Trends And Predictors Of Delay In Hospital Presentation After Symptom Onset Among Ischemic Stroke Patients: A Single-center Study

Background: Delivery of acute ischemic stroke therapies is contingent on the duration from last known normal (LKN) to emergency department arrival time (EDAT). Methods: We studied patients presenting to Yale-New Haven Hospital from 2010-2020 who met these criteria 1) ischemic stroke, 2) age ≥ 18, 3) not transferred from another hospital, and 4) stroke symptom onset prior to hospital presentation. The outcome was LKN to EDAT dichotomized at 4.5 hours. Temporal trends were assessed by linear regression. Covariates analyzed for association with later arrival were: age, gender, race, ethnicity, median household income < $50,000 by ZIP, arrival means, and NIHSS. We built a multivariable logistic regression model by stepwise selection with variables significant at p-value < 0.05). Results: We included 5,242 ischemic stroke patients; 1,964 (37.5%) presented early (<4.5 hrs). Patients presenting early decreased from 47.2% to 32.3% over time (p<0.01, Figure 1 ) and downward slope was steeper among non-White patients. Compared to early presenters, late presenters were more likely younger (median 72 vs 74 years; p<0.001), of non-White race (35.3% vs 26.8%, p<0.001), of Hispanic ethnicity (8.2% vs 6.2%, p=0.010), have a median household income < $50,000 (27.0% vs 21.2%, p=<0.001), arrive by means other than emergency medical services (EMS) (66.4% vs 85.8%, p<0.001), and have an NIHSS < 4 (57.5% vs 41.6%, p<0.001). In a multivariable model, non-White race (OR 1.4, 95% C.I. 1.2-1.7), arrival by means other than EMS (OR 2.4, 95% C.I. 1.9-3.0), and NIHSS < 4 (OR 1.6, 95% C.I. 1.3-1.9) were significant, independent predictors of presenting later. Conclusion: Frequency of ischemic stroke patients presenting beyond 4.5 hrs increased from 2010 to 2020. Non-White race, arriving by means other than EMS, and minor stroke symptoms were linked with delay in presentation. Further study is necessary to identify and target barriers to timely hospital presentation among ischemic stroke patients.