Outcomes at discharge.

Background and aimThe COVID-19 pandemic imposed significant pressures on healthcare services such as stroke care. This study aimed to assess the quality of stroke care and, outcome before, during and post lockdown.MethodsNationwide registry-based cohort study of patients with acute stroke admitted to hospitals in England, Wales, and Northern Ireland were analyzed. This included 114 hospitals for study cohorts of 261,451 in the pre-pandemic control period (01/04/2017–25/03/2020). The exposures studied include 16,843 during the first lockdown (26/03/2020–23/06/2020), 48,004 during the second lockdown (05/11/2020-17/05/2021), and 82,732 post-lockdowns (18/07/2021–30/06/2022).Logistic regression was used to compare odds of receiving aspects of acute stroke care across pandemic periods compared to the pre-pandemic period. Survival after stroke was assessed using restricted mean survival time (RMST) analysis, with models adjusted for age, sex, and stroke severity.ResultsAdmission to a stroke unit within 4-hours increased by 8% during the first lockdown but fell by 7% in the second lockdown and remained lower post-pandemic. During the first lockdown, brain imaging within 1-hour increased by 3%, but was not maintained thereafter. Stroke multidisciplinary access increased during the first lockdown but decreased in subsequent periods. Access to thrombectomy sequentially increased across time periods; by 40% during first lockdown (adjusted Odd-Ratio: 1.4; 95% CI:1.24–1.58), second lockdown (aOR: 1.77; 1.66–1.92), and 2-folds post-lockdown (aOR: 2.03; 1.92–2.15). Thrombolysis rates fell during the pandemic and did not recover post-pandemic. Although proportion of patients discharged with good recovery did not alter, 7-day mortality increased by 10% (hazard ratio: 1.10, 1.04-1.18) in the first lockdown period but improved thereafter.ConclusionThis nationwide population data showed unprecedented levels of pressure from the COVID-19 pandemic which have had an enduring effect on the quality of hospital stroke care and patient outcomes. Stroke care has not fully recovered post-pandemic period suggesting limited resilience.

研究背景与目的：新型冠状病毒肺炎（COVID-19）疫情对包括卒中诊疗在内的医疗服务造成了显著压力。本研究旨在评估封控前、封控期间及封控后卒中诊疗质量与患者结局。
研究方法：本研究针对英格兰、威尔士及北爱尔兰地区医院收治的急性卒中患者开展基于全国登记库的队列研究并进行分析。研究纳入114家医院，大流行前对照期（2017年4月1日—2020年3月25日）的队列规模为261451例；纳入的暴露队列分别为：首次封控期（2020年3月26日—2020年6月23日）的16843例患者、第二次封控期（2020年11月5日—2021年5月17日）的48004例患者，以及封控后时期（2021年7月18日—2022年6月30日）的82732例患者。采用logistic回归模型，对比大流行各时期与大流行前时期患者接受急性卒中诊疗服务的概率差异；采用限制性平均生存时间（restricted mean survival time, RMST）分析评估卒中后生存情况，模型校正了年龄、性别及卒中严重程度等混杂因素。
研究结果：首次封控期内，4小时内收入卒中单元的患者比例提升8%，但第二次封控期该比例下降7%，且大流行后仍维持在较低水平。首次封控期内，1小时内完成脑部影像学检查的患者比例提升3%，但后续时期未维持该水平。卒中多学科诊疗的可及性在首次封控期有所提升，但后续时期出现下降。各时期卒中血管内取栓术的可及性逐步提升：首次封控期较大流行前提升40%（校正比值比（adjusted Odd-Ratio, aOR）=1.4；95%置信区间（CI）：1.24~1.58），第二次封控期aOR=1.77（95%CI：1.66~1.92），封控后时期提升至2倍（aOR=2.03；95%CI：1.92~2.15）。疫情期间静脉溶栓率有所下降，且大流行后未恢复至此前水平。尽管出院时获得良好预后的患者比例未发生明显变化，但首次封控期的7天死亡率提升10%（风险比（hazard ratio, HR）=1.10；95%CI：1.04~1.18），后续时期该指标有所改善。
研究结论：本项全国性人群研究数据显示，COVID-19疫情带来的压力前所未有，且对医院卒中诊疗质量及患者结局产生了持久影响；卒中诊疗服务在大流行后未完全恢复，提示其韧性有限。