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

ObjectiveTo 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).DesignTwo cohorts of patients who had an STEMI and stroke in the Aquitaine Cardio-Neuro-Vascular (CNV) registry.Setting6 emergency medical services, 30 emergency units (EUs), 14 hospitalisation units and 11 cathlabs in the Aquitaine region.ParticipantsThis 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.MethodHospital 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 measuresSTEMI cohort, first medical contact-to-procedure time; stroke cohort, EU admission-to-imaging time.ResultsPer-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).ConclusionsThe 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 numberNCT04979208.

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

“…While the COVID-19 pandemic crisis is nearly resolved, our findings remain valuable for health institutions and professionals to prepare for future health crises. The structured emergency pathway for strokes and STEMI patients and hospital reorganisations ensured sustained care quality 12. In our study, the COVID-19 crisis did not have any differential impact on social health inequalities, suggesting a good resilience of the French healthcare network.…”

“…Guidelines and national stroke and STEMI improvement programmes recommend the implementation of such structured pathways, which include close collaborations between healthcare professionals and patient orientation to the EMS system and specialised technical platforms. A study of the impacts of changes in the use of care and implementation of hospital reorganisation spurred by the COVID-19 pandemic on acute management times for stroke and STEMI revealed no deep alteration of the emergency pathway construct 12. Socially and/or clinically vulnerable populations have also benefited from the resilience of the STEMI and stroke pathways.…”

“…Data are collected prospectively by physicians; consolidated retrospectively by clinical research assistants and then extracted from the hospital information system. Data from the two cohorts were integrated into one data warehouse enabling the reconstruction of the STEMI or stroke management pathway 12…”

“…From February to March 2020, many health authorities, including those in France, implemented strict nationwide lockdowns and series of policies to curb the surge of patients requiring critical care. This crisis, and particularly the lockdown periods, induced the major reorganisation of healthcare systems and modified the use of care to accommodate the onslaught of patients with COVID-19 12. Studies of the association between the COVID-19 pandemic and the quality of stroke and STEMI management have yielded contrasting results, with most revealing longer management delays and reductions in the number of procedures performed 9 10 13…”

Advances in Stroke: A Focus on Health Policy Literature From 2022

“…Management did not differ for STEMI patients and the delays in stroke care could not be definitively determined. 1 Inpatient admissions to a United States Veterans Affairs stroke service went unchanged but 1 medical center reported fewer telestroke consultations during the first and second waves of coronavirus disease 2019 public health mandates. 2 A single-center study in China reported that half as many patients with large vessel occlusion were treated during the pandemic, plus a 2-fold increase in door-to-puncture times, longer hospital stays, and greater hospitalization costs.…”