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Introduction: Shortening onset-to-arrival (OTA) time among acute ischemic stroke (AIS) patients is an important public health goal in order to increase the proportion of patients eligible for disability-reducing treatment. Understanding factors associated with delays in OTA will help to focus educational interventions. Hypothesis: AIS patients with greater stroke severity are more likely to arrive early (OTA≤3.5 hours); and among AIS patients arriving acutely (within 8 hours), stroke severity will also predict shorter OTA time. Methods: Prospective study of all AIS patients presenting to the 60 of 70 Massachusetts hospitals participating in the Coverdell Registry from 2005-13, excluding patients transferred from another acute care facility or with symptom onset after hospital arrival. Logistic and linear regression analyses identified predictors of OTA within 3.5 hours, and predictors of shorter OTA among patients presenting within 8 hours, accounting for clustering by hospital. Results: Among 51,631 AIS patients, 6,904 patients (13.4%) were transferred or presented from another acute care facility and complete time data were documented in 82% of the remaining patients for a final sample of 36,680. Median OTA was 6.2 hours (IQR 1.2-18.8 hours). Predictors of OTA within 3.5 hours included stroke severity, younger age, male gender, race, private insurance, ambulance arrival, later year of presentation, and medical history (Table). Among the 19,831 patients arriving acutely (OTA≤8 hours), predictors of shorter OTA duration included stroke severity, non-black race, ambulance arrival, and medical history (Table). Conclusions: Black patients and patients with lower NIHSS are more likely to have delayed arrival. Future work should focus on reducing disparities in care-seeking behavior.

Introduction: Shorter onset-to-arrival (OTA) time is critical for acute ischemic stroke (AIS) patients potentially eligible for disability-reducing treatment including intravenous tPA and endovascular thrombectomy. Hypothesis: Patients with earlier arrival would be more likely to be discharged home and have lower 30-day and 1-year mortality. Methods: Prospective study of all AIS patients presenting to the 60 of 70 Massachusetts hospitals participating in the Coverdell Registry from 2005-13, excluding patients without documented onset or arrival times. Logistic regression analyses identified predictors of discharge disposition, in-hospital, 30-day, and 1-year mortality, accounting for clustering by hospital. Results: Among the 41,856 patients in the sample, 30-day mortality was 6.7% and 1-year mortality was 12.6%. Of the 17,664 patients from 2011-13 with confirmed discharge disposition, 43.1% were discharged home, 8.4% died in-hospital or were discharged to hospice. Predictors of discharge disposition and mortality are outlined in the Table. OTA within 3.5 hours was associated with discharge to home, but had no affect on in-hospital, 30-day, or 1-year mortality. This pattern persisted both with and without tPA administration included in the model. Patients treated with tPA were more likely to be discharged to home. tPA administration was associated with in-hospital mortality, but reduced 1-year mortality. 30-day and 1-year mortality improved over the 8 years in the study period. Conclusions: Patients arriving within 3.5 hours are more likely to be discharged to home, and patients treated with tPA are more likely to be discharged to home and have lower 1-year mortality.

Introduction: Rapid evaluation and treatment are critical for improving outcomes of acute ischemic stroke patients. Arrival by ambulance is associated with more rapid imaging and tPA administration. Predictors of arrival by ambulance have not been well described. Hypothesis: Ischemic stroke patients with increased stroke severity are more likely to arrive to the hospital by ambulance. Methods: Prospective study of all ischemic stroke patients presenting to Massachusetts hospitals participating in the Coverdell Registry from 2005-13 (60 of the states’ 70 hospitals license to receive stroke patients). Logistic regression analysis identified predictors of ambulance use, accounting for clustering by hospital. Results: Among 54,164 acute ischemic stroke patients in the sample, 60.2% (n=32,622) arrived by ambulance. Among the 29,236 patients in whom NIHSS was documented, 59.5% (n=17,380) arrived by ambulance. In bivariate analysis, patients arriving by ambulance had higher NIHSS (mean 8.3 versus 4.5, p Conclusions: While patients with increased stroke severity are more likely to present via EMS, the use of ambulance transport by stroke patients decreased significantly over time. Widespread public education efforts are still needed to stress the importance of ambulance use for suspected stroke symptoms.