Social and clinical vulnerability in stroke and STEMI management during the COVID-19 pandemic: a registry-based study

Abstract

Objective: This study aims to evaluate whether the first wave of the COVID-19 pandemic resulted in a deterioration in the quality of care for socially and/or clinically vulnerable stroke and ST-segment elevation myocardial infarction (STEMI) patients.

Design: Two cohorts of STEMI and stroke patients in the Aquitaine neurocardiovascular registry.

Setting: Six emergency medical services, 30 emergency units, 14 hospitalisation units and 11 catheterisation laboratories in the Aquitaine region in France.

Participants: This study involved 9218 patients (6436 stroke and 2782 STEMI patients) in the neurocardiovascular registry from January 2019 to August 2020.

Primary outcome measures: Care management times in both cohorts: first medical contact-to-procedure time for the STEMI cohort and emergency unit admission-to-imaging time for the stroke cohort. Associations between social (deprivation index) and clinical (age >65 years, neurocardiovascular history) vulnerabilities and care management times were analysed using multivariate linear mixed models, with an interaction on the time period (pre-wave, per-wave and post-first COVID-19 wave).

Results: The first medical contact procedure time was longer for elderly (p<0.001) and 'very socially disadvantaged' (p=0.003) STEMI patients, with no interaction regarding the COVID-19 period (age, p=0.54; neurocardiovascular history, p=0.70; deprivation, p=0.64). We found no significant association between vulnerabilities and the admission imaging time for stroke patients, and no interaction with respect to the COVID-19 period (age, p=0.81; neurocardiovascular history, p=0.34; deprivation, p=0.95).

Conclusions: This study revealed pre-existing inequalities in care management times for vulnerable STEMI and stroke patients; however, these inequalities were neither accentuated nor reduced during the first COVID-19 wave. Measures implemented during the crisis did not alter the structured emergency pathway for these patients.

Trial registration number: NCT04979208.

Keywords: COVID-19; Health Equity; Health Services Accessibility; Health policy; Organisation of health services; Quality in health care.

Figure 1

Estimation of each clinical and social factor (95% CI) on emergency unit admission-to-imaging time. Estimated overall effects expressed as exp(ß) with 95% CI; results of multivariate linear regression mixed models; variable to be explained: Y=log (emergency unit admission-to-imaging time); (A) results adjusted on period and gender; (B) cardiovascular history was a history of stroke, transient ischaemic attack, coronary artery disease or myocardial infarction; results adjusted on period, age, gender, diabetes and smoking as risk factors, deprivation index; (C) the reference modality for the deprivation index Fdep15 in five categories was ‘most disadvantaged’; results adjusted on period, age, gender, country of birth, urbanicity of residence.

Figure 2

Estimation of each clinical and social factor (95% CI) on FMC-to-procedure time. Estimated overall effects expressed as exp(ß) with 95% CI; results of multivariate linear regression mixed models; variable to be explained: Y=log (FMC-to-procedure time); (A) results adjusted on period and gender; (B) cardiovascular history was a history of stroke, transient ischaemic attack, coronary artery disease or myocardial infarction; results adjusted on period, age, gender, diabetes, hypertension, dyslipidaemia, obesity and smoking as risk factors; (C) the reference modality for the deprivation index Fdep15 in five categories was ‘most disadvantaged’; results adjusted on period, age, gender, country of birth, urbanicity of residence. FMC, first medical contact; STEMI, ST-segment elevation myocardial infarction.