Academic and Community Hospitals differ in stroke subtype classification and cardiac monitoring: the DiVERT
David Z Rose1, Ruchir A Shah2, Josh Snavely3
1Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, United States.
Insights
Community hospitals use fewer cardiac monitors for stroke patients than academic centers, despite higher rates of cryptogenic stroke. This difference in atrial fibrillation detection strategies needs addressing to prevent recurrent strokes.
Area of Science:
- Neurology
- Cardiology
- Healthcare Management
Background:
- Cardiac monitoring strategies for detecting occult atrial fibrillation (AF) post-stroke vary across healthcare institutions.
- Discrepancies may stem from differing stroke subtype classifications and cardiology consultation rates between Community Hospitals (CoH) and Academic Centers (AcC).
- Standardizing monitoring protocols can improve AF detection, treatment, and reduce stroke recurrence.
Purpose of the Study:
- To characterize and compare post-stroke cardiac monitoring practices between Community Hospitals and Academic Centers.
- To identify heterogeneity in AF detection strategies and its potential impact on patient outcomes.
- To inform the development of guideline-directed monitoring protocols.
Main Methods:
- The DiVERT (SeconDary Stroke PreVEntion ThRough Pathway ManagemenT) study assessed post-stroke cardiac monitoring.
- Care pathways were evaluated through in-person stakeholder interviews.
- Patient-level data were analyzed using electronic medical records.
Main Results:
- Community Hospitals (CoH) reported significantly higher rates of cryptogenic stroke (83.6% vs. 33.1%) compared to Academic Centers (AcC).
- CoH consulted cardiology less frequently (12.3% vs. 34.7%) and ordered fewer cardiac monitors (6.8% vs. 69.2%) than AcC.
- Significant differences in patient demographics, length of stay, and stroke subtype classification were observed between CoH and AcC.
Conclusions:
- Significant heterogeneity exists in cardiac monitoring practices post-stroke between CoH and AcC.
- CoH's lower utilization of cardiac monitoring, despite higher cryptogenic stroke rates, highlights a critical gap in AF detection.
- Addressing this heterogeneity through standardized protocols is crucial for improving AF detection, treatment, and preventing recurrent strokes.
Background:
Cardiac monitoring strategies to detect occult atrial fibrillation (AF) post-stroke differ among healthcare institutions. This may be related to discrepancies in stroke subtype classification/adjudication, and/or consultation of cardiology specialists at Community Hospitals (CoH) and Academic Centers (AcC). Identifying the degree of heterogeneity may encourage development of guideline-directed monitoring protocols, result in higher AF detection rates and treatments, and fewer strokes.
Methods:
The DiVERT (SeconDary Stroke PreVEntion ThRough Pathway ManagemenT) study was designed to characterize post-stroke cardiac monitoring practices in a hospital setting. Care pathways were assessed with in-person stakeholder interviews; patient-level data were reviewed using electronic medical records.
Results:
DiVERT identified 2,475 patients with diagnoses of cryptogenic (83.6% vs. 33.1%, p < 0.001), large vessel disease (LVD) (13.3% vs. 37.0%, p < 0.001), or small vessel disease (SVD) (3.1% vs. 29.9%, p < 0.001) stroke, at CoH and AcC, respectively. CoH consulted cardiology significantly less than AcC (12.3% vs. 34.7%, p < 0.001) and ordered significantly fewer short- or long-term cardiac monitors than AcC (6.8% vs. 69.2%, p < 0.001). CoH had shorter length of stay (5.3 vs. 9.4 days, p < 0.001) and patient demographics were significantly different (p < 0.001 for age, ethnicity and race).
Conclusion:
Significant heterogeneity in cardiac monitoring post-stroke exists: CoH reported 2.5-times more cryptogenic stroke than AcC yet ordered 10-times fewer short/long-term cardiac monitors to look for AF. Significant differences in patient demographics among institutions may account for this discrepancy. Regardless, efforts to reduce heterogeneity are warranted to improve AF detection and treatment and prevent recurrent stroke.
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