COVID-19 Pandemic and Quality of Care and Outcomes of Acute Stroke Hospitalizations

The Paul Coverdell National Acute Stroke Program

Xin Tong, MPH; Sallyann M. Coleman King, MD; Ganesh Asaithambi, MD; Erika Odom, PhD; Quanhe Yang, PhD; Xiaoping Yin, MS; Robert K. Merritt, MS


Prev Chronic Dis. 2021;18(8):e82 

In This Article

Abstract and Introduction


Introduction: Studies documented significant reductions in emergency department visits and hospitalizations for acute stroke during the COVID-19 pandemic. A limited number of studies assessed the adherence to stroke performance measures during the pandemic. We examined rates of stroke hospitalization and adherence to stroke quality-of-care measures before and during the early phase of pandemic.

Methods: We identified hospitalizations with a clinical diagnosis of acute stroke or transient ischemic attack among 406 hospitals who contributed data to the Paul Coverdell National Acute Stroke Program. We used 10 performance measures to examine the effect of the pandemic on stroke quality of care. We compared data from 2 periods: pre–COVID-19 (week 11–24 in 2019) and COVID-19 (week 11–24 in 2020). We used χ 2 tests for differences in categorical variables and the Wilcoxon–Mann–Whitney rank test or Kruskal–Wallis test for continuous variables.

Results: We identified 64,461 hospitalizations. We observed a 20.2% reduction in stroke hospitalizations (from 35,851 to 28,610) from the pre–COVID-19 period to the COVID-19 period. Hospitalizations among patients aged 85 or older, women, and non-Hispanic White patients declined the most. A greater percentage of patients aged 18 to 64 were hospitalized with ischemic stroke during COVID-19 than during pre–COVID-19 (34.4% vs 32.5%, P < .001). Stroke severity was higher during COVID-19 than during pre–COVID-19 for both hemorrhagic stroke and ischemic stroke, and in-hospital death among patients with ischemic stroke increased from 4.3% to 5.0% (P = .003) during the study period. We found no differences in rates of receiving care across stroke type during the study period.

Conclusion: Despite a significant reduction in stroke hospitalizations, more severe stroke among hospitalized patients, and an increase in in-hospital death during the pandemic period, we found no differences in adherence to quality of stroke care measures.


The US declared a national emergency in response to the COVID-19 pandemic on March 13, 2020.[1] At the same time, the Centers for Medicare and Medicaid Services (CMS) announced that patient hospitalization data from the first 6 months of 2020 would not be used in any hospital-based performance or payment programs, citing the need to focus on preparing for a potential surge of patients.[2] Other quality improvement programs followed CMS recommendations.[2] Since the start of the COVID-19 pandemic in the US, several studies have reported significant reductions in emergency department visits and hospitalizations for stroke.[1,3–5] Stay-at-home orders, social distancing, and fear of contracting SARS-CoV-2 in health care settings might have contributed to these reductions.[4,5] These reports are concerning given the established benefits of time-sensitive acute stroke treatments on long-term outcomes and lower 30-day mortality rates among patients treated in an integrated stroke care system.[4] Despite multiple studies on the effect of the pandemic on stroke hospitalizations and treatment outcomes, only a few studies have assessed changes in quality of stroke care during the early phase of the COVID-19 pandemic. We used a multistate stroke registry to examine rates of stroke hospitalizations before and during the early phase of the COVID-19 pandemic as well as adherence to evidence-based performance measures for stroke hospitalizations during the pandemic.