The hypercoagulable state in COVID-19: incidence, pathophysiology, and management.   Thromb Res. 2020;194:101-115. doi:10.1016/j.thromres.2020.06.029 PubMedGoogle ScholarCrossref
9.
Centers for Disease Control and Prevention. COVID data tracker. US Department of Health and Human Services; 2020. Accessed March 8, 2021. https://covid.cdc.gov/covid-data-tracker
10.
Yaghi  S , Ishida  K , Torres  J ,  et al.  SARS-CoV-2 and stroke in a New York healthcare system.   Stroke. 2020;51(7):2002-2011. doi:10.1161/STROKEAHA.120.030335PubMedGoogle ScholarCrossref
11.
Madjid  M , Safavi-Naeini  P , Solomon  SD , Vardeny  O .  Potential effects of coronaviruses on the cardiovascular system: a review.   JAMA Cardiol. 2020;5(7):831-840. doi:10.1001/jamacardio.2020.1286 PubMedGoogle ScholarCrossref
12.
Richardson  S , Hirsch  JS , Narasimhan  M ,  et al; Northwell COVID-19 Research Consortium.  Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area.   JAMA. 2020;323(20):2052-2059. doi:10.1001/jama.2020.6775 PubMedGoogle ScholarCrossref
13.
Merkler  AE , Parikh  NS , Mir  S ,  et al.  Risk of ischemic stroke in patients with coronavirus disease 2019 (COVID-19) vs patients with influenza.   JAMA Neurol. 2020;77(11):1-7. doi:10.1001/jamaneurol.2020.2730 PubMedGoogle Scholar
14.
Agarwal  S , Scher  E , Rossan-Raghunath  N ,  et al.  Acute stroke care in a New York City comprehensive stroke center during the COVID-19 pandemic.   J Stroke Cerebrovasc Dis. 2020;29(9):105068. doi:10.1016/j.jstrokecerebrovasdis.2020.105068 PubMedGoogle Scholar
15.
Nannoni  S , de Groot  R , Bell  S , Markus  HS .  Stroke in COVID-19: a systematic review and meta-analysis.   Int J Stroke. 2021;16(2):137-149. doi:10.1177/1747493020972922 PubMedGoogle ScholarCrossref
16.
de Havenon  A , Ney  JP , Callaghan  B ,  et al.  Impact of COVID-19 on outcomes in ischemic stroke patients in the United States.   J Stroke Cerebrovasc Dis. 2021;30(2):105535. doi:10.1016/j.jstrokecerebrovasdis.2020.105535 PubMedGoogle Scholar
17.
Markus  HS , Brainin  M .  COVID-19 and stroke—a global World Stroke Organization perspective.   Int J Stroke. 2020;15(4):361-364. doi:10.1177/1747493020923472 PubMedGoogle ScholarCrossref
18.
Clinical Data Base. Vizient; 2021. Accessed April 24, 2020. https://www.vizientinc.com/our-solutions/clinical-solutions/clinical-data-base
19.
Chang  TE , Tong  X , George  MG ,  et al; Paul Coverdell National Acute Stroke Program Team.  Trends and factors associated with concordance between International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification codes and stroke clinical diagnoses.   Stroke. 2019;50(8):1959-1967. doi:10.1161/STROKEAHA.118.024092 PubMedGoogle ScholarCrossref
20.
World Health Organization. Emergency use ICD codes for COVID-19 disease outbreak. World Health Organization; 2020. Accessed June 29, 2020. https://www.who.int/classifications/icd/covid19/en/
21.
Centers for Medicare and Medicaid Services. ICD-10-CM Official Guidelines for Coding and Reporting: FY 2019 (October 1, 2018-September 30, 2019). 2019. Accessed January 25, 2021. https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2019-ICD10-Coding-Guidelines-.pdf
22.
Chang  HJ , Chen  PC , Yang  CC , Su  YC , Lee  CC .  Comparison of Elixhauser and Charlson methods for predicting oral cancer survival.   Medicine (Baltimore). 2016;95(7):e2861. doi:10.1097/MD.0000000000002861 PubMedGoogle Scholar
23.
Yu  AYX , Holodinsky  JK , Zerna  C ,  et al.  Use and utility of administrative health data for stroke research and surveillance.   Stroke. 2016;47(7):1946-1952. doi:10.1161/STROKEAHA.116.012390 PubMedGoogle ScholarCrossref
24.
Czeisler  ME , Marynak  K , Clarke  KEN ,  et al.  Delay or avoidance of medical care because of COVID-19–related concerns—United States, June 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(36):1250-1257. doi:10.15585/mmwr.mm6936a4 PubMedGoogle ScholarCrossref
25.
Centers for Disease Control and Prevention. COVID-19: people with certain medical conditions. US Department of Health and Human Services. February 11, 2020. Updated March 29, 2021. Accessed June 30, 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html
26.
McClure  ES , Vasudevan  P , Bailey  Z , Patel  S , Robinson  WR .  Racial capitalism within public health—how occupational settings drive COVID-19 disparities.   Am J Epidemiol. 2020;189(11):1244-1253. doi:10.1093/aje/kwaa126 PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close