NeuroVoices: Ralph Sacco, MD, MS, on Florida Stroke Registry, Advancing Stroke Knowledge

Ralph Sacco, MD, MS, FAAN, FAHA

The Florida Stroke Registry began at the University of Miami in 2017 as a National Institute of Health (ISC) funded program focused on reducing health disparities in stroke treatment and improving healthcare outcomes. Through the comprehensive collection, analysis, and management of stroke center data, the registry is an evidence-based quality improvement program that can ultimately lead to better practices for stroke prevention, treatment and rehabilitation while developing interventions that can also advance stroke care.

At the American Stroke Association’s (ASA) International Stroke Conference 2021, March 17-19, a number of abstracts contained data from the registry. Ralph Sacco, MD, MS, FAAN, FAHA, director of the Florida Stroke Registry, claims the data will translate into better care for not only patients with stroke in the Florida region, but beyond.

Sacco, who also serves as the chair of neurology and the Olemberg Family Chair of Neurological Disorders at Miller School of Medicine headlined the latest edition of NeuroVoices. In the first half of our conversation, he shared his thoughts on the wide range of data presented and how it can positively impact stroke care moving forward.

NeurologyLive: What is the Florida Stroke Registry? How did you plan to execute this widespread amount of research?

Ralph Sacco, MD, MS, FAAN, FAHA: The Florida Stroke Registry started with funding from the National Institute of Health. We had a grant that was basically focused on trying to reduce stroke disparities. It’s been known, for example, that African American and Hispanic people sometimes have a greater risk of stroke. There was a concern that acute stroke care could be less high quality in these individual populations, so we started the registry in collaboration with the American Heart Association. They have a program called “Get With the Guidelines” that included many stroke centers in the state of Florida and we unified together as the Florida Stroke Registry.

Originally, we worked with Puerto Rico as well, where there are big disparities. We began to collect data together and created a number of resources to try to improve the quality of care, including trying to reduce any disparities, regional and sex, between White people and these other racial groups. After 5 years when the grant was finishing up, we then got the interest of the Florida Department of Health to fund the registry and continue it. Since 2017, the Florida Stroke Registry is funded by the Department of Health and has now gone up to 127 hospitals that are unified in the state of Florida.

It’s a law in the Florida statutes that acute stroke hospitals need to be a part of the Florida Stroke Registry. The goal of the registry is to collect information, share best practices, and benchmark your performance. We’ve created a number of products, the first being our hospital dashboard. We give access to how hospitals look each year compared to other hospitals in the region and state in terms of how they look for care for White, African American, Hispanic, etc. We’ll also show them how men and women are doing in their individual hospital and how they match up with the state.

All of this is, if anything, to then provide them with other resources to improve care and eliminate disparities. The second thing we’ve created is our regional dashboards, and that’s where we work with EMS and provide them data regarding the quality of care in their region. The third thing is our annual stroke dashboards, where we put all the hospitals together to look at all these acute stroke metrics overall and compare the state of Florida to other hospitals in other states.

The research that came out is a variety of projects. When you get all these hospitals working together, collecting this data, trying to improve care, there are many different things that 1 can look at. Obviously, we want this to be a resource for young investigators and other stroke investigators in the state. Some of the things that we presented at ISC are projects that are beginning to come out of the registry, some of which address disparities, some of them addressing intracerebral hemorrhage and other types of stroke outcomes. Some of them address issues with delay in care and some of them are now focusing on transitions of care.

We hope to expand the registry, get more hospitals engaged, and begin to collect other aspects of data. Say we have this acute hospital data and aca-data and connect it with our registry, we can then look at longitudinal care. This way if someone gets hospitalized, we can make sure that their transitions of care are good and that they don’t have a recurrent stroke or rehospitalization. That’s the Florida Stroke Registry in a nutshell.

Out of all the data presented, what was the most surprising to you?

There were a couple that were worth noting. First, was the study on disparities and timelines of hospital presentation. We found significant racial and ethnic differences in the time coming into the hospital. That’s the biggest thing. We know that time is brain and that you have to get to a stroke hospital as quickly as possible. We found a difference between those coming in within 4 ½ hours versus beyond 4 ½ hours. For now, we use 4 ½ hours as 1 of the cutoffs since IVT TPA should only be given during that time. We did find that people who came later were sometimes more African American. There were delays in getting acute care but also outcomes that were worse for those who came later.

The earlier you come in, the better the modified Rankin Scale, or disability scale, will be at discharge. We need to do everything we can to educate people to still call 9-1-1 urgently. We especially need to work harder in educating about the warning signs within the African American communities.

Another study was on cardiac monitoring and that fits in with something else that was presented at ISC. We looked at the overall amount of prolonged cardiac monitoring in cases of ischemic stroke within the registry. Cardiac monitoring occurs when you have a stroke, and the reason is because you want to look for atrial fibrillation, which is an abnormal heart rhythm that can increase the risk of stroke if its left untreated. In our cryptogenic, or unexplained strokes, its been shown in other studies that the more you monitor, the more you find atrial fibrillation.

We tried to look at the differences in amount of monitoring that was done in the Florida Stroke Registry, as well as certain predictors of that, and found that the majority of patients with stroke with transient attack received cardiac monitoring. But there were differences between age, race, and ethnic groups in relation to ECG monitoring overall in the registry. Another way we need to educate all of our stroke clinicians is to make sure they monitor appropriately across all groups. Not just monitoring during the hospital, sometimes there’s also cardiac monitoring after they leave the hospital.

The other big presentation at the meeting, the Stroke AF trial, which wasn’t our study, showed that even in non-cryptogenic strokes, that when you do these implantable cardiac monitors, you find more atrial fibrillation more frequently than the non-implantable cardiac monitors. We do need to be looking for that constantly. Again, if we find that atrial fibrillation with them, then people can be placed on anti-coagulants to prevent another stroke.

We also presented a couple pieces of research on level of consciousness, both in intracerebral hemorrhage as well as in ischemic strokes. Sometimes people who present with impaired level of consciousness could have a worse stroke and potentially worse outcome. But the concern is will we make early decisions about withdrawal of care when somebody has a reduced level of consciousness?

My colleague Ayham Alkhachroum, MD, will be focusing on whether sometimes people with an impaired level of consciousness can actually recover and that we should not be making too quick of a decision about withdrawal of care in people who do present this. He’s done a number of analyses of level of conscious, how frequent it is, what are the predictors, and basically tried to focus on other biomarkers to use among people who have impaired levels of consciousness so that we can be able to detect early recovery. In other words, we shouldn’t be giving up all of our hope in someone with an impaired level of conscious, particularly in the early phase when they first present with a stroke, whether its hemorrhagic or ischemic.

The last study I wanted to mention looked at racial and ethic differences in intracerebral hemorrhage outcomes. Hemorrhagic strokes are sometimes more fatal and have a lot of morbidity. In other studies, they’ve shown to be more frequent in African Americans and Hispanics. In our study, we found that there were more African Americans and Hispanics that had these intracerebral hemorrhages, as well as a greater frequency of high blood pressure. In the non-Hispanic whites, there was some relationship with the prior use of anticoagulants. The point of that poster presentation was just as we focus on ischemic stroke, we also need to focus on intracerebral hemorrhage and looking at risk factors to control particularly high blood pressure in African Americans to reduce that risk.

Transcript has been edited for clarity. For more coverage of ISC 2021, click here.