J Stroke.  2022 Jan;24(1):79-87. 10.5853/jos.2021.02530.

Effect of the Coronavirus Disease 2019 Pandemic on the Quality of Stroke Care in Stroke Units and Alternative Wards: A National Comparative Analysis

• Cadilhac DA
• Kim J
• Cloud G
• Anderson CS
• Tod EK
• Breen SJ
• Faux S
• Kleinig T
• Castley H
• Lindley RI
• Middleton S
• Yan B
• Hill K
• Jones B
• Shah D
• Jaques K
• Clissold B
• Campbell B
• Lannin NA
• on Behalf of the AuSCR COVID-19 Reporting Consortium Group

• KMID: 2525333
• DOI: http://doi.org/10.5853/jos.2021.02530

Abstract

Background and Purpose
Changes to hospital systems were implemented from March 2020 in Australia in response to the coronavirus disease 2019 pandemic, including decreased resources allocated to stroke units. We investigate changes in the quality of acute care for patients with stroke or transient ischemic attack during the pandemic according to patients’ treatment setting (stroke unit or alternate ward).
Methods
We conducted a retrospective cohort study of patients admitted with stroke or transient ischemic attack between January 2019 and June 2020 in the Australian Stroke Clinical Registry (AuSCR). The AuSCR monitors patients’ treatment setting, provision of allied health and nursing interventions, prescription of secondary prevention medications, and discharge destination. Weekly trends in the quality of care before and during the pandemic period were assessed using interrupted time series analyses.
Results
In total, 18,662 patients in 2019 and 8,850 patients in 2020 were included. Overall, 75% were treated in stroke units. Before the pandemic, treatment in a stroke unit was superior to alternate wards for the provision of all evidence-based therapies assessed. During the pandemic period, the proportion of patients receiving a swallow screen or assessment, being discharged to rehabilitation, and being prescribed secondary prevention medications decreased by 0.58% to 1.08% per week in patients treated in other ward settings relative to patients treated in stroke units. This change represented a 9% to 17% increase in the care gap between these treatment settings during the period of the pandemic that was evaluated (16 weeks).
Conclusions
During the first 6 months of the pandemic, widening care disparities between stroke units and alternate wards have occurred.

Keyword

Quality of health care; Stroke; COVID-19

Figure

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  Figure 1. Proportion of patients (A) provided antithrombotic medication within 48 hours of arrival (excluding patients with intracerebral hemorrhage), (B) mobilized during the admission, (C) provided swallow screen or assessment, and (D) discharged to rehabilitation. The vertical line (week 61) indicates the week of the interruption used in this study (1/3/2020, the first coronavirus disease 2019 [COVID-19] related death in Australia). Significant difference in weekly trend between groups prior to interruption (β and 95% confidence intervals [CIs] presented): provided antithrombotic medication within 48 hours of arrival 0.09 (95% CI, 0.04 to 0.14); mobilized during the admission –0.15 (95% CI, –0.23 to –0.07). Significant difference during week of interruption between groups (week 61): provided antithrombotic medication within 48 hours of arrival –5.35 (95% CI, –9.08 to –1.61); provided swallow screen or assessment –5.81 (95% CI, –8.62 to –2.99); discharged to rehabilitation –2.2 (95% CI, –3.72 to –0.68). Significant difference in weekly trend between groups in post-interruption period: provided swallow screen or assessment 0.86 (95% CI, 0.48 to 1.24); discharged to rehabilitation 0.6 (95% CI, 0.37 to 0.83). β in a period signifies the difference in the average weekly percentage change over several weeks (trend) between groups. β during the week of the interruption signifies the difference in a percentage change during that week between groups. Positive values indicate a greater relative percentage increase in the provision of evidence-based care in stroke units compared with other ward settings. Negative values indicate a greater relative percentage decrease in the provision of evidence-based care in stroke units compared with other ward settings. Other point estimates relevant to the figure are provided in the Supplementary Table 1.

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  Figure 2. Proportion of patients prescribed secondary prevention medications (A: antihypertensive medication; B: antithrombotic medication; C: lipid lowering medication) at discharge and (D) discharged to the community with a care plan. The vertical line (week 61) indicates the week of the interruption used in this study (1/3/2020, the first coronavirus disease 2019 [COVID-19] related death in Australia). Significant difference in weekly trend between groups prior to interruption (β and 95% confidence intervals [CIs] presented): discharged to the community with a care plan –0.09 (95% CI, –0.17 to –0.01). Significant difference during week of interruption between groups (week 61): discharged to the community with a care plan 3.61 (95% CI, 0.28 to 6.94). Significant difference in weekly trend between groups in post-interruption period: provided antihypertensive medication at discharge 0.58 (95% CI, 0.08 to 1.07); provided antithrombotic medication at discharge 1.08 (95% CI, 0.78 to 1.38); provided lipid lowering medication at discharge 0.69 (95% CI, 0.28 to 1.09). β in a period signifies the the difference in the average weekly percentage change over several weeks (trend) between groups. β during the week of the interruption signifies the difference in a percentage change during that week between groups. Positive values indicate a greater relative percentage increase in the provision of evidence-based care in stroke units compared with other ward settings. Negative values indicate a greater relative percentage decrease in the provision of evidence-based care in stroke units compared with other ward settings. Other point estimates relevant to the figure are provided in the Supplementary Table 2.

Reference

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