Determinants of Emergency Medical Services Utilization Among Acute Ischemic Stroke Patients in Hubei Province in China
Background and Purpose—Emergency medical services (EMS) can effectively shorten the prehospital delay for patients with acute ischemic stroke. This study aimed to investigate EMS utilization and its associated factors in patients with acute ischemic stroke in China.
Methods—A cross-sectional study was conducted from October 1, 2014, to January 31, 2015, which included 2096 patients admitted for acute ischemic stroke from 66 hospitals in Hubei province in China. A multivariable stepwise logistic regression model was undertaken to identify the factors associated with EMS utilization.
Results—Of the 2096 participants, only 323 cases (15.4%) used EMS. Those acute ischemic stroke patients who previously used EMS (odds ratio [OR] =9.8), whose National Institutes of Health Stroke Scale score was ≥10 (OR=3.7), who lived in urban communities (OR=2.5), who had sudden onset of symptoms (OR=2.4), who experienced their first stroke (OR=1.8), and who recognized initial symptom as stroke (OR=1.4) were more likely to use EMS. Additionally, when acute ischemic stroke patients’ stroke symptom were noticed first by others (OR=2.1), rather than by the patients, EMS was more likely to be used.
Conclusions—A very low proportion of patients with acute ischemic stroke used the EMS in Hubei province in China. Considerable education programs are required regarding knowledge of potential symptoms and the importance of EMS for stroke.
Stroke was the first leading cause of death and the most prominent for disability-adjusted life-years in China.1 Recombinant tissue-type plasminogen activator, when given to patients with appropriate acute ischemic stroke (AIS) soon after symptom onset, can reduce the risk of severe disability and mortality.2 Unfortunately, <5% of AIS patients received intravenous recombinant tissue-type plasminogen activator in China3 mainly because the best treatment window for thrombolysis is often missed.4
Utilization of emergency medical services (EMS) can increase the likelihood of appropriate therapy with recombinant tissue-type plasminogen activator.5,6 Recently, several studies have been conducted to investigate EMS utilization and its influencing factors with acute stroke in developed countries.7,8 However, information about EMS utilization among AIS patients in China is still unclear. We conducted this study to investigate the prevalence of EMS utilization by AIS patients across central China and to examine its influencing factors.
This cross-sectional study was conducted from October 1, 2014, to January 31, 2015, in Hubei province (Central China). The study included 2176 patients hospitalized with AIS in neurology departments from 66 hospitals. Hospitals from the provincial capital of Wuhan and 12 cities district government seats were invited to participate if they met the following eligibility criteria: (1) Level III or Level II hospitals, which were large hospital serving as major referral centers in the provincial capitals and major cities with >500 beds and (2) neurologists were available, allowing intravenous thrombolytic therapy to be performed 24 hours a day, 7 days a week. The criteria for participating patients were the following: (1) patients hospitalized with AIS within 7 days of symptom onset and aged ≥18 years and (2) clinical examination and neuroimaging indicated AIS. Finally, we excluded 80 events that occurred in the hospitals or nursing homes and included 2096 confirmed cases of AIS for analyses.
A standard-structured anonymous questionnaire was completed for each participant after verbal consent. The questionnaire documented sociodemographic and socioeconomic characteristics, stroke severity, some other related variables (progression of symptoms, previous use of EMS, etc), and EMS utilization. In China, the EMS is organized on a municipal basis with a single call center that answers all emergency phone calls. EMS utilization was defined as calling 120 emergency calls and using an ambulance for transportation to a hospital. Stroke severity was determined using a retrospectively derived National Institutes of Health Stroke Scale (NIHSS) score. NIHSS score <10 is defined as mild stroke and NIHSS score ≥10 as moderate to severe stroke.
Descriptive analysis was performed for sociodemographics data, stroke symptoms and severity, and some other related variables. Pearson chi-square tests were conducted to compare the utilization rate of EMS between groups. Multivariable stepwise logistic regression analysis was performed to identify the predictors associated with EMS utilization. Adjusted odds ratios (ORs) and 95% confidence intervals for each variable were calculated. A 2-sided P<0.05 was considered statistically significant. All analyses used SPSS 12.0 for Windows.
Table 1 presents participant characteristics and the difference between patients who used EMS and those who did not. The study participants had a mean age of 65.5 (SD=12.0) years, and 62.7% were men. Of the 2096 AIS patients, only 323 cases (15.4%) used EMS. Pearson chi-square tests indicated that EMS utilization was associated with patients’ age, residence area, NIHSS score, progression of stroke symptoms (sudden or gradual), who noticed the symptoms first, whether the problem was recognized as stroke or not, and whether EMS was previously used or not.
Table 2 shows the adjusted ORs and 95% confidence intervals for EMS utilization. AIS patients who previously used EMS (OR=9.8), whose NIHSS score ≥10 (OR=3.7), who lived in urban communities (OR=2.5), who had sudden onset of stroke symptoms (OR=2.4), who experienced their first stroke (OR=1.8), and who recognized initial symptom as stroke (OR=1.4) were more likely to use EMS. Additionally, when AIS patients’ stroke symptom was noticed first by others (OR=2.1) rather than by the patients, EMS was more likely to be used.
Our study demonstrated a very low rate of EMS utilization among patients with AIS in Hubei province in China. The proportion was much lower than that in England9 (78.8%), Germany7 (72.0%), Sweden10 (53.2%), and the United States11 (51.0%). Consistent with previous studies, our study confirmed that EMS utilization was positively associated with the following factors: severe stroke, living in urban communities, or sudden stroke attack.12,13 However, we found that patients with a history of stroke were less likely to use EMS, which was inconsistent with previous reports showing no association between previous stroke and EMS utilization.12
It was worth noting that the most powerful factor associated with increased EMS utilization was previous use of EMS. Patients with experience in using EMS may have greater awareness of the importance of appropriate use of EMS for acute stroke symptoms, and they may also have better knowledge about how to use it. With regard to stroke symptoms, we found that patients who recognized initial symptoms as stroke-related were more likely to use EMS, which suggested that early recognition of stroke symptoms was an important factor influencing the EMS utilization. However, about 60% patients did not recognize initial symptoms as stroke-related. Therefore, more health education programs are needed regarding identification of potential symptoms and the need to call EMS immediately when the stroke attacks.
This study indicated an inadequate use of EMS among AIS patients in China and revealed the associated factors, which may be used to arouse public attention and to promote the appropriate utilization of EMS. Nevertheless, this study was conducted in one medium development central province in China. Findings of this study need to be verified in other areas.
Sources of Funding
This project was supported by the Stroke Quality Control Center of Hubei Province and the Preventive Medical Association of Hubei Province.
- Received October 18, 2015.
- Revision received November 27, 2015.
- Accepted December 10, 2015.
- © 2016 American Heart Association, Inc.
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