THRIVE Score Accurately Predicts Ischemic Stroke Treatment Outcomes

WHO FUCKING CARES?  Survivors want results, you blithering idiots. Have you never talked to ANY survivor?  And using subjective Rankin scores is the height of stupidity.
http://www.neurologyadvisor.com/stroke/thrive-score-predicting-outcomes-et-ivt-stroke/article/684557/
Total Health Risks in Vascular Events (THRIVE) score is an easy and practical tool for predicting stroke outcomes in clinical practice, according to results of a study published in the European Journal of Neurology.¹ The application of THRIVE scoring not only predicted both good and poor outcomes in stroke patients following either intravenous thrombolysis (IVT) or endovascular therapy (ET) with great accuracy, but also the degree of ischemia following these treatments. These predictions are all extremely valuable in determining individual treatment, as well as patient selection for clinical trials.
The THRIVE score is a validated tool that uses 10 levels of clinical factors readily recognizable in the clinical practice setting, including age, stroke severity (measured by admission National Institute of Health Stroke Scale [NIHSS]), and the presence of 7 chronic health variables (hypertension, atrial fibrillation, diabetes mellitus, coronary artery disease, congestive heart failure, current tobacco use, and cholesterol levels).²

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  In the current study, investigators from multiple departments of the European Medical School in Oldenburg, Germany, evaluated a total of 1038 patients with anterior circulation large vessel occlusions treated between January 2008 and October 2016 with either IVT (n=546) or ET (n=492).
The general trend in all groups was that clinical outcomes (measured by modified Rankin scale scores [mRS] at discharge) and radiological outcomes were inversely related to THRIVE scores: increasing scores strongly predicted both lower probability of a good outcome (mRS 0-2; P <.001 Mantel-Haenszel chi-squared test for trend) and a higher probability of a poor outcome (mRS 5-6; P <.001 Mantel-Haenszel chi-squared test for trend) or in-hospital death (P <.001 Mantel-Haenszel chi-squared test for trend).
When compared with patients with identical THRIVE scores, THRIVE-c scores (which use age and NIHSS as continuous variables) significantly improved the accuracy of predicting good and poor outcomes and in-hospital death in the IVF group. The improvement in prediction in the ET group was significant only for poor outcomes, with non-significant trends towards better prediction of THRIVE-c for in-hospital death. Both THRIVE and THRIVE-c scores showed similar accuracy in predicting good outcomes in patients who had ET.

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The large sample size and homogeneity of the patient population were particular strengths of this study, which was the first to report that THRIVE scores predicted the extent of ischemia on follow-up images. There was no correlation between THRIVE scores and the incidence of symptomatic intracranial hemorrhage (SICH) in either the ET or IVF group.
In the ET group, THRIVE score robustly predicted outcomes, independent of blood vessel recanalization. The same factor could not be assessed in the IVF group, as the data was not consistently available. Other limitations to the study included nonrandomized and retrospective collection of clinical outcomes data, similar to an observational study. Markers of clinical outcomes at discharge or time of in-hospital death were used to measure early outcomes, which varied the time across the patient bases.

Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials

This makes it sound like tPA is 32.9% effective as compared to 12% from an earlier report. Your doctor should be able to compare their hospital statistics to see if they are least match this better result.  If your hospital doesn't even know how well tPA works then the head stroke doctor should be fired.
http://www.mdlinx.com/internal-medicine/newsl-article.cfm/5461158/ZZF307965849E94474BB34FC062CEC0F93/?
Alteplase is effective for treatment of acute ischaemic stroke but debate continues about its use after longer times since stroke onset, in older patients, and among patients who have had the least or most severe strokes. Authors assessed the role of these factors in affecting good stroke outcome in patients given alteplase. Irrespective of age or stroke severity, and despite an increased risk of fatal intracranial haemorrhage during the first few days after treatment, alteplase significantly improves the overall odds of a good stroke outcome when delivered within 4•5 h of stroke onset, with earlier treatment associated with bigger proportional benefits.
Methods

• Authors did a pre–specified meta–analysis of individual patient data from 6756 patients in nine randomised trials comparing alteplase with placebo or open control.
• They included all completed randomised phase 3 trials of intravenous alteplase for treatment of acute ischaemic stroke for which data were available.
• Retrospective checks confirmed that no eligible trials had been omitted.
• They defined a good stroke outcome as no significant disability at 3—6 months, defined by a modified Rankin Score of 0 or 1. (mine was obviously a failure)
• Additional outcomes included symptomatic intracranial haemorrhage (defined by type 2 parenchymal haemorrhage within 7 days and, separately, by the SITS–MOST definition of parenchymal type 2 haemorrhage within 36 h), fatal intracranial haemorrhage within 7 days, and 90–day mortality.

Results

• Alteplase increased the odds of a good stroke outcome, with earlier treatment associated with bigger proportional benefit.
• Treatment within 3•0 h resulted in a good outcome for 259 (32•9%) of 787 patients who received alteplase versus 176 (23•1%) of 762 who received control (OR 1•75, 95% CI 1•35—2•27); delay of greater than 3•0 h, up to 4•5 h, resulted in good outcome for 485 (35•3%) of 1375 versus 432 (30•1%) of 1437 (OR 1•26, 95% CI 1•05—1•51); and delay of more than 4•5 h resulted in good outcome for 401 (32•6%) of 1229 versus 357 (30•6%) of 1166 (OR 1•15, 95% CI 0•95—1•40).
• Proportional treatment benefits were similar irrespective of age or stroke severity.
• Alteplase significantly increased the odds of symptomatic intracranial haemorrhage (type 2 parenchymal haemorrhage definition 231 [6•8%] of 3391 vs 44 [1•3%] of 3365, OR 5•55, 95% CI 4•01—7•70, p<0•0001; SITS–MOST definition 124 [3•7%] vs 19 [0•6%], OR 6•67, 95% CI 4•11—10•84, p<0•0001) and of fatal intracranial haemorrhage within 7 days (91 [2•7%] vs 13 [0•4%]; OR 7•14, 95% CI 3•98—12•79, p<0•0001).
• The relative increase in fatal intracranial haemorrhage from alteplase was similar irrespective of treatment delay, age, or stroke severity, but the absolute excess risk attributable to alteplase was bigger among patients who had more severe strokes.
• There was no excess in other early causes of death and no significant effect on later causes of death.
• Consequently, mortality at 90 days was 608 (17•9%) in the alteplase group versus 556 (16•5%) in the control group (hazard ratio 1•11, 95% CI 0•99—1•25, p=0•07).
• Taken together, therefore, despite an average absolute increased risk of early death from intracranial haemorrhage of about 2%, by 3—6 months this risk was offset by an average absolute increase in disability–free survival of about 10% for patients treated within 3•0 h and about 5% for patients treated after 3•0 h, up to 4•5 h.

How Well Do Standard Stroke Outcome Measures Reflect Quality of Life?

I'm sure our insurance doesn't care about our quality of life. Plateau and get them off of insurance.
http://stroke.ahajournals.org/content/44/11/3161.abstract.html?etoc

1. Myzoon Ali, PhD;
2. Rachael Fulton, MSc;
3. Terry Quinn, MD;
4. Marian Brady, PhD
5. on behalf of the VISTA Collaboration*

+ Author Affiliations

1. From the Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, United Kingdom (M.A., M.B.); and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Western Infirmary, United Kingdom (M.A., R.F., T.Q.).

1. Correspondence to Myzoon Ali, PhD, Nursing, Midwifery and Allied Health Professions Research Unit, Buchanan House, Glasgow Caledonian University, Glasgow, G4 0B, United Kingdom. E-mail myzoon.ali@gcu.ac.uk

Abstract

Background and Purpose—Quality of life (QoL) is important to stroke survivors yet is often recorded as a secondary measure in acute stroke randomized controlled trials. We examined whether commonly used stroke outcome measures captured aspects of QoL.

Methods—We examined primary outcomes by National Institutes of Health Stroke Scale (NIHSS), Barthel Index (BI) and modified Rankin Scale (mRS), and QoL by Stroke Impact Scale (SIS) and European Quality of Life Scale (EQ-5D) from the Virtual International Stroke Trials Archive (VISTA). Using Spearman correlations and logistic regression, we described the relationships between QoL mRS, NIHSS, and BI at 3 months, stratified by respondent (patient or proxy). Using χ² analyses, we examined the mismatch between good primary outcome (mRS ≤1, NIHSS ≤5, or BI ≥95) but poor QoL, and poor primary outcome (mRS ≥3, NIHSS ≥20, or BI ≤60) but good QoL.

Results—Patient-assessed QoL had a stronger association with mRS (EQ-5D weighted score n=2987, P<0.0001, r=−0.7, r²=0.53; SIS recovery n=2970, P<0.0001, r=−0.71, r²=0.52). Proxy responses had a stronger association with BI (EQ-5D weighted score n=837, P<0.0001, r=0.78, r²=0.63; SIS recovery n=867, P<0.0001, r=0.68, r²=0.48). mRS explained more of the variation in QoL (EQ-5D weighted score=53%, recovery by SIS v3.0=52%) than NIHSS or BI and resulted in fewer mismatches between good primary outcome and poor QoL (P<0.0001, EQ-5D weighted score=8.5%; SIS recovery=10%; SIS-16=4.4%).

Conclusions—The mRS seemed to align closely with stroke survivors’ interests, capturing more information on QoL than either NIHSS or BI. This further supports its recommendation as a primary outcome measure in acute stroke randomized controlled trials.

Regional Variation in Stroke Rehabilitation Outcomes

Where do you fall in outcomes compared to these 143,036 people? Your doctor should be using that as a baseline to determine how good their hospital is in getting patients back to recovery. A great or even good stroke association should be keeping this data as a running total so changes over the years can be measured. But, alas we have no 'good' stroke association. We don't have any stroke association worthy of the name.
http://www.sciencedirect.com/science/article/pii/S0003999313005832

Purchase $31.50

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Abstract

Objective

To examine and describe regional variation in outcomes for persons with stroke receiving inpatient medical rehabilitation.

Design

Retrospective cohort design.

Setting

Inpatient rehabilitation units and facilities contributing to the Uniform Data System for Medical Rehabilitation (UDSMR) from the United States.

Participants

143,036 patients with stroke discharged from inpatient rehabilitation during 2006 and 2007.

Interventions

Not applicable.

Main Outcome Measures

Community discharge, length of stay, discharge functional status ratings (motor, cognitive), across ten geographic service regions defined by the Centers for Medicare and Medicaid Services (CMS).

Results

Approximately 71% of the sample was discharged to the community. After adjusting for covariates, the percentage discharged to the community varied from 79.1% in the southwest (CMS 9) to 59.4% in the northeast (CMS 2). Adjusted length of stay varied by 2.1 days with CMS 1 having the longest length of stay at 18.3 days and CMS 5 and 9 being the shortest at 16.2 days.

Conclusion

Rehabilitation outcomes for persons with stroke varied across CMS regions. Substantial variation in discharge destination and length of stay remained after adjusting for demographic and clinical characteristics.

Call Your Representative to Express concerns About Proposed Stroke Measure

You'll have to see what you want to do with this. From the

Burke Rehab Center, White Plains, NY

http://www.burke.org/media/news/2013/07/call-your-representative-to-express-concerns-about/108
The Centers for Medicare and Medicaid Services (CMS) has proposed adding two new stroke outcome measures—a 30-day acute ischemic stroke mortality measure and a 30-day acute ischemic stroke hospital readmission measure—to its hospital Inpatient Quality Reporting program, as part of its FY2014 hospital inpatient prospective payment system proposed rule. The American Heart Association/American Stroke Association and many other patient and provider organizations have very serious concerns about CMS's proposal. In addition, neither of these measures have been endorsed by the National Quality Forum (NQF). In fact, the NQF rejected the stroke hospital readmission measure last fall, and CMS withdrew the stroke mortality measure from NQF consideration.
We believe these measures are fatally flawed because they do not adjust for stroke severity—the single most important variable for determining whether a stroke patient has a good outcome or not.  This concern was validated by a paper published in JAMA last summer that found that 58 percent of hospitals would be misclassified if the stroke mortality measure is not adjusted to account for stroke mortality. If these measures aren't fixed before being implemented, they could unfairly penalize hospitals caring for the most severe stroke patients, worsen health disparities, and undermine the work many of us have been doing to implement stroke systems of care in our communities and regions.
 And if we had objective diagnosis of stroke severity this could be solved.
More at link.