Impact of the Dedicated Neurointensivists on the Outcome in Patients with Ischemic Stroke Based on the Linked Big Data for Stroke in Korea

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Abstract

Background

Neurocritical care by dedicated neurointensivists may improve outcomes of critically ill patients with severe brain injury. In this study, we aimed to validate whether neurointensive care could improve the outcome in patients with critically ill acute ischemic stroke using the linked big dataset on stroke in Korea.

Methods

We included 1,405 acute ischemic stroke patients with mechanical ventilator support in the intensive care unit after an index stroke. Patients were retrieved from linking the Clinical Research Center for Stroke Registry and the Health Insurance Review and Assessment Service data from the period between January 2007 and December 2014. The outcomes were mortality at discharge and at 3 months after an index stroke. The main outcomes were compared between the centers with and without dedicated neurointensivists.

Results

Among the included patients, 303 (21.6%) were admitted to the centers with dedicated neurointensivists. The patients treated by dedicated neurointensivists had significantly lower in-hospital mortality (18.3% vs. 26.8%, P = 0.002) as well as lower mortality at 3-month (38.0% vs. 49.1%, P < 0.001) than those who were treated without neurointensivists. After adjusting for confounders, a treatment without neurointensivists was independently associated with higher in-hospital mortality (odds ratio [OR], 1.59; 95% confidence intervals [CIs], 1.13–2.25; P = 0.008) and 3-month mortality (OR, 1.48; 95% CIs, 1.12–1.95; P = 0.005).

Conclusion

Treatment by dedicated neurointensivists is associated with lower in-hospital and 3-month mortality using the linked big datasets for stroke in Korea. This finding stresses the importance of neurointensivists in treating patients with severe ischemic stroke.

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Most cited references 19

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Management and outcome of mechanically ventilated neurologic patients.

Fekri Abroug, Konstantinos Raymondos, Pablo Desmery … (2011)

To describe and compare characteristics, ventilatory practices, and associated outcomes among mechanically ventilated patients with different types of brain injury and between neurologic and nonneurologic patients. Secondary analysis of a prospective, observational, and multicenter study on mechanical ventilation. Three hundred forty-nine intensive care units from 23 countries. We included 552 mechanically ventilated neurologic patients (362 patients with stroke and 190 patients with brain trauma). For comparison we used a control group of 4,030 mixed patients who were ventilated for nonneurologic reasons. None. We collected demographics, ventilatory settings, organ failures, and complications arising during ventilation and outcomes. Multivariate logistic regression analysis was performed with intensive care unit mortality as the dependent variable. At admission, a Glasgow Coma Scale score ≤8 was observed in 68% of the stroke, 77% of the brain trauma, and 29% of the nonneurologic patients. Modes of ventilation and use of a lung-protective strategy within the first week of mechanical ventilation were similar between groups. In comparison with nonneurologic patients, patients with neurologic disease developed fewer complications over the course of mechanical ventilation with the exception of a higher rate of ventilator-associated pneumonia in the brain trauma cohort. Neurologic patients showed higher rates of tracheotomy and longer duration of mechanical ventilation. Mortality in the intensive care unit was significantly (p < .001) higher in patients with stroke (45%) than in brain trauma (29%) and nonneurologic disease (30%). Factors associated with mortality were: stroke (in comparison to brain trauma), Glasgow Coma Scale score on day 1, and severity at admission in the intensive care unit. In our study, one of every five mechanically ventilated patients received this therapy as a result of a neurologic disease. This cohort of patients showed a higher mortality rate than nonneurologic patients despite a lower incidence of extracerebral organ dysfunction.

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Comparison of the performance of SAPS II, SAPS 3, APACHE II, and their customized prognostic models in a surgical intensive care unit.

Robert Marx, Y Sakr, C Krauss … (2008)

The Simplified Acute Physiology Score (SAPS) 3 has recently been developed, but not yet validated in surgical intensive care unit (ICU) patients. We compared the performance of SAPS 3 with SAPS II and the Acute Physiology and Chronic Health Evaluation (APACHE) II score in surgical ICU patients. Prospectively collected data from all patients admitted to a German university hospital postoperative ICU between August 2004 and December 2005 were analysed. The probability of ICU mortality was calculated for SAPS II, APACHE II, adjusted APACHE II (adj-APACHE II), SAPS 3, and SAPS 3 customized for Europe [C-SAPS3 (Eu)] using standard formulas. To improve calibration of the prognostic models, a first-level customization was performed, using logistic regression on the original scores, and the corresponding probability of ICU death was calculated for the customized scores (C-SAPS II, C-SAPS 3, and C-APACHE II). The study included 1851 patients. Hospital mortality was 9%. Hosmer and Lemeshow statistics showed poor calibration for SAPS II, APACHE II, adj-APACHE II, SAPS 3, and C-SAPS 3 (Eu), but good calibration for C-SAPS II, C-APACHE II, and C-SAPS 3. Discrimination was generally good for all models [area under the receiver operating characteristic curve ranged from 0.78 (C-APACHE II) to 0.89 (C-SAPS 3)]. The C-SAPS 3 score appeared to have the best calibration curve on visual inspection. In this group of surgical ICU patients, the performance of SAPS 3 was similar to that of APACHE II and SAPS II. Customization improved the calibration of all prognostic models.

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Early neurological deterioration in acute stroke: clinical characteristics and impact on outcome.

Jamie Kwan, D. Hand (2006)

A significant proportion of acute stroke patients suffer neurological deterioration during the first few days of recovery. To explore the frequency, clinical characteristics, and consequences of early neurological deterioration during the acute recovery period. We assessed all consecutive patients admitted to a University hospital with suspected stroke. We recorded the following on admission: baseline characteristics, physiological parameters and laboratory results. On day 5 we recorded occurrence of complications, and functional outcome. Early neurological deterioration was defined as an increase in National Institute of Health Stroke Score (NIHSS) by two or more points (or stroke-related death) between admission and day 5. We recruited 188 stroke patients, of whom 36 (19%) suffered early neurological deterioration. Patients with early neurological deterioration were significantly more likely to: (i) arrive at the hospital earlier (median 2.25 vs. 7.2 h, p = 0.015); (ii) have a history of atrial fibrillation (33% vs. 16%, p = 0.039); (iii) be current non-smokers (24% vs. 11%, p = 0.041); (iv) have a severe stroke-more total anterior circulation strokes (67% vs. 26%, p < 0.001) and worse NIHSS and GCS scores; (v) have intracerebral haemorrhage (22% vs. 7%, p = 0.011); (vi) have higher serum urea (mean 7.8 vs. 6.5 mmol/l, p = 0.035) and leukocyte count (mean 12.6 vs. 9.7 x 10(9)/l, p = 0.044); and (vi) die in hospital (44% vs. 10%, OR 12.8, 95%CI 3.8-43.1, p < 0.001). Early neurological deterioration is a frequent and important complication in acute stroke, with a poor short-term prognosis. Effective treatment strategies are urgently needed to reduce its occurrence and impact on recovery.

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Author and article information

Journal

Journal ID (nlm-ta): J Korean Med Sci

Journal ID (iso-abbrev): J. Korean Med. Sci

Journal ID (publisher-id): JKMS

Title: Journal of Korean Medical Science

Publisher: The Korean Academy of Medical Sciences

ISSN (Print): 1011-8934

ISSN (Electronic): 1598-6357

Publication date (Electronic): 26 March 2020

Publication date Collection: 01 June 2020

Volume: 35

Issue: 21

Electronic Location Identifier: e135

Affiliations

[1 ]Department of Neurology, Seoul National University Hospital, Seoul, Korea.

[2 ]Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea.

[3 ]Department of Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

[4 ]Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea.

[5 ]Health Insurance Review and Assessment Service, Wonju, Korea.

Author notes

Address for Correspondence: Byung-Woo Yoon, MD, PhD. Department of Neurology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea. bwyoon@ 123456snu.ac.kr

Address for Correspondence: Sang-Bae Ko, MD, PhD. Department of Neurology and Critical Care Medicine Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea. sangbai1378@ 123456gmail.com

^*Tae Jung Kim and Ji Sung Lee contributed equally to this work.

Author information

Tae Jung Kim https://orcid.org/0000-0003-3616-5627

Ji Sung Lee https://orcid.org/0000-0001-8194-3462

Jae Sun Yoon https://orcid.org/0000-0002-4303-2964

Mi Sun Oh https://orcid.org/0000-0002-6741-0464

Ji-Woo Kim https://orcid.org/0000-0002-4070-3021

Keun-Hwa Jung https://orcid.org/0000-0003-1433-8005

Kyung-Ho Yu https://orcid.org/0000-0002-8997-5626

Byung-Chul Lee https://orcid.org/0000-0002-3885-981X

Sang-Bae Ko https://orcid.org/0000-0002-9429-9597

Byung-Woo Yoon https://orcid.org/0000-0002-8597-807X

Article

DOI: 10.3346/jkms.2020.35.e135

PMC ID: 7261699

PubMed ID: 32476299

SO-VID: 2e5147a8-6b53-4ef9-b9bf-0043b06c3a85

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 05 February 2020

Date accepted : 22 March 2020

Funding

Funded by: Ministry of Health and Welfare, CrossRef https://doi.org/10.13039/501100003625;

Impact of the Dedicated Neurointensivists on the Outcome in Patients with Ischemic Stroke Based on the Linked Big Data for Stroke in Korea

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Abstract

Background

Methods

Results

Conclusion

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Most cited references 19

Management and outcome of mechanically ventilated neurologic patients.

Comparison of the performance of SAPS II, SAPS 3, APACHE II, and their customized prognostic models in a surgical intensive care unit.

Early neurological deterioration in acute stroke: clinical characteristics and impact on outcome.

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