National Trends in Stroke Presentation, Treatments, and Outcomes During the First 2 Years of the COVID-19 Pandemic

Abstract

Background and objectives: Early presentation and acute treatment for patients presenting with ischemic stroke are associated with improved outcomes. The onset of the COVID-19 pandemic was associated with a large decrease in patients presenting with ischemic stroke, but it is unknown whether these changes persisted.

Methods: This study analyzed emergency department (ED) stroke presentations (n = 158,060) to all nonfederal hospitals in the 50 states and Washington, D.C., from 2019 through 2021 using administrative claims data of traditional fee-for-service Medicare enrollees aged 66 years or older. Patients presenting with stroke were identified using the ICD-10 CM (I63.X). We examined the number of beneficiaries presenting with ischemic stroke to the ED, both overall and by demographic categories (race, age, sex, region, Medicaid eligibility, comorbidity status), admission rates conditional on presentation, use of neurovascular interventions, thirty-day mortality, intensive care unit and mechanical ventilation use, length of stay, and discharge destination.

Results: With the onset of the pandemic in March 2020, there was a drop of 32.1% in ED stroke presentations compared with March 2019 levels, and by December 2021, the rate remained 17.7% lower than baseline levels in December 2019. Relative to the prepandemic period, there were decreases in the proportions of those dually eligible for Medicaid (-0.8%, p < 0.0001) or Black (-0.8%, p < 0.0001), as well as those with atrial fibrillation (-1.1%, p < 0.0001), hypertension (-0.7%, p < 0.0001), and chronic obstructive pulmonary disease (-1.8%, p < 0.0001). Admitted patients were more often discharged to home as opposed to postacute care settings (+3.5%, p < 0.0001). The percentage of patients receiving intravenous thrombolysis changed minimally while those receiving intracranial mechanical thrombectomy (+17.8%, p < 0.0001) and carotid interventions (+6.9%, p < 0.0001) increased from baseline throughout the pandemic. Adjusted thirty-day mortality or referral to hospice increased (+1.81%, p < 0.0001) with larger increases seen among Black beneficiaries and those dually eligible for Medicaid.

Discussion: After an initial sharp decline, stroke presentations remained substantially lower than at baseline through the end of 2021, especially among racial minority and those dually eligible for Medicaid. The observed increased mortality rates for those presenting with stroke may have resulted from later time of presentation after the onset of symptoms or preferential presentation of more vs less severe strokes.