Stroke Evaluations Dropped Nearly 40% During Early COVID-19 Pandemic

With the COVID-19 pandemic apparently keeping patients away from seeking necessary care for other conditions, pharmacists might need to read between the lines when they get questions about new and mysterious symptoms and strongly urge some patients to seek emergency care. A new report about declines in stroke evaluation reveals why that is so important.

LOUIS – Many Americans having strokes aren’t seeking potentially life-saving care, likely because they are fearful of going to overcrowded hospitals dealing with the COVID-19 pandemic.

A letter published in the New England Journal of Medicine points out that the  number of patients evaluated for signs of stroke at U.S. hospitals has dropped by nearly 40% during the COVID-19 pandemic.

To reach that conclusion, Washington University School of Medicine in St. Louis researchers analyzed stroke evaluations at more than 800 hospitals across 49 states and the District of Columbia.

“Our stroke team has maintained full capacity to provide emergency stroke treatment at all times, even during the height of the pandemic,” said lead author Akash Kansagra, MD, an assistant professor of radiology at Washington University’s Mallinckrodt Institute of Radiology (MIR). “Nevertheless, we have seen a smaller number of stroke patients coming to the hospital and some patients arriving at the hospital after a considerable delay. It is absolutely heartbreaking to meet a patient who might have recovered from a stroke but, for whatever reason, waited too long to seek treatment.”

Nearly 800,000 people in the U.S. experience a stroke every year and better diagnostic tools, surgeries to remove blood clots or repair broken blood vessels, and clot-busting drugs give them the best chance ever to recover. The key, however, is prompt treatment, as clot-busting drugs are generally safe only within 4½ hours of symptom onset, and surgeries are only possible within 24 hours of symptom onset, according to the study.

Researchers note that the effect the Covid-19 pandemic on medical care for conditions other than Covid-19 has been difficult to quantify. Yet, they add, “Any decrease in care for patients with acute conditions such as ischemic stroke may be consequential because timely treatment may decrease the incidence of disability.:”

To help quantify the situation, the study team used the numbers of patients in a commercial neuroimaging database associated with the RAPID software platform (iSchemaView) as a surrogate for the quantity of care that hospitals provided to patients with acute ischemic stroke. That software system is often used to select patients who might benefit from endovascular thrombectomy by identifying occlusions of major brain arteries or regions of the brain with potentially reversible ischemia that have not become infarcted.

With access to data on 231,753 patients who underwent imaging processed with RAPID software in 856 hospitals in the United States from July 1, 2019 through April 27, 2020, the authors point out that the daily counts of unique patients who underwent imaging decreased in March 2020. As a result, researchers decided to compare the mean daily counts per hospital of patients in the RAPID system before the widely-recognized pandemic from Feb. 1, 2020, through Feb. 29, 2020, with the mean daily counts per hospital of patients in a 14-day epoch during the early pandemic, from March 26, 2020, through April 8, 2020.

“During the prepandemic epoch, the numbers of patients per hospital who underwent imaging were similar to the baseline numbers immediately before the prepandemic epoch,” researches report. “he nadir of the daily counts after the first case of Covid-19 was reported in the United States occurred during the 14-day epoch.”

The study notes that the number of patients who underwent imaging decreased by 39%, from 1.18 patients per day per hospital in the prepandemic period to 0.72 patients per day per hospital in the early-pandemic period.

“An apparent increase in the number of patients who underwent imaging after the early-pandemic epoch warrants further investigation,” the authors add.

They advise that the decrease in the use of stroke imaging from the prepandemic epoch to the early-pandemic epoch was seen across all age, sex, and stroke severity subgroups, explaining that “this suggests a decrease in the number of evaluations both in patients with severe strokes and in nonelderly patients who may have been at low risk for Covid-19 complications. Decreases in the numbers of patients who underwent stroke imaging were seen in most states and across a range of hospital volumes. These decreases suggest that differences in regional incidences of Covid-19 were not the primary cause of decreased use of stroke imaging.”

“Across the board, everybody is affected by this decrease,” Kansagra said. “It is not limited to just hospitals in urban settings or rural communities, small hospitals or large hospitals. It is not just the old or the young or the people with minor strokes who aren’t showing up. Even patients with really severe strokes are seeking care at reduced rates. This is a widespread and very scary phenomenon.”

He points out that the decrease was great even in geographic areas where COVID-19 cases were few and hospitals were not overwhelmed, so patients should not have found it unusually difficult to obtain treatment.

“I suspect we are witnessing a combination of patients being reluctant to seek care out of fear that they might contract COVID-19, and the effects of social distancing,” he added. “The response of family and friends is really important when a loved one is experiencing stroke symptoms. Oftentimes, the patients themselves are not in a position to call 911, but family and friends recognize the stroke symptoms and make the call. In an era when we are all isolating at home, it may be that patients who have strokes aren’t discovered quickly enough.”

That’s a critical problem, he adds, because “the effect of coming in too late is the same in many respects as not coming in at all. When patients come in too late, they may no longer be candidates for treatments that they would have qualified for just hours before. And as a result, they may not have access to treatments that are extremely effective in reducing death and disability.”

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