Effects of healthcare system transformations spurred by the COVID-19 pandemic on management of stroke and STEMI: a registry-based cohort study in France

Abstract

Objective: To assess the impact of changes in use of care and implementation of hospital reorganisations spurred by the COVID-19 pandemic (first wave) on the acute management times of patients who had a stroke and ST-segment elevation myocardial infarction (STEMI).

Design: Two cohorts of patients who had an STEMI and stroke in the Aquitaine Cardio-Neuro-Vascular (CNV) registry.

Setting: 6 emergency medical services, 30 emergency units (EUs), 14 hospitalisation units and 11 cathlabs in the Aquitaine region.

Participants: This study involved 9218 patients (6436 patients who had a stroke and 2782 patients who had an STEMI) in the CNV Registry from January 2019 to August 2020.

Method: Hospital reorganisations, retrieved in a scoping review, were collected from heads of hospital departments. Other data were from the CNV Registry. Associations between reorganisations, use of care and care management times were analysed using multivariate linear regression mixed models. Interaction terms between use-of-care variables and period (pre-wave, per-wave and post-wave) were introduced.

Main outcome measures: STEMI cohort, first medical contact-to-procedure time; stroke cohort, EU admission-to-imaging time.

Results: Per-wave period management times deteriorated for stroke but were maintained for STEMI. Per-wave changes in use of care did not affect STEMI management. No association was found between reorganisations and stroke management times. In the STEMI cohort, the implementation of systematic testing at admission was associated with a 41% increase in care management time (exp=1.409, 95% CI 1.075 to 1.848, p=0.013). Implementation of plan blanc, which concentrated resources in emergency activities, was associated with a 19% decrease in management time (exp=0.801, 95% CI 0.639 to 1.023, p=0.077).

Conclusions: The pandemic did not markedly alter the functioning of the emergency network. Although stroke patient management deteriorated, the resilience of the STEMI pathway was linked to its stronger structuring. Transversal reorganisations, aiming at concentrating resources on emergency care, contributed to maintenance of the quality of care.

Trial registration number: NCT04979208.

Keywords: COVID-19; health policy; myocardial infarction; organisation of health services; quality in health care; stroke.

Figure 1

Weekly cumulated number of care structures having implemented reorganisations, by reorganisation category—minimum and maximum number and proportion of care structures having implemented reorganisation, by reorganisation category and by period (pre-wave, per-wave and post-wave). EMS, emergency medical service; EU, emergency unit; plan blanc, emergency plan to cope with a sudden increase of activity; STEMI, ST-segment elevation myocardial infarction.

Figure 2

Stroke and STEMI cohorts. Estimation of the reorganisations and use of care effects (95% CI) on care management times. Stroke cohort (N=4603)—estimated overall effects expressed as exp(β) with 95% CI; results of multivariate linear regression mixed models; variable to be explained: Y=log (EU admission-to-imaging time); results adjusted on period, age, gender, urbanicity of residence, FDep15, APL MG 18, residence-EU distance, presence of stroke unit, MRI 24 hours a day, presence of interventional neuroradiology unit, care during on-call activity, mode of transport, calls to emergency services activity, mRS less than 1 before stroke, NIHSS at entry, previous stroke or transient ischaemic attack. STEMI cohort (N=1843)—estimated overall effects expressed as exp(β) with 95% CI; results of multivariate linear regression mixed models; variable to be explained: Y=log (FMC-to-procedure time); results adjusted on period, age, gender, urbanicity of residence, FDep15, APL MG 18, residence-to-cathlab distance, cathlab hospital status, care during on-call activity, mode of transport, calls to emergency services activity, FMC-to-cathlab distance, diabetes mellitus, coronary artery disease or STEMI history). Light grey: interaction with the COVID-19 period, Dark grey: raw results without interaction with the COVID-19 period. APL MG 2018, potential accessibility to general practitioners; EU, emergency unit; FDep15, deprivation index; FMC, first medical contact; MICU, mobile intensive care units; mRS, modified Rankin Scale; NIHSS, National Institute of Health Stroke Score; plan blanc, emergency plan to cope with a sudden increase of activity; STEMI, ST-segment elevation myocardial infarction.