The indirect impact of COVID-19 on hospitalization and mortality for ischemic stroke

BACKGROUND: Fear of contracting COVID infection may cause delay or reduction in hospital admissions for acute cerebrovascular events. The main objective of this study was to measure the indirect impact of the pandemic on the volume of hospitalizations for ischemic stroke (IS), in-hospital and 30-day mortality, 30-day readmissions and out-of-hospital IS mortality. METHODS: Study design was a quasi-experimental population-based interrupted time-series. Data were drawn from the Health Information System of the Emilia-Romagna region (Italy). To evaluate volume of hospitalizations and inpatient mortality, we included all inpatient care hospitalizations with a principal diagnosis of IS (ICD-9-CM: 433.x1, 434.x1, 436) between 2015-2021. To evaluate out-of-hospital mortality, we included all patients who died at home for IS (ICD-10 cause of death: H34.1, I63.x, I64.x). RESULTS: We observed in 2020 a 13% decrease in IS hospitalizations and an increase in the proportion of in-hospital mortality (+20%), out-of-hospital mortality (2 more deaths per day on average), and 30-day mortality (+4%). Compared to 2020, 2021 showed a 16% lower in-hospital mortality and a 7% lower 30-day mortality. Change in out-of-hospital mortality was not statistically significant. Comparing 2021 to 2015-2019, almost all outcomes did not significantly differ (in-hospital mortality: +0.62%; 30-day mortality: -3.18%; 30-day readmissions: +2.34%). Wee found a significant 12% decrease in hospital admissions and an increase in out-of-hospital mortality by 1.37 deaths per day on average, in 2021 compared to 2015-2019. CONCLUSIONS: COVID pandemic caused a reduction in hospital admissions, resulting in worse outcomes, mostly in 2020 and to a lesser extent in 2021. The improvement in 2021 for most outcomes may have benefitted by the vaccine indirect effect. KEY MESSAGES: • Reduction in IS admissions due to COVID had a negative impact on patient outcomes. • This lesson needs to be acknowledged and considered in a preparedness framework for future pandemics.