Stroke Care Trends During COVID-19 Pandemic in Zanjan Province, Iran. From the CASCADE Initiative: Statistical Analysis Plan and Preliminary Results

doi:10.1016/j.jstrokecerebrovasdis.2020.105321

Multicenter Study

. 2020 Dec;29(12):105321.

doi: 10.1016/j.jstrokecerebrovasdis.2020.105321. Epub 2020 Sep 16.

Stroke Care Trends During COVID-19 Pandemic in Zanjan Province, Iran. From the CASCADE Initiative: Statistical Analysis Plan and Preliminary Results

Abdoreza Ghoreishi¹, Shahram Arsang-Jang², Ziad Sabaa-Ayoun³, Nawaf Yassi⁴, P N Sylaja⁵, Yama Akbari⁶, Afshin A Divani⁷, Jose Biller⁸, Thanh Phan⁹, Sandy Steinwender¹⁰, Brian Silver¹¹, Ramin Zand¹², Hamidon Bin Basri¹³, Omer M Iqbal¹⁴, Annemarei Ranta¹⁵, Sean Ruland⁸, Elizabeth Macri⁷, Henry Ma⁹, Thanh N Nguyen¹⁶, Shahram Abootalebi¹⁷, Animesh Gupta⁷, Matias Alet¹⁸, Simona Lattanzi¹⁹, Masoom Desai²⁰, Rubens J Gagliardi²¹, Tarun Girotra⁷, Manabu Inoue²², Takeshi Yoshimoto²², Cristian Flavo Isaac²³, Stephan A Mayer²⁴, Negar Morovatdar²⁵, Yongchai Nilanont²⁶, Christa O'Hana S Nobleza²⁷, Hamidreza Saber²⁸, Saltanat Kamenova²⁹, Aida Kondybayeva³⁰, Jerzy Krupinski³¹, James E Siegler³², Saverio Stranges³³, Michel T Torbey⁷, Diana Yorio³⁴, María Cristina Zurrú³⁵, Clio Aracelli Rubinos³⁶, Reza Bavarsad Shahripour³⁷, Afshin Borhani-Haghighi³⁸, Mario Di Napoli³⁹, M Reza Azarpazhooh⁴⁰

Affiliations

¹ Stroke Research Group, Department of Neurology and Stroke Unit, Vali-e-Asr hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran.
² Department of Biostatistics and Epidemiology, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran.
³ Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada; Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
⁴ Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Australia; Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia.
⁵ Comprehensive Stroke Care Program, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum, Kerala, India.
⁶ Departments of Neurology, Neurological Surgery, and Anatomy & Neurobiology, Beckman Laser Institute & Medical Clinic, University of California, Irvine, CA, USA.
⁷ Department of Neurology, School of Medicine, University of New Mexico, Albuquerque, NM, USA.
⁸ Department of Neurology, Loyola University, Stritch School of Medicine, Chicago, IL, USA.
⁹ Department of Neurology, Monash Health and Department of Medicine, School of Clinical Sciences, Monash University, Australia.
¹⁰ Health Information Science, Western University, London, Ontario, Canada; Regional Stroke Prevention, Southwestern Ontario Stroke Network, London Health Sciences, London, Ontario, Canada.
¹¹ Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA.
¹² Department of Neurology, Neuroscience Institute, Geisinger Medical Center, Danville, PA, USA.
¹³ Department of Medicine, Faculty of Medicine and Health Sciences, UPM, Serdang, Malaysia.
¹⁴ Department of Pathology and Ophthalmology, Center for Translational Research & Education, Loyola University Stritch School of Medicine, Maywood, IL, USA.
¹⁵ Department of Medicine and Neurology, University of Otago and Wellington Hospital, Wellington, New Zealand.
¹⁶ Boston Medical Center, Boston University School of Medicine, Boston, MA, USA.
¹⁷ Dr. Everett Chalmers Regional Hospital, Dalhousie University, New Brunswick, Canada.
¹⁸ Vascular Neurology Division, Department of Neurology, Fleni, Buenos Aires, Argentina.
¹⁹ Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Via Conca, Ancona, Italy.
²⁰ Department of Neurology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA.
²¹ Neurology Department, Santa Casa of Sao Paulo Medical School, Sao Paulo, Brazil.
²² Department of Cerebrovascular Medicine/Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
²³ Hospital Dr. Arturo Oñativia, Rafael Calzada, Alte Brown, Pcia de Bs As, Argentina.
²⁴ Westchester Medical Center Health Network, Director of Neurocritical Care and Emergency Neurological Services, Valhalla, NY, USA; Westchester Medical Center Health Network, New York Medical College, Valhalla, NY, USA.
²⁵ Clinical Research Development Unit, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
²⁶ Siriraj Stroke Center, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
²⁷ Departments of Neurology and Neurosurgery, Division of Neuroscience Critical Care, University of Mississippi Medical Center, Jackson, MS, USA.
²⁸ Wayne State University, Detroit, MI, USA.
²⁹ Department of Medicine, Al-Farabi Kazakh National University, Almaty, Kazakhstan.
³⁰ Department of Neurology, Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan.
³¹ Department of Neurology, Hospital Universitari MutuaTerrassa, Terrassa, Barcelona, Spain; Department of Life Sciences, CBS, Manchester Metropolitan University, Manchester, UK.
³² Department of Neurology, Cooper University Hospital, Camden, NJ, USA.
³³ Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Population Health, Luxembourg Institute of Health, Strassen, Luxembourg.
³⁴ Department of Neurology, British Hospital, Montevideo, Uruguay.
³⁵ Department of Neurology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
³⁶ Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
³⁷ UCSD Stroke center, Department of Neurosciences, University of California, San Diego, USA.
³⁸ Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
³⁹ Department of Neurology and Stroke Unit, San Camillo de' Lellis General District Hospital, Rieti, Italy; Neurological Section, Neuro-epidemiology Unit, SMDN-Centre for Cardiovascular Medicine and Cerebrovascular Disease Prevention, Sulmona, L'Aquila, Italy.
⁴⁰ Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Clinical Neurological Sciences, Western University, London, ON, Canada; Department of Neurology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. Electronic address: reza.azarpazhooh@lhsc.on.ca.

PMID: 33069086
PMCID: PMC7494258
DOI: 10.1016/j.jstrokecerebrovasdis.2020.105321

Multicenter Study

Stroke Care Trends During COVID-19 Pandemic in Zanjan Province, Iran. From the CASCADE Initiative: Statistical Analysis Plan and Preliminary Results

Abdoreza Ghoreishi et al. J Stroke Cerebrovasc Dis. 2020 Dec.

. 2020 Dec;29(12):105321.

doi: 10.1016/j.jstrokecerebrovasdis.2020.105321. Epub 2020 Sep 16.

Authors

Affiliations

¹ Stroke Research Group, Department of Neurology and Stroke Unit, Vali-e-Asr hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran.
² Department of Biostatistics and Epidemiology, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran.
³ Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada; Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
⁴ Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Australia; Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia.
⁵ Comprehensive Stroke Care Program, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum, Kerala, India.
⁶ Departments of Neurology, Neurological Surgery, and Anatomy & Neurobiology, Beckman Laser Institute & Medical Clinic, University of California, Irvine, CA, USA.
⁷ Department of Neurology, School of Medicine, University of New Mexico, Albuquerque, NM, USA.
⁸ Department of Neurology, Loyola University, Stritch School of Medicine, Chicago, IL, USA.
⁹ Department of Neurology, Monash Health and Department of Medicine, School of Clinical Sciences, Monash University, Australia.
¹⁰ Health Information Science, Western University, London, Ontario, Canada; Regional Stroke Prevention, Southwestern Ontario Stroke Network, London Health Sciences, London, Ontario, Canada.
¹¹ Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA.
¹² Department of Neurology, Neuroscience Institute, Geisinger Medical Center, Danville, PA, USA.
¹³ Department of Medicine, Faculty of Medicine and Health Sciences, UPM, Serdang, Malaysia.
¹⁴ Department of Pathology and Ophthalmology, Center for Translational Research & Education, Loyola University Stritch School of Medicine, Maywood, IL, USA.
¹⁵ Department of Medicine and Neurology, University of Otago and Wellington Hospital, Wellington, New Zealand.
¹⁶ Boston Medical Center, Boston University School of Medicine, Boston, MA, USA.
¹⁷ Dr. Everett Chalmers Regional Hospital, Dalhousie University, New Brunswick, Canada.
¹⁸ Vascular Neurology Division, Department of Neurology, Fleni, Buenos Aires, Argentina.
¹⁹ Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Via Conca, Ancona, Italy.
²⁰ Department of Neurology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA.
²¹ Neurology Department, Santa Casa of Sao Paulo Medical School, Sao Paulo, Brazil.
²² Department of Cerebrovascular Medicine/Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
²³ Hospital Dr. Arturo Oñativia, Rafael Calzada, Alte Brown, Pcia de Bs As, Argentina.
²⁴ Westchester Medical Center Health Network, Director of Neurocritical Care and Emergency Neurological Services, Valhalla, NY, USA; Westchester Medical Center Health Network, New York Medical College, Valhalla, NY, USA.
²⁵ Clinical Research Development Unit, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
²⁶ Siriraj Stroke Center, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
²⁷ Departments of Neurology and Neurosurgery, Division of Neuroscience Critical Care, University of Mississippi Medical Center, Jackson, MS, USA.
²⁸ Wayne State University, Detroit, MI, USA.
²⁹ Department of Medicine, Al-Farabi Kazakh National University, Almaty, Kazakhstan.
³⁰ Department of Neurology, Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan.
³¹ Department of Neurology, Hospital Universitari MutuaTerrassa, Terrassa, Barcelona, Spain; Department of Life Sciences, CBS, Manchester Metropolitan University, Manchester, UK.
³² Department of Neurology, Cooper University Hospital, Camden, NJ, USA.
³³ Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Population Health, Luxembourg Institute of Health, Strassen, Luxembourg.
³⁴ Department of Neurology, British Hospital, Montevideo, Uruguay.
³⁵ Department of Neurology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
³⁶ Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
³⁷ UCSD Stroke center, Department of Neurosciences, University of California, San Diego, USA.
³⁸ Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
³⁹ Department of Neurology and Stroke Unit, San Camillo de' Lellis General District Hospital, Rieti, Italy; Neurological Section, Neuro-epidemiology Unit, SMDN-Centre for Cardiovascular Medicine and Cerebrovascular Disease Prevention, Sulmona, L'Aquila, Italy.
⁴⁰ Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Clinical Neurological Sciences, Western University, London, ON, Canada; Department of Neurology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. Electronic address: reza.azarpazhooh@lhsc.on.ca.

PMID: 33069086
PMCID: PMC7494258
DOI: 10.1016/j.jstrokecerebrovasdis.2020.105321

Abstract

Background: The emergence of the COVID-19 pandemic has significantly impacted global healthcare systems and this may affect stroke care and outcomes. This study examines the changes in stroke epidemiology and care during the COVID-19 pandemic in Zanjan Province, Iran.

Methods: This study is part of the CASCADE international initiative. From February 18, 2019, to July 18, 2020, we followed ischemic and hemorrhagic stroke hospitalization rates and outcomes in Valiasr Hospital, Zanjan, Iran. We used a Bayesian hierarchical model and an interrupted time series analysis (ITS) to identify changes in stroke hospitalization rate, baseline stroke severity [measured by the National Institutes of Health Stroke Scale (NIHSS)], disability [measured by the modified Rankin Scale (mRS)], presentation time (last seen normal to hospital presentation), thrombolytic therapy rate, median door-to-needle time, length of hospital stay, and in-hospital mortality. We compared in-hospital mortality between study periods using Cox-regression model.

Results: During the study period, 1,026 stroke patients were hospitalized. Stroke hospitalization rates per 100,000 population decreased from 68.09 before the pandemic to 44.50 during the pandemic, with a significant decline in both Bayesian [Beta: -1.034; Standard Error (SE): 0.22, 95% CrI: -1.48, -0.59] and ITS analysis (estimate: -1.03, SE = 0.24, p < 0.0001). Furthermore, we observed lower admission rates for patients with mild (NIHSS < 5) ischemic stroke (p < 0.0001). Although, the presentation time and door-to-needle time did not change during the pandemic, a lower proportion of patients received thrombolysis (-10.1%; p = 0.004). We did not see significant changes in admission rate to the stroke unit and in-hospital mortality rate; however, disability at discharge increased (p < 0.0001).

Conclusion: In Zanjan, Iran, the COVID-19 pandemic has significantly impacted stroke outcomes and altered the delivery of stroke care. Observed lower admission rates for milder stroke may possibly be due to fear of exposure related to COVID-19. The decrease in patients treated with thrombolysis and the increased disability at discharge may indicate changes in the delivery of stroke care and increased pressure on existing stroke acute and subacute services. The results of this research will contribute to a similar analysis of the larger CASCADE dataset in order to confirm findings at a global scale and improve measures to ensure the best quality of care for stroke patients during the COVID-19 pandemic.

Keywords: COVID-19; Disability; Epidemiology; Mortality; Outcome; Stroke; Stroke care.

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Figures

Fig 1 — **Fig. 1**
Stroke hospitalization rate per 100,000 population before and during the COVID-19 pandemic. Results from the CASCADE initiative. Recruiting centre Valiasr Hospital, Zanjan, Iran.

Fig 2 — **Fig. 2**
Cox proportional hazard analysis of in-hospital mortality model. Results from the CASCADE initiative. Recruiting centre Valiasr Hospital, Zanjan, Iran. HR: Hazard Ratio. The number of days of hospitalization until death was calculated based on the difference between date of death and date of admission.

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References

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1. Azarpazhooh MR, Morovatdar N, Avan A, Phan TG, Divani AA, Yassi N. COVID-19 pandemic and burden of non-communicable diseases: an ecological study on data of 185 countries. J Stroke Cerebrovasc Dis. 2020 - PMC - PubMed
1. Azarpazhooh MR, Amiri A, Morovatdar N, Steinwender S, Rezaei Ardani A, Yassi N. Correlations between COVID-19 and burden of dementia: an ecological study and review of literature. J Neurol Sci. 2020;416 - PMC - PubMed
1. Martinez R, Lloyd-Sherlock P, Soliz P, Ebrahim S, Vega E, Ordunez P. Trends in premature avertable mortality from non-communicable diseases for 195 countries and territories, 1990-2017: a population-based study. Lancet Glob Health. 2020;8(4):e511–e523. - PubMed
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[1] Adhanom Ghebreyesus T. We now have a name for the disease caused by the novel coronavirus: COVID-19 [Internet]. twitter . 2020 [cited 2020 Jul 22]. Available from: https://twitter.com/DrTedros/status/1227297754499764230.

[2] Adhanom Ghebreyesus T. We now have a name for the disease caused by the novel coronavirus: COVID-19 [Internet]. twitter . 2020 [cited 2020 Jul 22]. Available from: https://twitter.com/DrTedros/status/1227297754499764230.

[3] Azarpazhooh MR, Morovatdar N, Avan A, Phan TG, Divani AA, Yassi N. COVID-19 pandemic and burden of non-communicable diseases: an ecological study on data of 185 countries. J Stroke Cerebrovasc Dis. 2020 - PMC - PubMed

[4] Azarpazhooh MR, Morovatdar N, Avan A, Phan TG, Divani AA, Yassi N. COVID-19 pandemic and burden of non-communicable diseases: an ecological study on data of 185 countries. J Stroke Cerebrovasc Dis. 2020 - PMC - PubMed

[5] Azarpazhooh MR, Amiri A, Morovatdar N, Steinwender S, Rezaei Ardani A, Yassi N. Correlations between COVID-19 and burden of dementia: an ecological study and review of literature. J Neurol Sci. 2020;416 - PMC - PubMed

[6] Azarpazhooh MR, Amiri A, Morovatdar N, Steinwender S, Rezaei Ardani A, Yassi N. Correlations between COVID-19 and burden of dementia: an ecological study and review of literature. J Neurol Sci. 2020;416 - PMC - PubMed

[7] Martinez R, Lloyd-Sherlock P, Soliz P, Ebrahim S, Vega E, Ordunez P. Trends in premature avertable mortality from non-communicable diseases for 195 countries and territories, 1990-2017: a population-based study. Lancet Glob Health. 2020;8(4):e511–e523. - PubMed

[8] Martinez R, Lloyd-Sherlock P, Soliz P, Ebrahim S, Vega E, Ordunez P. Trends in premature avertable mortality from non-communicable diseases for 195 countries and territories, 1990-2017: a population-based study. Lancet Glob Health. 2020;8(4):e511–e523. - PubMed

[9] Bersano A, Kraemer M, Touzé E, Weber R, Alamowitch S, Sibon I. Stroke care during the COVID-19 pandemic: experience from three large European countries. Eur J Neurol. 2020 - PMC - PubMed

[10] Bersano A, Kraemer M, Touzé E, Weber R, Alamowitch S, Sibon I. Stroke care during the COVID-19 pandemic: experience from three large European countries. Eur J Neurol. 2020 - PMC - PubMed

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Stroke Care Trends During COVID-19 Pandemic in Zanjan Province, Iran. From the CASCADE Initiative: Statistical Analysis Plan and Preliminary Results

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Stroke Care Trends During COVID-19 Pandemic in Zanjan Province, Iran. From the CASCADE Initiative: Statistical Analysis Plan and Preliminary Results

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