Determinants of Emergency Medical Services Utilization
Among Acute Ischemic Stroke Patients in Hubei Province
in China
Xiaoxv Yin, PhD*; Tingting Yang, MS*; Yanhong Gong, PhD; Yanfeng Zhou, PhD;
Wenzhen Li, PhD; Xingyue Song, MPH; Mengdie Wang, MD; Bo Hu, MD; Zuxun Lu, MD
Downloaded from http://stroke.ahajournals.org/ by guest on June 18, 2017
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. 2016;47:891-894. DOI: 10.1161/STROKEAHA.115.011877.)
Key Words: China ◼ emergency medical services ◼ human ◼ stroke ◼ utilization
S
troke 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.
Methods
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.
Received October 18, 2015; final revision received November 27, 2015; accepted December 10, 2015.
From the School of Public Health, Tongji Medical College, Huazhong University of Science and Technology (X.Y., T.Y., Y.G., Y.Z., W.L., X.S., Z.L.),
and Department of Neurology, Union Hospital (M.W., B.H.), Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China;
and The Stroke Quality Control Center of Hubei Province, Wuhan, Hubei, People’s Republic of China (B.H.).
*Dr Yin and T. Yang are joint first authors.
Correspondence to Zuxun Lu, MD, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030,
People’s Republic of China, E-mail [email protected] or Bo Hu, MD, Department of Neurology, Union Hospital, Huazhong University of Science and
Technology, Wuhan, 430022, People’s Republic of China, E-mail [email protected]
© 2016 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.115.011877
891
892 Stroke March 2016
Table 1. Descriptive Statistics of Sample Characteristics and Associations With EMS Utilization (n, %)
Used EMS
Case
Yes
No
2096 (100.0)
323 (15.4)
1773 (84.6)
Variables
Total
Age, y
1024 (49.4)
129 (12.6)
895 (87.4)
>65
1048 (50.6)
191 (18.2)
857 (81.8)
1311 (62.7)
192 (14.6)
1119 (85.4)
779 (37.3)
129 (16.6)
650 (83.4)
814 (38.8)
129 (15.8)
685 (84.2)
1282 (61.2)
194 (15.1)
1088 (84.9)
Gender
Female
0.241
Education level
Illiterate or primary only
Secondary and higher
0.659
The per capital monthly household income, Yuan
0.191
Downloaded from http://stroke.ahajournals.org/ by guest on June 18, 2017
<1000 (US $161)
297 (14.3)
35 (11.8)
262 (88.2)
1000 (US $161)~
1007 (48.4)
155 (15.4)
852 (84.6)
3000 (US $483)~
653 (31.3)
107 (16.4)
546 (83.6)
5000 (US $805)~
126 (6.0)
24 (19.0)
102 (81.0)
Urban
1379 (65.8)
252 (18.3)
1127 (81.7)
Rural
717 (34.2)
71 (9.9)
646 (90.1)
Yes
2031 (96.9)
313 (15.4)
1718 (84.6)
No
65 (3.1)
10 (15.4)
55 (84.6)
155 (7.4)
23 (14.8)
132 (85.2)
1937 (92.6)
300 (15.5)
1637 (84.5)
Yes
684 (32.6)
100 (14.6)
584 (85.4)
No
1412 (67.4)
223 (15.8)
1189 (84.2)
1506 (71.9)
177 (11.8)
1329 (88.2)
588 (28.1)
146 (24.8)
442 (75.2)
1764 (84.4)
271 (15.4)
1493 (84.6)
327 (15.6)
52 (15.9)
275 (84.1)
Residence
<0.001
Medical insurance
0.995
Living condition
Alone
Not alone
0.830
Previous stroke
0.485
Who noticed the symptoms first
Patients
Someone else
<0.001
Site of onset
At home
Outside the home
0.804
Presence of bystander at the time of symptom onset
0.154
Yes
342 (16.3)
44 (12.9)
298 (87.1)
No
1754 (84.7)
279 (15.9)
1475 (84.1)
Sudden
1873 (89.4)
308 (16.4)
1565 (83.6)
Gradual
223 (10.6)
15 (6.7)
208 (93.3)
Yes
705 (33.6)
99 (14.0)
606 (86.0)
No
1391 (66.4)
224 (16.1)
1167 (83.9)
Yes
868 (41.4)
155 (17.9)
713 (82.1)
No
1228 (58.6)
168 (13.7)
1060 (86.3)
Yes
216 (10.3)
124 (57.4)
92 (42.6)
No
1880 (89.7)
199 (10.6)
1681 (98.4)
1851 (88.3)
151 (8.5)
1622 (91.5)
Progression of symptoms
<0.001
Similar symptoms before
0.217
Recognized the problem as stroke
0.009
Previous use of EMS
<0.001
NIHSS score
<10 at admission
≥10 at admission
…
<0.001
≤65
Male
P Value
<0.001
245 (11.7)
94 (29.1)
229 (70.9)
EMS indicates emergency medical services; and NIHSS, National Institutes of Health Stroke Scale.
Yin et al Emergency Medical Services Utilization in China 893
Table 2. Factors Contributing to the Utilization of EMS in
Multivariable Logistic Regression Analysis
Variables
OR
95% CI
Previous use of EMS vs not
9.8
7.0–13.8*
NIHSS score ≥10 vs <10
3.7
2.6–5.2*
Urban vs rural
2.5
1.8–3.5*
Symptom onset sudden vs gradual
2.4
1.3–4.2†
Others noticed the symptoms first vs patients first
noticed
2.1
1.5–2.7*
No previous stroke vs previous stroke
1.8
1.4–2.5†
Recognized the problem as stroke vs not
1.4
1.0–1.8‡
CI indicates confidence interval; EMS, emergency medical services; NIHSS,
National Institutes of Health Stroke Scale; and OR, odds ratio.
*P<0.001.
†P<0.01.
‡P<0.05.
Downloaded from http://stroke.ahajournals.org/ by guest on June 18, 2017
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.
Results
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.
Discussion
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.
Disclosures
None.
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Determinants of Emergency Medical Services Utilization Among Acute Ischemic Stroke
Patients in Hubei Province in China
Xiaoxv Yin, Tingting Yang, Yanhong Gong, Yanfeng Zhou, Wenzhen Li, Xingyue Song,
Mengdie Wang, Bo Hu and Zuxun Lu
Downloaded from http://stroke.ahajournals.org/ by guest on June 18, 2017
Stroke. 2016;47:891-894; originally published online January 14, 2016;
doi: 10.1161/STROKEAHA.115.011877
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2016 American Heart Association, Inc. All rights reserved.
Print ISSN: 0039-2499. Online ISSN: 1524-4628
The online version of this article, along with updated information and services, is located on the
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An erratum has been published regarding this article. Please see the attached page for:
/content/47/3/e58.full.pdf
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Correction
In the article by Yin et al (Yin X, Yang T, Gong Y, Zhou Y, Li W, Song X, Wang M, Hu B, Lu Z.
Determinants of emergency medical services utilization among acute ischemic stroke patients in
Hubei Province in China. Stroke. 2016;47:891–894. DOI: 10.1161/STROKEAHA.115.011877.),
which published online on January 14, 2016, and appeared in the March 2016 issue of the journal,
a correction was needed.
On page 891, in the affiliations, “Correspondence to Bo Hu, MD, Department of Neurology,
Union Hospital, Huazhong University of Science and Technology, Wuhan, 430022, People’s
Republic of China, E-mail [email protected] or Zuxun Lu, MD, School of Public Health,
Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s
Republic of China, E-mail [email protected],” has been changed to read “Correspondence to
Zuxun Lu, MD, School of Public Health, Tongji Medical College, Huazhong University of Science
and Technology, Wuhan, 430030, People’s Republic of China, E-mail [email protected] or
Bo Hu, MD, Department of Neurology, Union Hospital, Huazhong University of Science and
Technology, Wuhan, 430022, People’s Republic of China, E-mail [email protected].”
This correction has been made to the online and print version of the article, which is available
at http://stroke.ahajournals.org/content/47/3/891.
(Stroke. 2016;47:e58. DOI: 10.1161/STR.0000000000000097.)
© 2016 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STR.0000000000000097
e58