Epidemiology and Biostatistics Publications


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


Abdoreza Ghoreishi, Vali-e-Asr Hospital, Zanjan University of Medical Sciences (ZUMS)
Shahram Arsang-Jang, School of Medicine, Zanjan University of Medical Sciences (ZUMS)
Ziad Sabaa-Ayoun, Robarts Research Institute
Nawaf Yassi, University of Melbourne
P. N. Sylaja, Sree Chitra Tirunal Institute for Medical Sciences and Technology
Yama Akbari, UCI Beckman Laser Institute & Medical Clinic
Afshin A. Divani, UNM School of Medicine
Jose Biller, Loyola University Stritch School of Medicine
Thanh Phan, Monash University
Sandy Steinwender, The University of Western Ontario
Brian Silver, University of Massachusetts Medical School
Ramin Zand, Geisinger Medical Center
Hamidon Bin Basri, Universiti Putra Malaysia
Omer M. Iqbal, Loyola University Stritch School of Medicine
Annemarei Ranta, University of Otago
Sean Ruland, Loyola University Stritch School of Medicine
Elizabeth Macri, UNM School of Medicine
Henry Ma, Monash University
Thanh N. Nguyen, Boston Medical Center
Shahram Abootalebi, Dalhousie University
Animesh Gupta, UNM School of Medicine
Matias Alet, Neurol. Div. Hospitals
Simona Lattanzi, Università Politecnica delle Marche
Masoom Desai, University of Oklahoma Health Sciences Center
Rubens J. Gagliardi, Santa Casa of Sao Paulo Medical School
Tarun Girotra, UNM School of Medicine
Manabu Inoue, Kokuritsu Junkankibyo Senta
Takeshi Yoshimoto, Kokuritsu Junkankibyo Senta
Cristian Flavo Isaac, Hospital Dr. Arturo Oñativia
Stephan A. Mayer, Westchester Medical Center
Negar Morovatdar, Mashhad University of Medical Sciences
Yongchai Nilanont, Siriraj Hospital

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Journal of Stroke and Cerebrovascular Diseases





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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.

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