The prognosis of patients after stroke is usually assessed using clinical scales, such as the modified Rankin scale score (mRS). Survival and Discharge 90 Days (DAOH-90), a measure of survival, time spent in hospitalization or rehabilitation, readmissions, etc., is an objective measure of clinical outcomes that can be obtained from large management datasets without patient contact. Recently, a study published in the Journal of the American Heart Association aimed to evaluate the comparability of DAOH with mRS after acute stroke reperfusion therapy and its relationship with other prognostic variables.
Background:
Measuring the prognosis of patients after stroke is critical for audits, quality improvement, and clinical research. The mRS score is one of the standard prognostic indicators for stroke patients. The advantage of mRS is that it uses clear evidence of effectiveness, it is a graded measure of outcomes, and it can be done in a face-to-face setting or through structured telephone follow-up. However, mRS has significant variability and is less practical in large-scale trials due to the need for specialized individual patient follow-up.
Days to Survival and Discharge (DAOH) is a prognostic indicator for patients in cardiovascular and surgical populations that circumvents the limitations of mRS. DAOH calculates the number of days of survival and discharge from a reference time point (e.g., hospitalization or surgical indicators) to a defined follow-up period (common reference time points are 30 days, 90 days, or 1 year). Length of hospital stay includes time spent in rehabilitation or hospitalization, which adds up to non-contiguous times in these settings, e.g., rehospitalization within a defined follow-up period. In population studies of stroke, similar endpoints were referred to as 'days at home', 'time at home', or 'days at home', compared to mRS, and were used as a secondary endpoint in multicenter stroke trials and as primary endpoints in trials of haloperidol for delirium. DAOH has several advantages over mRS, it is less labor-intensive to collect data, it is economical, and in many cases it is possible to use component data that has already been routinely collected. However, to date, its use as a primary outcome measure for hyperacute stroke has been limited.
Methods and Results
Serial patients with ischemic stroke treated with intravenous thrombolysis or endovascular thrombectomy were analyzed. DAOH-90 is calculated based on the national minimum data set, which is a mandatory national official database. The mRS score (mRS-90) at day 90 was assessed by face-to-face or telephone follow-up. This study included 1278 ischemic stroke patients (714 males, median age 70 years [59~79], median United States National Institutes of Health stroke scale score 14[9~20]). The median score of DAOH-90 was 71 points [29~84], and the median score of mRS-90 was 3 points [2~5]. The DAOH-90 was associated with the United States National Institutes of Health Stroke Scale score (Spearman rho - 0.44, P<0.001) and the early CT score of the Alberta Stroke Program (Spearman rho 0.24, P<0.001) at admission. The mRS-90 was strongly correlated with DAOH-90 (Spearman correlation coefficient -0.79, P<0.001). The mRS score was predicted >The area under the receiver operating curve was 0.86 (95%CI: 0.84~0.88) for 0, the area under the receiver operating curve for the mRS score >1 was 0.88 (95%CI: 0.86~0.90), and the area under the receiver operating curve for the mRS score >2 was 0.90 (95%CI: 0.89~0.92).
Figure 1. Influencing factors of DAOH after admission (recanalization status, early neurological improvement, ICU hospitalization)
Figure 2.DAOH distribution stratified by mRS score
Discussion and conclusions
DAOH-90 is reasonably comparable as a composite measure of hospitalization and mortality with established mRS-90 stroke outcomes in stroke patients treated with IVT and EVT. DAOH is an objective indicator that can be determined from clinical and management datasets, and its place in stroke trials warrants further investigation.
When previously described poor prognostic factors are present, the DAOH-90 score decreases. Therefore, the association of DAOH score with age, admission NIHSS score, and ASPECTS provides evidence of validity consistent with theoretical expectations. In the full dataset and subgroup analysis, the strong correlation between the 90-day mRS score and the DAOH-90 score showed that the DAOH-90 conveyed similar information to the standard mRS, and using the same predictors, the multivariate model that predicted dichotomous mRS-90 (mRS score ≤2) exhibited similar discriminant power in predicting dichotomous DAOH-90 (DAOH score >70), again demonstrating that DAOH-90 is reasonably comparable. Two smaller studies also reported a close relationship between DAOH-90 and mRS, with a correlation coefficient of -0.73 in both studies.
In this study, the distribution of DAOH was similar in patients with mRS scores of 0 and 1. Nonetheless, DAOH performed well in differentiating between common mRS groups with superior outcomes (mRS score 0~1 vs 2~6), functional independence (mRS score 0~2 vs 3~6), or more severe outcomes. The good discrimination ability of DAOH for various mRS binary classifications may be due to the low DAOH value of the mRS 6 group and the high DAOH value of the mRS 0 group. While DAOH rigorously measures mortality and hospitalization, the correlation with mRS may indicate that DAOH is influenced by factors such as disability, dependency, activity, and burden of care.
There is high internal validity in this cohort study, but external validation is required in other stroke populations. Only stroke patients treated with IVT and EVT were included, so the findings may be less applicable to patients who are not candidates for acute reperfusion therapy. The study was a retrospective analysis, so it was not possible to determine why patients had unexpected DAOH scores. Studies compared two outcome measures, neither of which was the 'gold standard', and the use of mRS as a routine method of collection was one of the primary outcome measures in stroke studies. There are other measurement systems, such as the Patient-Reported Outcome Measurement Information System or the Neuroquality System, which are considered patient-centered because they include patient input in the development process, and many patients consider important measurement structures. In the future, DAOH-90 should also be compared with other patient-centred outcome measures.
DAOH-90 is reasonably comparable with the accepted mRS-90 outcome in stroke patients receiving reperfusion therapy. DAOH-90 is readily available from official databases, so it may be useful for large-scale clinical trials and comparative studies.
参考文献：Joseph Donnelly , Jae Beom Hong , Luke Boyle,etal. Days Alive and Out of Hospital as an Outcome Measure in Patients Receiving Hyperacute Stroke Intervention.J Am Heart Assoc. 2024; 13:e032321. DOI: 10.1161/JAHA.123.032321 1
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(Source: Editorial Department of International Circulation)