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Mocco J, Fargen KM, Goyal M, Levy EI, Mitchell PJ, Campbell BCV, Majoie CBLM, Dippel DWJ, Khatri P, Hill MD, Saver JL. Neurothrombectomy trial results: stroke systems, not just devices, make the difference. Int J Stroke 2016; 10:990-3. [PMID: 26404879 DOI: 10.1111/ijs.12614] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 07/01/2015] [Indexed: 11/26/2022]
Abstract
The overwhelming benefit demonstrated in the four recent randomized trials comparing intra-arterial therapies to medical management alone will have a transformative effect on the emergent management of strokes throughout the world. New generation neurothrombectomy devices were critical to trial success, but not the sole driver of patient outcomes in these trials. Patients in the positive trials were treated at hospitals with complex, efficient, resource-rich, team-based stroke systems in place. To ensure attainment of trial results in actual practice, patients should receive treatment at facilities certified as having the resources, personnel, organization, and continuous quality improvement processes characteristic of trial centers. It is our hope that, through greater education initiatives, robust resource investment, and developing quality-based certification processes, the results demonstrated by these trials may be extrapolated to greater numbers of centers - in turn allowing greater access for patients to high-quality, advanced stroke care.
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Affiliation(s)
- J Mocco
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, USA
| | - Kyle M Fargen
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Mayank Goyal
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Elad I Levy
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Peter J Mitchell
- Department of Radiology, University of Melbourne, Melbourne, Victoria, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Center at the Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Charles B L M Majoie
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Neuroscience Institute, Cincinnati, OH, USA
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Jeffery L Saver
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
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Using Radiological Data to Estimate Ischemic Stroke Severity. J Stroke Cerebrovasc Dis 2016; 25:792-8. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 12/09/2015] [Indexed: 11/17/2022] Open
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Bekelis K, Missios S, Coy S, MacKenzie TA. Comparison of outcomes of patients with inpatient or outpatient onset ischemic stroke. J Neurointerv Surg 2016; 8:1221-1225. [PMID: 26733583 DOI: 10.1136/neurintsurg-2015-012145] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 11/27/2015] [Accepted: 12/02/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND Reperfusion times for ischemic stroke occurring in the outpatient setting have improved significantly in recent years. However, quality improvement efforts have largely ignored ischemic stroke occurring in patients hospitalized for unrelated indications. METHODS We performed a cohort study involving patients with ischemic stroke (with inpatient or outpatient onset) from 2009 to 2013 who were registered in the Statewide Planning and Research Cooperative System (SPARCS) database. A propensity score-adjusted regression analysis was used to assess the association of location of onset and outcomes. Mixed effects methods were employed to control for clustering at the hospital level. RESULTS Of the 176 571 ischemic strokes, 160 157 (90.7%) occurred outside of a hospital and 16 414 (9.3%) occurred in patients hospitalized for unrelated indications. Using a logistic regression model with propensity score adjustment, we demonstrated that inpatient stroke onset was associated with increased inpatient mortality (OR 3.09; 95% CI 2.81 to 3.38), rate of discharge to rehabilitation (OR 2.57; 95% CI 2.37 to 2.79), and length of stay (LOS) (β=11.58; 95% CI 10.73 to 12.42). In addition, it was associated with lower odds (OR 0.69; 95% CI 0.62 to 0.77) of undergoing stroke-related interventions (mechanical thrombectomy and intravenous tissue plasminogen activator) compared with outpatient stroke onset. CONCLUSIONS Using a comprehensive all-payer cohort of patients with ischemic stroke in New York State, we identified an association of inpatient stroke onset with fewer stroke-related interventions and increased mortality, rate of discharge to rehabilitation, and LOS.
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Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA
| | - Symeon Missios
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Shannon Coy
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Todd A MacKenzie
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA.,Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.,Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Wolff C, Boehme AK, Albright KC, Wu TC, Mullen MT, Branas CC, Grotta JC, Savitz SI, Carr BG. Sex Disparities in Access to Acute Stroke Care: Can Telemedicine Mitigate this Effect? JOURNAL OF HEALTH DISPARITIES RESEARCH AND PRACTICE 2016; 9:5. [PMID: 27668134 PMCID: PMC5032905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Women have more frequent and severe ischemic strokes than men, and are less likely to receive treatment for acute stroke. Primary stroke centers (PSCs) have been shown to utilize treatment more frequently. Further, as telemedicine (TM) has expanded access to acute stroke care we sought to investigate the association between PSC, TM and access to acute stroke care in the state of Texas. METHODS Texas hospitals and resources were identified from the 2009 American Hospital Association Annual Survey. Hospitals were categorized as: (1) stand-alone PSCs not using telemedicine for acute stroke care, (2) PSCs using telemedicine for acute stroke care (PSC-TM), (3) non-PSC hospitals using telemedicine for acute stroke care, or (4) non-PSC hospitals not using telemedicine for acute stroke care. The proportion of the population who could reach a PSC within 60 minutes was determined for stand-alone PSCs, PSC-TM, and non-PSCs using TM for stroke care. RESULTS Overall, women were as likely to have 60-minute access to a PSC or PSC-TM as their male counterparts (POR 1.02, 95% CI 1.02-1.03). Women were also just as likely to have access to acute stroke care via PSC or PSC-TM or TM as men (POR 1.03, 95% CI 1.02-1.04). DISCUSSION Our study found no sex disparities in access to stand alone PSCs or to hospitals using TM in the state of Texas. The results of this study suggest that telemedicine can be used as part of an inclusive strategy to improve access to care equally for men and women.
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Affiliation(s)
| | | | | | - Tzu-Ching Wu
- University of Texas-Houston Memorial Herman Medical Center
| | | | | | - James C Grotta
- University of Texas-Houston Memorial Herman Medical Center
| | - Sean I Savitz
- University of Texas-Houston Memorial Herman Medical Center
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Aparicio HJ, Carr BG, Kasner SE, Kallan MJ, Albright KC, Kleindorfer DO, Mullen MT. Racial Disparities in Intravenous Recombinant Tissue Plasminogen Activator Use Persist at Primary Stroke Centers. J Am Heart Assoc 2015; 4:e001877. [PMID: 26467999 PMCID: PMC4845141 DOI: 10.1161/jaha.115.001877] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Primary stroke centers (PSCs) utilize more recombinant tissue plasminogen activator (rt-PA) than non-PSCs. The impact of PSCs on racial disparities in rt-PA use is unknown. METHODS AND RESULTS We used data from the Nationwide Inpatient Sample from 2004 to 2010, limited to states that publicly reported hospital identity and race. Hospitals certified as PSCs by The Joint Commission were identified. Adults with a diagnosis of ischemic stroke were analyzed. Rt-PA use was defined by the International Classification of Diseases, 9th Revision procedure code 99.10. Discharges (304 152 patients) from 26 states met eligibility criteria, and of these 71.5% were white, 15.0% black, 7.9% Hispanic, and 5.6% other. Overall, 24.7% of white, 27.4% of black, 16.2% of Hispanic, and 29.8% of other patients presented to PSCs. A higher proportion received rt-PA at PSCs than non-PSCs in all race/ethnic groups (white 7.6% versus 2.6%, black 4.8% versus 2.0%, Hispanic 7.1% versus 2.4%, other 7.2% versus 2.5%, all P<0.001). In a multivariable model adjusting for year, age, sex, insurance, medical comorbidities, a diagnosis-related group-based mortality risk indicator, ZIP code median income, and hospital characteristics, blacks were less likely to receive rt-PA than whites at non-PSCs (odds ratio=0.58, 95% CI 0.50 to 0.67) and PSCs (odds ratio=0.63, 95% CI 0.54 to 0.74) and Hispanics were less likely than whites to receive rt-PA at PSCs (odds ratio=0.77, 95% CI: 0.63 to 0.95). In the fully adjusted model, interaction between race and presentation to a PSC for likelihood of receiving rt-PA did not reach significance (P=0.98). CONCLUSIONS Racial disparities in intravenous rt-PA use were not reduced by presentation to PSCs. Black patients were less likely to receive thrombolytic treatment than white patients at both non-PSCs and PSCs. Hispanic patients were less likely to be seen at PSCs relative to white patients and were less likely to receive intravenous rt-PA in the fully adjusted model.
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Affiliation(s)
- Hugo J Aparicio
- Department of Neurology, Boston University, Boston, MA (H.J.A.) Department of Neurology, University of Pennsylvania, Philadelphia, PA (H.J.A., S.E.K., M.T.M.)
| | - Brendan G Carr
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C.)
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (H.J.A., S.E.K., M.T.M.)
| | - Michael J Kallan
- Center for Clinical Epidemiology & Biostatistics, University of Pennsylvania, Philadelphia, PA (M.J.K.)
| | - Karen C Albright
- Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham, AL (K.C.A.) Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center, University of Alabama at Birmingham, AL (K.C.A.) Department of Epidemiology, University of Alabama at Birmingham, AL (K.C.A.)
| | | | - Michael T Mullen
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (H.J.A., S.E.K., M.T.M.) Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (M.T.M.)
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Kilsdonk M, Siesling S, Otter R, Harten WV. Evaluating the impact of accreditation and external peer review. Int J Health Care Qual Assur 2015; 28:757-77. [DOI: 10.1108/ijhcqa-05-2014-0055] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
– Accreditation and external peer review play important roles in assessing and improving healthcare quality worldwide. Evidence on the impact on the quality of care remains indecisive because of programme features and methodological research challenges. The purpose of this paper is to create a general methodological research framework to design future studies in this field.
Design/methodology/approach
– A literature search on effects of external peer review and accreditation was conducted using PubMed/Medline, Embase and Web of Science. Three researchers independently screened the studies. Only original research papers that studied the impact on the quality of care were included. Studies were evaluated by their objectives and outcomes, study size and analysis entity (hospitals vs patients), theoretical framework, focus of the studied programme, heterogeneity of the study population and presence of a control group.
Findings
– After careful selection 50 articles were included out of an initial 2,025 retrieved references. Analysis showed a wide variation in methodological characteristics. Most studies are performed cross-sectionally and results are not linked to the programme by a theoretical framework.
Originality/value
– Based on the methodological characteristics of previous studies the authors propose a general research framework. This framework is intended to support the design of future research to evaluate the effects of accreditation and external peer review on the quality of care.
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Rhudy JP, Bakitas MA, Hyrkäs K, Jablonski-Jaudon RA, Pryor ER, Wang HE, Alexandrov AW. Effectiveness of regionalized systems for stroke and myocardial infarction. Brain Behav 2015; 5:e00398. [PMID: 26516616 PMCID: PMC4614047 DOI: 10.1002/brb3.398] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 07/18/2015] [Accepted: 08/16/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Acute ischemic stroke (AIS) and ST-segment elevation myocardial infarction (STEMI) are ischemic emergencies. Guidelines recommend care delivery within formally regionalized systems of care at designated centers, with bypass of nearby centers of lesser or no designation. We review the evidence of the effectiveness of regionalized systems in AIS and STEMI. METHODS Literature was searched using terms corresponding to designation of AIS and STEMI systems and from 2010 to the present. Inclusion criteria included report of an outcome on any dependent variable mentioned in the rationale for regionalization in the guidelines and an independent variable comparing care to a non- or pre-regionalized system. Designation was defined in the AIS case as certification by the Joint Commission as either a primary (PSC) or comprehensive (CSC) stroke center. In the STEMI case, the search was conducted linking "regionalization" and "myocardial infarction" or citation as a model system by any American Heart Association statement. RESULTS For AIS, 17 publications met these criteria and were selected for review. In the STEMI case, four publications met these criteria; the search was therefore expanded by relaxing the criteria to include any historical or anecdotal comparison to a pre- or nonregionalized state. The final yield was nine papers from six systems. CONCLUSION Although regionalized care results in enhanced process and reduced unadjusted rates of disparity in access and adverse outcomes, these differences tend to become nonsignificant when adjusted for delayed presentation and hospital arrival by means other than emergency medical services. The benefits of regionalized care occur along with a temporal trend of improvement due to uptake of quality initiatives and guideline recommendations by all systems regardless of designation. Further research is justified with a randomized registry or cluster randomized design to support or refute recommendations that regionalization should be the standard of care.
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Affiliation(s)
- James P Rhudy
- School of Nursing University of Alabama at Birmingham Alabama
| | - Marie A Bakitas
- School of Nursing University of Alabama at Birmingham Alabama
| | - Kristiina Hyrkäs
- Center for Nursing Research and Quality Outcomes Maine Medical Center Birmingham Alabama
| | | | - Erica R Pryor
- School of Nursing University of Alabama at Birmingham Alabama
| | - Henry E Wang
- Department of Emergency Medicine University of Alabama at Birmingham Birmingham Alabama
| | - Anne W Alexandrov
- College of Nursing University of Tennessee Health Sciences Center Memphis Tennessee
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Fehnel CR, Lee Y, Wendell LC, Thompson BB, Potter NS, Mor V. Post-Acute Care Data for Predicting Readmission After Ischemic Stroke: A Nationwide Cohort Analysis Using the Minimum Data Set. J Am Heart Assoc 2015; 4:e002145. [PMID: 26396202 PMCID: PMC4599502 DOI: 10.1161/jaha.115.002145] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Reducing hospital readmissions is a key component of reforms for stroke care. Current readmission prediction models lack accuracy and are limited by data being from only acute hospitalizations. We hypothesized that patient-level factors from a nationwide post-acute care database would improve prediction modeling. METHODS AND RESULTS Medicare inpatient claims for the year 2008 that used International Classification of Diseases, Ninth Revision codes were used to identify ischemic stroke patients older than age 65. Unique individuals were linked to comprehensive post-acute care assessments through use of the Minimum Data Set (MDS). Logistic regression was used to construct risk-adjusted readmission models. Covariates were derived from MDS variables. Among 39 178 patients directly admitted to nursing homes after hospitalization due to acute stroke, there were 29 338 (75%) with complete MDS assessments. Crude rates of readmission and death at 30 days were 8448 (21%) and 2791 (7%), respectively. Risk-adjusted models identified multiple independent predictors of all-cause 30-day readmission. Model performance of the readmission model using MDS data had a c-statistic of 0.65 (95% CI 0.64 to 0.66). Higher levels of social engagement, a marker of nursing home quality, were associated with progressively lower odds of readmission (odds ratio 0.71, 95% CI 0.55 to 0.92). CONCLUSIONS Individual clinical characteristics from the post-acute care setting resulted in only modest improvement in the c-statistic relative to previous models that used only Medicare Part A data. Individual-level characteristics do not sufficiently account for the risk of acute hospital readmission.
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Affiliation(s)
- Corey R Fehnel
- Division of Neurocritical Care, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI (C.R.F., L.C.W., B.B.T., S.P.)
| | - Yoojin Lee
- Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (Y.L., V.M.)
| | - Linda C Wendell
- Division of Neurocritical Care, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI (C.R.F., L.C.W., B.B.T., S.P.)
| | - Bradford B Thompson
- Division of Neurocritical Care, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI (C.R.F., L.C.W., B.B.T., S.P.)
| | - N Stevenson Potter
- Division of Neurocritical Care, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI (C.R.F., L.C.W., B.B.T., S.P.)
| | - Vincent Mor
- Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (Y.L., V.M.)
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Uchino K, Man S, Schold JD, Katzan IL. Stroke Legislation Impacts Distribution of Certified Stroke Centers in the United States. Stroke 2015; 46:1903-8. [PMID: 26089328 DOI: 10.1161/strokeaha.114.008007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The number of certified primary stroke centers (PSCs) have increased dramatically during the past decade in the United States We aimed to understand the factors affecting PSC distribution in the United States, including the impact of state stroke legislation. METHODS PSCs certified by national organization or state until December 2013 were searched from available databases. The proportion of PSC among short-term general hospitals in each state was calculated and factors affecting its distribution were analyzed. RESULTS By the end of 2013, the proportion of PSC varied from 4% to 100% among the 50 states and District of Columbia. The 18 states that had legislation in designating stroke centers and regulating stroke triage had higher PSC percentages (median, 43%; range, 13%-100%) than the remaining states (median, 13%; range, 4%-75%; P<0.001). State stroke legislation, urbanization, state economic output, and larger hospital size independently increased the likelihood of a hospital to be stroke certified. From 2009 to 2013, states with stroke legislation had greater increase of PSC percentages when compared with the states without legislation (median increase, 16% versus 6%; P=0.0067). Among the 1505 stroke centers, 74% were certified by the Joint Commission, 20% by state, and 6% by other organizations. Stroke centers certified only by state were smaller in size by hospital bed count compared with those certified by the Joint Commission (P<0.001). CONCLUSIONS State stroke legislation, a generalizable intervention, increased the number of certified stroke centers in the United States, potentially improving accessibility of standardized care for patients with acute ischemic stroke.
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Affiliation(s)
- Ken Uchino
- From the Cerebrovascular Center, Neurological Insitute (K.U., S.M., I.L.K.) and Department of Quantitative Health Sciences (J.D.S.), Cleveland Clinic, OH.
| | - Shumei Man
- From the Cerebrovascular Center, Neurological Insitute (K.U., S.M., I.L.K.) and Department of Quantitative Health Sciences (J.D.S.), Cleveland Clinic, OH
| | - Jesse D Schold
- From the Cerebrovascular Center, Neurological Insitute (K.U., S.M., I.L.K.) and Department of Quantitative Health Sciences (J.D.S.), Cleveland Clinic, OH
| | - Irene L Katzan
- From the Cerebrovascular Center, Neurological Insitute (K.U., S.M., I.L.K.) and Department of Quantitative Health Sciences (J.D.S.), Cleveland Clinic, OH
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Xian Y, Wu J, O'Brien EC, Fonarow GC, Olson DM, Schwamm LH, Bhatt DL, Smith EE, Suter RE, Hannah D, Lindholm B, Maisch L, Greiner MA, Lytle BL, Pencina MJ, Peterson ED, Hernandez AF. Real world effectiveness of warfarin among ischemic stroke patients with atrial fibrillation: observational analysis from Patient-Centered Research into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) study. BMJ 2015; 351:h3786. [PMID: 26232340 PMCID: PMC4521370 DOI: 10.1136/bmj.h3786] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To examine the association between warfarin treatment and longitudinal outcomes after ischemic stroke in patients with atrial fibrillation in community practice. DESIGN Observational study. SETTING Hospitals (n = 1487) participating in the Get With The Guidelines (GWTG)-Stroke program in the United States, from 2009 to 2011. PARTICIPANTS 12,552 warfarin naive atrial fibrillation patients admitted to hospital for ischemic stroke and treated with warfarin compared with no oral anticoagulant at discharge, linked to Medicare claims for longitudinal outcomes. MAIN OUTCOME MEASURES Major adverse cardiovascular events (MACE) and home time, a patient centered outcomes measure defined as the total number of days free from institutional care after discharge. A propensity score inverse probability weighting method was used to account for all differences in observed characteristics between treatment groups. RESULTS Among 12,552 survivors of stroke, 11,039 (88%) were treated with warfarin at discharge. Warfarin treated patients were slightly younger and less likely to have a history of previous stroke or coronary artery disease but had similar severity of stroke as measured by the National Institutes of Health Stroke Scale. Relative to those not treated, patients treated with warfarin had more days at home (as opposed to institutional care) during the two years after discharge (adjusted home time difference 47.6 days, 99% confidence interval 26.9 to 68.2). Patients discharged on warfarin treatment also had a reduced risk of MACE (adjusted hazard ratio 0.87, 99% confidence interval 0.78 to 0.98), all cause mortality (0.72, 0.63 to 0.84), and recurrent ischemic stroke (0.63, 0.48 to 0.83). These differences were consistent among clinically relevant subgroups by age, sex, stroke severity, and history of previous coronary artery disease and stroke. CONCLUSIONS Among ischemic stroke patients with atrial fibrillation, warfarin treatment was associated with improved long term clinical outcomes and more days at home. Clinical trial registration Clinical trials NCT02146274.
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Affiliation(s)
- Ying Xian
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC, USA
| | - Jingjing Wu
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC, USA
| | - Emily C O'Brien
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC, USA
| | - Gregg C Fonarow
- Division of Cardiology, University of California, Los Angeles, CA, USA
| | - DaiWai M Olson
- Department of Neurology and Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lee H Schwamm
- Stroke Service, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Eric E Smith
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Robert E Suter
- The American Heart Association and University of Texas Southwestern, Dallas, TX, USA
| | - Deidre Hannah
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC, USA Division of Cardiology, University of California, Los Angeles, CA, USA Department of Neurology and Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA Stroke Service, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada The American Heart Association and University of Texas Southwestern, Dallas, TX, USA
| | - Brianna Lindholm
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC, USA Division of Cardiology, University of California, Los Angeles, CA, USA Department of Neurology and Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA Stroke Service, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada The American Heart Association and University of Texas Southwestern, Dallas, TX, USA
| | - Lesley Maisch
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC, USA Division of Cardiology, University of California, Los Angeles, CA, USA Department of Neurology and Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA Stroke Service, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada The American Heart Association and University of Texas Southwestern, Dallas, TX, USA
| | - Melissa A Greiner
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC, USA
| | - Barbara L Lytle
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC, USA
| | - Michael J Pencina
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC, USA
| | - Eric D Peterson
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC, USA
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Ramirez L, Krug A, Nhoung H, Kazaryan S, Gasparian G, Perese J, Razmara A, Liebeskind DS, Majersik JJ, Sanossian N. Vascular Neurologists as Directors of Stroke Centers in the United States. Stroke 2015. [PMID: 26219648 DOI: 10.1161/strokeaha.115.009888] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Hospital certification as primary and comprehensive stroke center is associated with improvement in care. We aimed to characterize the leadership at stroke centers nationwide to determine the proportion led by vascular neurologists, a board-recognized subspecialty focusing on stroke care. METHODS We identified hospitals in the United States holding primary and comprehensive stroke center designation as of September 2013. We contacted each hospital to identify the medical director and used data from relevant medical boards to determine specialization. Sex and date of medical school graduation were obtained from an online physician database. RESULTS Of the 1167 primary and 50 comprehensive stroke center hospitals certified by the Joint Commission (n=1114), Det Norske Veritas (n=68), and Healthcare Facilities Accreditation Program (n=35), we identified the director in 940 (77%). Leadership was most often by a neurologist (n=745; 79%) followed by physicians in emergency medicine (n=58; 6%) and internal medicine (n=17; 2%). Vascular neurologists (n=319) led about one-third of stroke centers. Directors were mostly men (n=764; 81%), with a median number of years after medical school graduation of 25 (interquartile range, 18-34). Comprehensive stroke centers were more likely than primary stroke centers to have leadership by vascular neurologist (77%, n=37 versus 32%, n=282; P<0.001). CONCLUSIONS Vascular neurologist led about one-third of stroke centers. There is opportunity for vascular neurologists to increase their role in stroke center directorship.
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Affiliation(s)
- Lucas Ramirez
- From the Keck School of Medicine (L.R., A.K., A.R., N.S.), Department of Neurology (L.R., A.R., N.S.), and Roxanna Todd Hodges Comprehensive Stroke Clinic, Department of Neurology (A.K., H.N., S.K., G.G., J.P., A.R., N.S.), University of Southern California, Los Angeles; Neurovascular Imaging Research Core, Department of Neurology, University of California Los Angeles (D.S.L.); and Stroke Center and Department of Neurology, University of Utah, Salt Lake City (J.J.M.)
| | - Aaron Krug
- From the Keck School of Medicine (L.R., A.K., A.R., N.S.), Department of Neurology (L.R., A.R., N.S.), and Roxanna Todd Hodges Comprehensive Stroke Clinic, Department of Neurology (A.K., H.N., S.K., G.G., J.P., A.R., N.S.), University of Southern California, Los Angeles; Neurovascular Imaging Research Core, Department of Neurology, University of California Los Angeles (D.S.L.); and Stroke Center and Department of Neurology, University of Utah, Salt Lake City (J.J.M.)
| | - Heng Nhoung
- From the Keck School of Medicine (L.R., A.K., A.R., N.S.), Department of Neurology (L.R., A.R., N.S.), and Roxanna Todd Hodges Comprehensive Stroke Clinic, Department of Neurology (A.K., H.N., S.K., G.G., J.P., A.R., N.S.), University of Southern California, Los Angeles; Neurovascular Imaging Research Core, Department of Neurology, University of California Los Angeles (D.S.L.); and Stroke Center and Department of Neurology, University of Utah, Salt Lake City (J.J.M.)
| | - Suzie Kazaryan
- From the Keck School of Medicine (L.R., A.K., A.R., N.S.), Department of Neurology (L.R., A.R., N.S.), and Roxanna Todd Hodges Comprehensive Stroke Clinic, Department of Neurology (A.K., H.N., S.K., G.G., J.P., A.R., N.S.), University of Southern California, Los Angeles; Neurovascular Imaging Research Core, Department of Neurology, University of California Los Angeles (D.S.L.); and Stroke Center and Department of Neurology, University of Utah, Salt Lake City (J.J.M.)
| | - Gregory Gasparian
- From the Keck School of Medicine (L.R., A.K., A.R., N.S.), Department of Neurology (L.R., A.R., N.S.), and Roxanna Todd Hodges Comprehensive Stroke Clinic, Department of Neurology (A.K., H.N., S.K., G.G., J.P., A.R., N.S.), University of Southern California, Los Angeles; Neurovascular Imaging Research Core, Department of Neurology, University of California Los Angeles (D.S.L.); and Stroke Center and Department of Neurology, University of Utah, Salt Lake City (J.J.M.)
| | - Joshua Perese
- From the Keck School of Medicine (L.R., A.K., A.R., N.S.), Department of Neurology (L.R., A.R., N.S.), and Roxanna Todd Hodges Comprehensive Stroke Clinic, Department of Neurology (A.K., H.N., S.K., G.G., J.P., A.R., N.S.), University of Southern California, Los Angeles; Neurovascular Imaging Research Core, Department of Neurology, University of California Los Angeles (D.S.L.); and Stroke Center and Department of Neurology, University of Utah, Salt Lake City (J.J.M.)
| | - Ali Razmara
- From the Keck School of Medicine (L.R., A.K., A.R., N.S.), Department of Neurology (L.R., A.R., N.S.), and Roxanna Todd Hodges Comprehensive Stroke Clinic, Department of Neurology (A.K., H.N., S.K., G.G., J.P., A.R., N.S.), University of Southern California, Los Angeles; Neurovascular Imaging Research Core, Department of Neurology, University of California Los Angeles (D.S.L.); and Stroke Center and Department of Neurology, University of Utah, Salt Lake City (J.J.M.)
| | - David S Liebeskind
- From the Keck School of Medicine (L.R., A.K., A.R., N.S.), Department of Neurology (L.R., A.R., N.S.), and Roxanna Todd Hodges Comprehensive Stroke Clinic, Department of Neurology (A.K., H.N., S.K., G.G., J.P., A.R., N.S.), University of Southern California, Los Angeles; Neurovascular Imaging Research Core, Department of Neurology, University of California Los Angeles (D.S.L.); and Stroke Center and Department of Neurology, University of Utah, Salt Lake City (J.J.M.)
| | - Jennifer J Majersik
- From the Keck School of Medicine (L.R., A.K., A.R., N.S.), Department of Neurology (L.R., A.R., N.S.), and Roxanna Todd Hodges Comprehensive Stroke Clinic, Department of Neurology (A.K., H.N., S.K., G.G., J.P., A.R., N.S.), University of Southern California, Los Angeles; Neurovascular Imaging Research Core, Department of Neurology, University of California Los Angeles (D.S.L.); and Stroke Center and Department of Neurology, University of Utah, Salt Lake City (J.J.M.)
| | - Nerses Sanossian
- From the Keck School of Medicine (L.R., A.K., A.R., N.S.), Department of Neurology (L.R., A.R., N.S.), and Roxanna Todd Hodges Comprehensive Stroke Clinic, Department of Neurology (A.K., H.N., S.K., G.G., J.P., A.R., N.S.), University of Southern California, Los Angeles; Neurovascular Imaging Research Core, Department of Neurology, University of California Los Angeles (D.S.L.); and Stroke Center and Department of Neurology, University of Utah, Salt Lake City (J.J.M.).
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Brubakk K, Vist GE, Bukholm G, Barach P, Tjomsland O. A systematic review of hospital accreditation: the challenges of measuring complex intervention effects. BMC Health Serv Res 2015. [PMID: 26202068 PMCID: PMC4511980 DOI: 10.1186/s12913-015-0933-x] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background The increased international focus on improving patient outcomes, safety and quality of care has led stakeholders, policy makers and healthcare provider organizations to adopt standardized processes for evaluating healthcare organizations. Accreditation and certification have been proposed as interventions to support patient safety and high quality healthcare. Guidelines recommend accreditation but are cautious about the evidence, judged as inconclusive. The push for accreditation continues despite sparse evidence to support its efficiency or effectiveness. Methods We searched MEDLINE, EMBASE and The Cochrane Library using Medical Subject Headings (MeSH) indexes and keyword searches in any language. Studies were assessed using the Cochrane Risk of Bias Tool and AMSTAR framework. 915 abstracts were screened and 20 papers were reviewed in full in January 2013. Inclusion criteria included studies addressing the effect of hospital accreditation and certification using systematic reviews, randomized controlled trials, observational studies with a control group, or interrupted time series. Outcomes included both clinical outcomes and process measures. An updated literature search in July 2014 identified no new studies. Results The literature review uncovered three systematic reviews and one randomized controlled trial. The lone study assessed the effects of accreditation on hospital outcomes and reported inconsistent results. Excluded studies were reviewed and their findings summarized. Conclusion Accreditation continues to grow internationally but due to scant evidence, no conclusions could be reached to support its effectiveness. Our review did not find evidence to support accreditation and certification of hospitals being linked to measurable changes in quality of care as measured by quality metrics and standards. Most studies did not report intervention context, implementation, or cost. This might reflect the challenges in assessing complex, heterogeneous interventions such as accreditation and certification. It is also may be magnified by the impact of how accreditation is managed and executed, and the varied financial and organizational healthcare constraints. The strategies hospitals should impelment to improve patient safety and organizational outcomes related to accreditation and certification components remains unclear. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-0933-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kirsten Brubakk
- South-Eastern Norway Regional Health Authority, Hamar, Norway.
| | - Gunn E Vist
- Prevention, Health promotion and Organization Unit, Norwegian Knowledge Centre for the Healthcare Services, Oslo, Norway.
| | - Geir Bukholm
- Norwegian Institute of Public Health, Oslo, Norway.
| | - Paul Barach
- Wayne State University School of Medicine, Michigan, USA.
| | - Ole Tjomsland
- Department of Medicine and Health, South-Eastern Norway Regional Health Authority, Hamar, Norway.
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Lyerly MJ, Wu TC, Mullen MT, Albright KC, Wolff C, Boehme AK, Branas CC, Grotta JC, Savitz SI, Carr BG. The effects of telemedicine on racial and ethnic disparities in access to acute stroke care. J Telemed Telecare 2015; 22:114-20. [PMID: 26116854 DOI: 10.1177/1357633x15589534] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 01/05/2015] [Indexed: 11/15/2022]
Abstract
Racial and ethnic disparities have been previously reported in acute stroke care. We sought to determine the effect of telemedicine (TM) on access to acute stroke care for racial and ethnic minorities in the state of Texas. Data were collected from the US Census Bureau, The Joint Commission and the American Hospital Association. Access for racial and ethnic minorities was determined by summing the population that could reach a primary stroke centre (PSC) or telemedicine spoke within specified time intervals using validated models. TM extended access to stroke expertise by 1.5 million residents. The odds of providing 60-minute access via TM were similar in Blacks and Whites (prevalence odds ratios (POR) 1.000, 95% CI 1.000-1.000), even after adjustment for urbanization (POR 1.000, 95% CI 1.000-1.001). The odds of providing access via TM were also similar for Hispanics and non-Hispanics (POR 1.000, 95% CI 1.000-1.000), even after adjustment for urbanization (POR 1.000, 95% CI 1.000-1.000). We found that telemedicine increased access to acute stroke care for 1.5 million Texans. While racial and ethnic disparities exist in other components of stroke care, we did not find evidence of disparities in access to the acute stroke expertise afforded by telemedicine.
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Affiliation(s)
- Michael J Lyerly
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL Stroke Program, Birmingham Veterans Affairs Medical Center, Birmingham, AL
| | - Tzu-Ching Wu
- Department of Neurology, University of Texas - Houston Memorial Hermann Medical Center, Houston, TX
| | - Michael T Mullen
- Department of Neurology, University of Pennsylvania, Philadelphia, PA
| | - Karen C Albright
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (COERE), University of Alabama at Birmingham, Birmingham, AL Center for Excellence in Comparative Effectiveness Research for Eliminating Disparities (CERED) Minority Health & Health Disparities Research Center (MHRC), University of Alabama at Birmingham, Birmingham, AL Geriatric Research Education and Clinical Center (GRECC), Birmingham Veterans Affairs Medical Center, Birmingham, AL
| | | | - Amelia K Boehme
- Gertrude Sergievsky Center, Department of Neurology, Columbia University, New York, NY
| | - Charles C Branas
- Department of Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - James C Grotta
- Department of Neurology, University of Texas - Houston Memorial Hermann Medical Center, Houston, TX
| | - Sean I Savitz
- Department of Neurology, University of Texas - Houston Memorial Hermann Medical Center, Houston, TX
| | - Brendan G Carr
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
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Fargen KM, Jauch E, Khatri P, Baxter B, Schirmer CM, Turk AS, Mocco J. Needed dialog: regionalization of stroke systems of care along the trauma model. Stroke 2015; 46:1719-26. [PMID: 25931466 DOI: 10.1161/strokeaha.114.008167] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 03/26/2015] [Indexed: 01/01/2023]
Affiliation(s)
- Kyle M Fargen
- Department of Neurosurgery, University of Florida, Gainesville (K.M.F.); Departments of Emergency Medicine (E.J.) and Radiology (A.S.T.), Medical University of South Carolina, Charleston; Department of Neurology and Rehabilitation Medicine, University of Cincinnati Neuroscience Institute, OH (P.K.); Department of Radiology, Erlanger Health System, Chattanooga, TN (B.B.); Department of Neurosurgery, Geisinger Health System, Danville, PA (C.M.S.); and Department of Neurosurgery, Mount Sinai Medical Center, New York (J.M.).
| | - Edward Jauch
- Department of Neurosurgery, University of Florida, Gainesville (K.M.F.); Departments of Emergency Medicine (E.J.) and Radiology (A.S.T.), Medical University of South Carolina, Charleston; Department of Neurology and Rehabilitation Medicine, University of Cincinnati Neuroscience Institute, OH (P.K.); Department of Radiology, Erlanger Health System, Chattanooga, TN (B.B.); Department of Neurosurgery, Geisinger Health System, Danville, PA (C.M.S.); and Department of Neurosurgery, Mount Sinai Medical Center, New York (J.M.)
| | - Pooja Khatri
- Department of Neurosurgery, University of Florida, Gainesville (K.M.F.); Departments of Emergency Medicine (E.J.) and Radiology (A.S.T.), Medical University of South Carolina, Charleston; Department of Neurology and Rehabilitation Medicine, University of Cincinnati Neuroscience Institute, OH (P.K.); Department of Radiology, Erlanger Health System, Chattanooga, TN (B.B.); Department of Neurosurgery, Geisinger Health System, Danville, PA (C.M.S.); and Department of Neurosurgery, Mount Sinai Medical Center, New York (J.M.)
| | - Blaise Baxter
- Department of Neurosurgery, University of Florida, Gainesville (K.M.F.); Departments of Emergency Medicine (E.J.) and Radiology (A.S.T.), Medical University of South Carolina, Charleston; Department of Neurology and Rehabilitation Medicine, University of Cincinnati Neuroscience Institute, OH (P.K.); Department of Radiology, Erlanger Health System, Chattanooga, TN (B.B.); Department of Neurosurgery, Geisinger Health System, Danville, PA (C.M.S.); and Department of Neurosurgery, Mount Sinai Medical Center, New York (J.M.)
| | - Clemens M Schirmer
- Department of Neurosurgery, University of Florida, Gainesville (K.M.F.); Departments of Emergency Medicine (E.J.) and Radiology (A.S.T.), Medical University of South Carolina, Charleston; Department of Neurology and Rehabilitation Medicine, University of Cincinnati Neuroscience Institute, OH (P.K.); Department of Radiology, Erlanger Health System, Chattanooga, TN (B.B.); Department of Neurosurgery, Geisinger Health System, Danville, PA (C.M.S.); and Department of Neurosurgery, Mount Sinai Medical Center, New York (J.M.)
| | - Aquilla S Turk
- Department of Neurosurgery, University of Florida, Gainesville (K.M.F.); Departments of Emergency Medicine (E.J.) and Radiology (A.S.T.), Medical University of South Carolina, Charleston; Department of Neurology and Rehabilitation Medicine, University of Cincinnati Neuroscience Institute, OH (P.K.); Department of Radiology, Erlanger Health System, Chattanooga, TN (B.B.); Department of Neurosurgery, Geisinger Health System, Danville, PA (C.M.S.); and Department of Neurosurgery, Mount Sinai Medical Center, New York (J.M.)
| | - J Mocco
- Department of Neurosurgery, University of Florida, Gainesville (K.M.F.); Departments of Emergency Medicine (E.J.) and Radiology (A.S.T.), Medical University of South Carolina, Charleston; Department of Neurology and Rehabilitation Medicine, University of Cincinnati Neuroscience Institute, OH (P.K.); Department of Radiology, Erlanger Health System, Chattanooga, TN (B.B.); Department of Neurosurgery, Geisinger Health System, Danville, PA (C.M.S.); and Department of Neurosurgery, Mount Sinai Medical Center, New York (J.M.)
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Fargen KM, Fiorella D, Albuquerque F, Mocco J. Systematic regionalization of stroke care. J Neurointerv Surg 2015; 7:229-30. [DOI: 10.1136/neurintsurg-2015-011694] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Mullen MT, Branas CC, Kasner SE, Wolff C, Williams JC, Albright KC, Carr BG. Optimization modeling to maximize population access to comprehensive stroke centers. Neurology 2015; 84:1196-205. [PMID: 25740858 DOI: 10.1212/wnl.0000000000001390] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The location of comprehensive stroke centers (CSCs) is critical to ensuring rapid access to acute stroke therapies; we conducted a population-level virtual trial simulating change in access to CSCs using optimization modeling to selectively convert primary stroke centers (PSCs) to CSCs. METHODS Up to 20 certified PSCs per state were selected for conversion to maximize the population with 60-minute CSC access by ground and air. Access was compared across states based on region and the presence of state-level emergency medical service policies preferentially routing patients to stroke centers. RESULTS In 2010, there were 811 Joint Commission PSCs and 0 CSCs in the United States. Of the US population, 65.8% had 60-minute ground access to PSCs. After adding up to 20 optimally located CSCs per state, 63.1% of the US population had 60-minute ground access and 86.0% had 60-minute ground/air access to a CSC. Across states, median CSC access was 55.7% by ground (interquartile range 35.7%-71.5%) and 85.3% by ground/air (interquartile range 59.8%-92.1%). Ground access was lower in Stroke Belt states compared with non-Stroke Belt states (32.0% vs 58.6%, p = 0.02) and lower in states without emergency medical service routing policies (52.7% vs 68.3%, p = 0.04). CONCLUSION Optimal system simulation can be used to develop efficient care systems that maximize accessibility. Under optimal conditions, a large proportion of the US population will be unable to access a CSC within 60 minutes.
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Affiliation(s)
- Michael T Mullen
- From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA.
| | - Charles C Branas
- From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Scott E Kasner
- From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Catherine Wolff
- From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Justin C Williams
- From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Karen C Albright
- From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Brendan G Carr
- From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA
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Lichtman JH, Leifheit-Limson EC, Goldstein LB. Centers for medicare and medicaid services medicare data and stroke research: goldmine or landmine? Stroke 2015; 46:598-604. [PMID: 25593137 DOI: 10.1161/strokeaha.114.003255] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Judith H Lichtman
- From the Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (J.H.L., E.C.L.-L.); and Department of Neurology, Duke Stroke Center, Duke University and Durham VAMC, Durham, NC (L.B.G.).
| | - Erica C Leifheit-Limson
- From the Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (J.H.L., E.C.L.-L.); and Department of Neurology, Duke Stroke Center, Duke University and Durham VAMC, Durham, NC (L.B.G.)
| | - Larry B Goldstein
- From the Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (J.H.L., E.C.L.-L.); and Department of Neurology, Duke Stroke Center, Duke University and Durham VAMC, Durham, NC (L.B.G.)
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Wang Y, Lichtman JH, Dharmarajan K, Masoudi FA, Ross JS, Dodson JA, Chen J, Spertus JA, Chaudhry SI, Nallamothu BK, Krumholz HM. National trends in stroke after acute myocardial infarction among Medicare patients in the United States: 1999 to 2010. Am Heart J 2015; 169:78-85.e4. [PMID: 25497251 DOI: 10.1016/j.ahj.2014.06.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 06/07/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Stroke is a common and important adverse event after acute myocardial infarction (AMI) in the elderly. It is unclear whether the risk of stroke after AMI has changed with improvements in treatments and outcomes for AMI in the last decade. METHODS To assess trends in risk of stroke after AMI, we used a national sample of Medicare data to identify Fee-for-Service patients (n = 2,305,441) aged ≥65 years who were discharged alive after hospitalization for AMI from 1999 to 2010. RESULTS We identified 57,848 subsequent hospitalizations for ischemic stroke and 4,412 hospitalizations for hemorrhagic stroke within 1 year after AMI. The 1-year rate of ischemic stroke decreased from 3.4% (95% CI 3.3%-3.4%) to 2.6% (2.5%-2.7%; P < .001). The risk-adjusted annual decline was 3% (hazard ratio, 0.97; [0.97-0.98]) and was similar across all age and sex-race groups. The rate of hemorrhagic stroke remained stable at 0.2% and did not differ by subgroups. The 30-day mortality for patients admitted with ischemic stroke after AMI decreased from 19.9% (18.8%-20.9%) to 18.3% (17.1%-19.6%) and from 48.3% (43.0%-53.6%) to 45.7% (40.3%-51.2%) for those admitted with hemorrhagic stroke. We observed a decrease in 1-year mortality from 37.8% (36.5%-39.1%) to 35.3% (33.8%-36.8%) for ischemic stroke and from 66.6% (61.4%-71.5%) to 60.6% (55.1%-65.9%) for hemorrhagic stroke. CONCLUSIONS From 1999 to 2010, the 1-year risk for ischemic stroke after AMI declined, whereas the risk of hemorrhagic stroke remained unchanged. However, 30-day and 1-year mortality continued to be high.
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Mullen MT, Wiebe DJ, Bowman A, Wolff CS, Albright KC, Roy J, Balcer LJ, Branas CC, Carr BG. Disparities in accessibility of certified primary stroke centers. Stroke 2014; 45:3381-8. [PMID: 25300972 PMCID: PMC4282182 DOI: 10.1161/strokeaha.114.006021] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE We examine whether the proportion of the US population with ≤60 minute access to Primary Stroke Centers (PSCs) varies based on geographic and demographic factors. METHODS Population level access to PSCs within 60 minutes was estimated using validated models of prehospital time accounting for critical prehospital time intervals and existing road networks. We examined the association between geographic factors, demographic factors, and access to care. Multivariable models quantified the association between demographics and PSC access for the entire United States and then stratified by urbanicity. RESULTS Of the 309 million people in the United States, 65.8% had ≤60 minute PSC access by ground ambulance (87% major cities, 59% minor cities, 9% suburbs, and 1% rural). PSC access was lower in stroke belt states (44% versus 69%). Non-whites were more likely to have access than whites (77% versus 62%), and Hispanics were more likely to have access than non-Hispanics (78% versus 64%). Demographics were not meaningfully associated with access in major cities or suburbs. In smaller cities, there was less access in areas with lower income, less education, more uninsured, more Medicare and Medicaid eligibles, lower healthcare utilization, and healthcare resources. CONCLUSIONS There are significant geographic disparities in access to PSCs. Access is limited in nonurban areas. Despite the higher burden of cerebrovascular disease in stroke belt states, access to care is lower in these areas. Selecting demographic and healthcare factors is strongly associated with access to care in smaller cities, but not in other areas, including major cities.
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Affiliation(s)
- Michael T Mullen
- From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.).
| | - Douglas J Wiebe
- From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.)
| | - Ariel Bowman
- From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.)
| | - Catherine S Wolff
- From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.)
| | - Karen C Albright
- From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.)
| | - Jason Roy
- From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.)
| | - Laura J Balcer
- From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.)
| | - Charles C Branas
- From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.)
| | - Brendan G Carr
- From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.)
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71
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Boan AD, Voeks JH, Feng WW, Bachman DL, Jauch EC, Adams RJ, Ovbiagele B, Lackland DT. The impact of ICD-9 revascularization procedure codes on estimates of racial disparities in ischemic stroke. J Stroke Cerebrovasc Dis 2014; 23:2681-2686. [PMID: 25263646 DOI: 10.1016/j.jstrokecerebrovasdis.2014.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 05/09/2014] [Accepted: 06/11/2014] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND The use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) diagnostic codes can identify racial disparities in ischemic stroke hospitalizations; however, inclusion of revascularization procedure codes as acute stroke events may affect the magnitude of the risk difference. This study assesses the impact of excluding revascularization procedure codes in the ICD-9 definition of ischemic stroke, compared with the traditional inclusive definition, on racial disparity estimates for stroke incidence and recurrence. METHODS Patients discharged with a diagnosis of ischemic stroke (ICD-9 codes 433.00-434.91 and 436) were identified from a statewide inpatient discharge database from 2010 to 2012. Race-age specific disparity estimates of stroke incidence and recurrence and 1-year cumulative recurrent stroke rates were compared between the routinely used traditional classification and a modified classification of stroke that excluded primary ICD-9 cerebral revascularization procedures codes (38.12, 00.61, and 00.63). RESULTS The traditional classification identified 7878 stroke hospitalizations, whereas the modified classification resulted in 18% fewer hospitalizations (n = 6444). The age-specific black to white rate ratios were significantly higher in the modified than in the traditional classification for stroke incidence (rate ratio, 1.50; 95% confidence interval [CI], 1.43-1.58 vs. rate ratio, 1.24; 95% CI, 1.18-1.30, respectively). In whites, the 1-year cumulative recurrence rate was significantly reduced by 46% (45-64 years) and 49% (≥ 65 years) in the modified classification, largely explained by a higher rate of cerebral revascularization procedures among whites. There were nonsignificant reductions of 14% (45-64 years) and 19% (≥ 65 years) among blacks. CONCLUSIONS Including cerebral revascularization procedure codes overestimates hospitalization rates for ischemic stroke and significantly underestimates the racial disparity estimates in stroke incidence and recurrence.
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Affiliation(s)
- Andrea D Boan
- Department of Neuroscience, Medical University of South Carolina, Charleston, South Carolina; Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina.
| | - Jenifer H Voeks
- Department of Neuroscience, Medical University of South Carolina, Charleston, South Carolina
| | - Wuwei Wayne Feng
- Department of Neuroscience, Medical University of South Carolina, Charleston, South Carolina
| | - David L Bachman
- Department of Neuroscience, Medical University of South Carolina, Charleston, South Carolina
| | - Edward C Jauch
- Department of Neuroscience, Medical University of South Carolina, Charleston, South Carolina; Division of Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Robert J Adams
- Department of Neuroscience, Medical University of South Carolina, Charleston, South Carolina
| | - Bruce Ovbiagele
- Department of Neuroscience, Medical University of South Carolina, Charleston, South Carolina
| | - Daniel T Lackland
- Department of Neuroscience, Medical University of South Carolina, Charleston, South Carolina
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72
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Handschu R, Scibor M, Wacker A, Stark DR, Köhrmann M, Erbguth F, Oschmann P, Schwab S, Marquardt L. Feasibility of Certified Quality Management in a Comprehensive Stroke Care Network Using Telemedicine: STENO Project. Int J Stroke 2014; 9:1011-6. [DOI: 10.1111/ijs.12342] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 05/20/2014] [Indexed: 01/30/2023]
Abstract
Background Stroke care networks with and without telemedicine have been established in several countries over the last decade to provide specialized stroke expertise to patients in rural areas. Acute consultation is a first step in the management of stroke, but not the only one. Methods of standardization of care and treatment are much needed. So far, quality management systems have only been used for single stroke units. To the best of our knowledge, we are the first stroke network worldwide to aim for certification of a network-wide quality management system. Methods The Stroke Network Using Telemedicine in Northern Bavaria (STENO), currently with 20 associated medical institutions, is one of the world's largest stroke networks, caring for over 5000 stroke patients each year. In 2010, we initiated the implementation of a network-wide ‘total’ quality management system according to ISO standard 9001:2008 in cooperation with the German Stroke Society and a third-party certification organization (LGA InterCert). Results Certification according to ISO 9001:2008 was awarded in March 2011 and maintained over a complete certification cycle of 3 years without major deviation from the norm in three external third-party audits. Thrombolysis rate significantly increased from 8·2% (2009) to 12·8% (2012). Conclusions Certified quality management within a large stroke network using telemedicine is possible and might improve stroke care procedures and thrombolysis rates. Outcome studies comparing conventional stroke care and telestroke care are inevitable.
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Affiliation(s)
- René Handschu
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
- Department of Neurology, Klinikum Neumarkt, Neumarkt, Germany
| | - Mateusz Scibor
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Angela Wacker
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - David R. Stark
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Martin Köhrmann
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Frank Erbguth
- Department of Neurology, Nuremberg Municipal Academic Hospital, Nuremberg, Germany
| | - Patrick Oschmann
- Department of Neurology, Klinikum Hohe Warte Bayreuth, Bayreuth, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Lars Marquardt
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
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73
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Burke JF, Skolarus LE, Adelman EE, Reeves MJ, Brown DL. Influence of hospital-level practices on readmission after ischemic stroke. Neurology 2014; 82:2196-204. [PMID: 24838793 PMCID: PMC4113457 DOI: 10.1212/wnl.0000000000000514] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 03/12/2014] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To inform stroke quality improvement initiatives by determining the relationship between hospital-level stroke practices and readmission after accounting for patient-level factors. METHODS Retrospective cohort study of adult patients hospitalized for ischemic stroke (principal ICD-9-CM codes 433.x1, 434.x1, and 436) in 5 states from 2003 to 2009 from State Inpatient Databases. The primary outcome was any unplanned readmission within 30 days. Multilevel logistic regression was used to estimate the association between hospital-level practice patterns of care (diagnostic testing, procedures, intensive care unit, tissue plasminogen activator, and therapeutic modalities) and readmission after adjustment for patient factors and whether individual patients received a given practice. RESULTS Thirty-day unplanned readmission occurred in 15.2% of stroke admissions; the median hospital readmission rate was 13.6% (interquartile range 9.8%-18.2%). Of the 25 hospital practice patterns of care analyzed, 3 practices were associated with readmission: hospitals with higher use of occupational therapy and higher proportion of transfers from other hospitals had lower adjusted readmission rates, whereas hospitals with higher use of hospice had higher predicted readmission rates. Readmission rates in lowest vs highest utilizing quintile were as follows: occupational therapy 16.2% (95% confidence interval [CI] 14.5%-18.0%) vs 12.3% (95% CI 11.3%-13.2%); transfers 13.8% (95% CI 13.2%-14.5%) vs 12.5% (95% CI 11.6%-13.5%); and hospice 13.1% (95% CI 12.3%-14.0%) vs 14.8% (95% CI 13.5%-16.1%). CONCLUSIONS Hospital practices have a role in stroke readmission that is complex and poorly understood. Further work is needed to identify specific strategies to reduce readmission rates and to ensure that public reporting of readmission rates will not result in adverse unintended consequences.
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Affiliation(s)
- James F Burke
- From the Department of Veterans Affairs (J.F.B.), VA Center for Clinical Management and Research, Ann Arbor VA Healthcare System, MI; Stroke Program (J.F.B., L.E.S., E.E.A., D.L.B.), University of Michigan, Ann Arbor; and Department of Epidemiology (M.J.R.), Michigan State University, East Lansing.
| | - Lesli E Skolarus
- From the Department of Veterans Affairs (J.F.B.), VA Center for Clinical Management and Research, Ann Arbor VA Healthcare System, MI; Stroke Program (J.F.B., L.E.S., E.E.A., D.L.B.), University of Michigan, Ann Arbor; and Department of Epidemiology (M.J.R.), Michigan State University, East Lansing
| | - Eric E Adelman
- From the Department of Veterans Affairs (J.F.B.), VA Center for Clinical Management and Research, Ann Arbor VA Healthcare System, MI; Stroke Program (J.F.B., L.E.S., E.E.A., D.L.B.), University of Michigan, Ann Arbor; and Department of Epidemiology (M.J.R.), Michigan State University, East Lansing
| | - Mathew J Reeves
- From the Department of Veterans Affairs (J.F.B.), VA Center for Clinical Management and Research, Ann Arbor VA Healthcare System, MI; Stroke Program (J.F.B., L.E.S., E.E.A., D.L.B.), University of Michigan, Ann Arbor; and Department of Epidemiology (M.J.R.), Michigan State University, East Lansing
| | - Devin L Brown
- From the Department of Veterans Affairs (J.F.B.), VA Center for Clinical Management and Research, Ann Arbor VA Healthcare System, MI; Stroke Program (J.F.B., L.E.S., E.E.A., D.L.B.), University of Michigan, Ann Arbor; and Department of Epidemiology (M.J.R.), Michigan State University, East Lansing
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74
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Iihara K, Nishimura K, Kada A, Nakagawara J, Toyoda K, Ogasawara K, Ono J, Shiokawa Y, Aruga T, Miyachi S, Nagata I, Matsuda S, Ishikawa KB, Suzuki A, Mori H, Nakamura F. The Impact of Comprehensive Stroke Care Capacity on the Hospital Volume of Stroke Interventions: A Nationwide Study in Japan: J-ASPECT Study. J Stroke Cerebrovasc Dis 2014; 23:1001-18. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.08.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 08/08/2013] [Accepted: 08/21/2013] [Indexed: 11/30/2022] Open
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Saposnik G. The art of estimating outcomes and treating patients with stroke in the 21st century. Stroke 2014; 45:1603-5. [PMID: 24743437 DOI: 10.1161/strokeaha.114.005242] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gustavo Saposnik
- From the Stroke Outcomes Research Unit, Stroke Outcomes Research Canada (SORCan), Division of Neurology, Department of Medicine, St. Michael's Hospital and Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; and Institute for Clinical Evaluative Sciences & Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada.
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76
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Johnson AM, Goldstein LB, Bennett P, O'Brien EC, Rosamond WD. Compliance with acute stroke care quality measures in hospitals with and without primary stroke center certification: the North Carolina Stroke Care Collaborative. J Am Heart Assoc 2014; 3:e000423. [PMID: 24721795 PMCID: PMC4187509 DOI: 10.1161/jaha.113.000423] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Organized stroke care is associated with improved outcomes. Data are limited on differences in changes in the quality of acute stroke care at The Joint Commission–certified Primary Stroke Centers (PSCs) versus non‐PSCs over time. Methods and Results We compared compliance with the Joint Commission's 10 acute stroke care performance measures and defect‐free care in PSCs and non‐PSCs participating in the Registry of the North Carolina Stroke Care Collaborative from January 2005 through February 2010. We included 29 654 cases presenting at 47 hospitals—10 PSCs, 8 preparing for certification, and 29 non‐PSCs—representing 43% of North Carolina's non–Veterans Affairs, acute care hospitals. Using a non‐PSC referent, odds ratios and 95% CIs were calculated using logistic regression and generalized estimating equations accounting for clustering of cases within hospitals. Time trends were presented graphically using simple linear regression. Performance measure compliance increased for all measures for all 3 groups in 2005–2010, with the exception of discharge on antithrombotics, which remained consistently high. PSCs and hospitals preparing for certification had better compliance with all but 2 performance measures compared with non‐PSCs (each P<0.01). Defect‐free care was delivered most consistently at hospitals preparing for certification (52.8%), followed by PSCs (45.0%) and non‐PSCs (21.9%). Between 2005 and 2010, PSCs and hospitals preparing for certification had a higher average annual percent increase in the provision of defect‐free care (P=0.01 and 0.04, respectively) compared with non‐PSCs. Conclusions PSC certification is associated with an overall improvement in the quality of stroke care in North Carolina; however, room for improvement remains.
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Affiliation(s)
- Anna M Johnson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
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77
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Abstract
The modern management of patients with ischemic stroke begins by having a system in place that organizes the provision of preventive, acute treatment, and rehabilitative services. In the acute setting, initial evaluation is aimed at rapidly establishing a diagnosis by excluding stroke mimics, distinguishing between ischemic and hemorrhagic strokes, and determining if the patient is a candidate for treatment with intravenous tissue plasminogen activator (IV-tPA, alteplase). In some centers, select patients who do not qualify for administration of IV-tPA may be considered for endovascular intervention. General measures include the use of platelet antiaggregants, treatment of fever, blood pressure management, and continuation of statins if the patient has already been taking them. Post-acute evaluation and management is aimed at secondary prevention and optimizing recovery, including recognition and treatment of post-stroke depression.
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Affiliation(s)
- Larry B Goldstein
- Duke University Medical Center and Durham VA Medical Center, Durham, NC
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78
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Kelly AG, Zahuranec DB, Holloway RG, Morgenstern LB, Burke JF. Variation in do-not-resuscitate orders for patients with ischemic stroke: implications for national hospital comparisons. Stroke 2014; 45:822-7. [PMID: 24523035 DOI: 10.1161/strokeaha.113.004573] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Decisions on life-sustaining treatments and the use of do-not-resuscitate (DNR) orders can affect early mortality after stroke. We investigated the variation in early DNR use after stroke among hospitals in California and the effect of this variation on mortality-based hospital classifications. METHODS Using the California State Inpatient Database from 2005 to 2011, ischemic stroke admissions for patients aged≥50 years were identified. Cases were categorized by the presence or the absence of DNR orders within the first 24 hours of admission. Multilevel logistic regression models with a random hospital intercept were used to predict inpatient mortality after adjusting for comorbidities, vascular risk factors, and demographics. Hospital mortality rank order was assigned based on this model and compared with the results of a second model that included DNR status. RESULTS From 355 hospitals, 252,368 cases were identified, including 33,672 (13.3%) with early DNR. Hospital-level-adjusted use of DNR varied widely (quintile 1, 2.2% versus quintile 5, 23.2%). Hospitals with higher early DNR use had higher inpatient mortality because inpatient mortality more than doubled from quintile 1 (4.2%) to quintile 5 (8.7%). Failure to adjust for DNR orders resulted in substantial hospital reclassification across the rank spectrum, including among high mortality hospitals. CONCLUSIONS There is wide variation in the hospital-level proportion of ischemic stroke patients with early DNR orders; this variation affects hospital mortality estimates. Unless the circumstances of early DNR orders are better understood, mortality-based hospital comparisons may not reliably identify hospitals providing a lower quality of care.
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Affiliation(s)
- Adam G Kelly
- From the Department of Neurology, University of Rochester Medical Center, NY (A.G.K., R.G.H.); and Stroke Program, University of Michigan Health Systems, Ann Arbor (D.B.Z., L.B.M., J.F.B.)
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Association Between the Volume of Inpatient Rehabilitation Therapy and the Risk of All-Cause and Cardiovascular Mortality in Patients With Ischemic Stroke. Arch Phys Med Rehabil 2014; 95:269-75. [DOI: 10.1016/j.apmr.2013.08.239] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Accepted: 08/17/2013] [Indexed: 11/21/2022]
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Lackland DT, Roccella EJ, Deutsch AF, Fornage M, George MG, Howard G, Kissela BM, Kittner SJ, Lichtman JH, Lisabeth LD, Schwamm LH, Smith EE, Towfighi A. Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association. Stroke 2014; 45:315-53. [PMID: 24309587 PMCID: PMC5995123 DOI: 10.1161/01.str.0000437068.30550.cf] [Citation(s) in RCA: 555] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden. METHODS Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and to indicate gaps in current knowledge. All members of the writing group had the opportunity to comment on this document and approved the final version. The document underwent extensive American Heart Association internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee. RESULTS The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both sexes and for all racial/ethnic and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among people <65 years of age represents a reduction in years of potential life lost. The decline in mortality results from reduced incidence of stroke and lower case-fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. Although it is difficult to calculate specific attributable risk estimates, efforts in hypertension control initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality. Although implemented later, diabetes mellitus and dyslipidemia control and smoking cessation programs, particularly in combination with treatment of hypertension, also appear to have contributed to the decline in stroke mortality. The potential effects of telemedicine and stroke systems of care appear to be strong but have not been in place long enough to indicate their influence on the decline. Other factors had probable effects, but additional studies are needed to determine their contributions. CONCLUSIONS The decline in stroke mortality is real and represents a major public health and clinical medicine success story. The repositioning of stroke from third to fourth leading cause of death is the result of true mortality decline and not an increase in mortality from chronic lung disease, which is now the third leading cause of death in the United States. There is strong evidence that the decline can be attributed to a combination of interventions and programs based on scientific findings and implemented with the purpose of reducing stroke risks, the most likely being improved control of hypertension. Thus, research studies and the application of their findings in developing intervention programs have improved the health of the population. The continued application of aggressive evidence-based public health programs and clinical interventions is expected to result in further declines in stroke mortality.
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81
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Affiliation(s)
- Larry B. Goldstein
- From the Department of Neurology, Duke Stroke Center, Duke University Medical Center and Durham VAMC, Durham, NC
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82
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Lichtman JH, Leifheit-Limson EC, Jones SB, Wang Y, Goldstein LB. Preventable readmissions within 30 days of ischemic stroke among Medicare beneficiaries. Stroke 2013; 44:3429-35. [PMID: 24172581 DOI: 10.1161/strokeaha.113.003165] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The Centers for Medicare and Medicaid Services proposes to use 30-day hospital readmissions after ischemic stroke as part of the Hospital Inpatient Quality Reporting Program for payment determination beginning in 2016. The proportion of poststroke readmissions that is potentially preventable is unknown. METHODS Thirty-day readmissions for all Medicare fee-for-service beneficiaries aged≥65 years discharged alive with a primary diagnosis of ischemic stroke (International Classification of Diseases, Ninth Revision, Clinical Modification 433, 434, 436) between December 2005 and November 2006 were analyzed. Preventable readmissions were identified based on 14 Prevention Quality Indicators developed for use with administrative data by the US Agency for Healthcare Research and Quality. National, hospital-level, and regional preventable readmission rates were estimated. Random-effects logistic regression was also used to determine patient-level factors associated with preventable readmissions. RESULTS Among 307 887 ischemic stroke discharges, 44 379 (14.4%) were readmitted within 30 days; 5322 (1.7% of all discharges) were the result of a preventable cause (eg, pneumonia), and 39 057 (12.7%) were for other reasons (eg, cancer). In multivariate analysis, older age and cardiovascular-related comorbid conditions were strong predictors of preventable readmissions. Preventable readmission rates were highest in the Southeast, Mid-Atlantic, and US territories and lowest in the Mountain and Pacific regions. CONCLUSIONS On the basis of Agency for Healthcare Research and Quality Prevention Quality Indicators, we found that a small proportion of readmissions after ischemic stroke were classified as preventable. Although other causes of readmissions not reflected in the Agency for Healthcare Research and Quality measures could also be avoidable, hospital-level programs intended to reduce all-cause readmissions and costs should target high-risk patients.
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Affiliation(s)
- Judith H Lichtman
- From the Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (J.H.L., E.C.L.-L., S.B.J.); Department of Biostatistics, Harvard School of Public Health, Boston, MA (Y.W.); and Department of Neurology, Duke Comprehensive Stroke Center, Duke University and Durham VAMC, Durham, NC (L.B.G.)
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Nahab F, Takesaka J, Mailyan E, Judd L, Culler S, Webb A, Frankel M, Choi D, Helmers S. Avoidable 30-day readmissions among patients with stroke and other cerebrovascular disease. Neurohospitalist 2013; 2:7-11. [PMID: 23983857 DOI: 10.1177/1941874411427733] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There are limited data on factors associated with 30-day readmissions and the frequency of avoidable readmissions among patients with stroke and other cerebrovascular disease. METHODS University HealthSystem Consortium (UHC) database records were used to identify patients discharged with a diagnosis of stroke or other cerebrovascular disease at a university hospital from January 1, 2007 to December 31, 2009 and readmitted within 30 days to the index hospital. Logistic regression models were used to identify patient and clinical characteristics associated with 30-day readmission. Two neurologists performed chart reviews on readmissions to identify avoidable cases. RESULTS Of 2706 patients discharged during the study period, 174 patients had 178 readmissions (6.4%) within 30 days. The only factor associated with 30-day readmission was the index length of stay >10 days (vs <5 days; odds ratio [OR] 2.3, 95% CI [1.4, 3.7]). Of 174 patients readmitted within 30 days (median time to readmission 10 days), 92 (53%) were considered avoidable readmissions including 38 (41%) readmitted for elective procedures within 30 days of discharge, 27 (29%) readmitted after inadequate outpatient care coordination, 15 (16%) readmitted after incomplete initial evaluations, 8 (9%) readmitted due to delayed palliative care consultation, and 4 (4%) readmitted after being discharged with inadequate discharge instructions. Only 5% of the readmitted patients had outpatient follow-up recommended within 1 week. CONCLUSIONS More than half of the 30-day readmissions were considered avoidable. Coordinated timing of elective procedures and earlier outpatient follow-up may prevent the majority of avoidable readmissions among patients with stroke and other cerebrovascular disease.
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Affiliation(s)
- Fadi Nahab
- Department of Neurology, Emory University, Atlanta, GA, USA
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84
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Kapral MK, Fang J, Silver FL, Hall R, Stamplecoski M, O'Callaghan C, Tu JV. Effect of a provincial system of stroke care delivery on stroke care and outcomes. CMAJ 2013; 185:E483-91. [PMID: 23713072 PMCID: PMC3708028 DOI: 10.1503/cmaj.121418] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Systems of stroke care delivery have been promoted as a means of improving the quality of stroke care, but little is known about their effectiveness. We assessed the effect of the Ontario Stroke System, a province-wide strategy of regionalized stroke care delivery, on stroke care and outcomes in Ontario, Canada. METHODS We used population-based provincial administrative databases to identify all emergency department visits and hospital admissions for acute stroke and transient ischemic attack from Jan. 1, 2001, to Dec. 31, 2010. Using piecewise regression analyses, we assessed the effect of the full implementation of the Ontario Stroke System in 2005 on the proportion of patients who received care at stroke centres, and on rates of discharge to long-term care facilities and 30-day mortality after stroke. RESULTS We included 243 287 visits by patients with acute stroke or transient ischemic attack. The full implementation of the Ontario Stroke System in 2005 was associated with an increase in rates of care at stroke centres (before implementation: 40.0%; after implementation: 46.5%), decreased rates of discharge to long-term care facilities (before implementation: 16.9%; after implementation: 14.8%) and decreased 30-day mortality for hemorrhagic (before implementation: 38.3%; after implementation: 34.4%) and ischemic stroke (before implementation: 16.3%; after implementation: 15.7%). The system's implementation was also associated with marked increases in the proportion of patients who received neuroimaging, thrombolytic therapy, care in a stroke unit and antithrombotic therapy. INTERPRETATION The implementation of an organized system of stroke care delivery was associated with improved processes of care and outcomes after stroke.
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Affiliation(s)
- Moira K Kapral
- Department of Medicine, University of Toronto, Toronto, Ontario.
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85
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Mullen MT, Judd S, Howard VJ, Kasner SE, Branas CC, Albright KC, Rhodes JD, Kleindorfer DO, Carr BG. Disparities in evaluation at certified primary stroke centers: reasons for geographic and racial differences in stroke. Stroke 2013; 44:1930-5. [PMID: 23640827 PMCID: PMC3747032 DOI: 10.1161/strokeaha.111.000162] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 04/01/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Evaluation at primary stroke centers (PSCs) has the potential to improve outcomes for patients with stroke. We looked for differences in evaluation at Joint Commission certified PSCs by race, education, income, and geography (urban versus nonurban; Southeastern Stroke Belt versus non-Stroke Belt). METHODS Community-dwelling, black and white participants from the national Reasons for Geographic And Racial Differences in Stroke (REGARDS) prospective population-based cohort were enrolled between January 2003 and October 2007. Participants were contacted at 6-month intervals for suspected stroke events. For suspected stroke events, it was determined whether the evaluating hospital was a certified PSC. RESULTS Of 1000 suspected strokes, 204 (20.4%) strokes were evaluated at a PSC. A smaller proportion of women than men (17.8% versus 23.0%; P=0.04), those with a previous stroke (15.1% versus 21.6%; P=0.04), those living in the Stroke Belt (14.7% versus 27.3%; P<0.001), and those in a nonurban area (9.1% versus 23.1%; P<0.001) were evaluated at a PSC. There were no differences by race, education, or income. In multivariable analysis, subjects were less likely to be evaluated at a PSC if they lived in a nonurban area (odds ratio, 0.39; 95% confidence interval, 0.22-0.67) or lived in the Stroke Belt (odds ratio, 0.54; 95% confidence interval, 0.38-0.77) or had a previous stroke (odds ratio, 0.46; 95% confidence interval, 0.27-0.78). CONCLUSIONS Disparities in evaluation by PSCs are predominately related to geographic factors but not to race, education, or low income. Despite an increased burden of cerebrovascular disease in the Stroke Belt, subjects there were less likely to be evaluated at certified hospitals.
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Affiliation(s)
- Michael T Mullen
- Department of Neurology, University of Pennsylvania, Philadelphia, PA 19104,
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86
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Zoraster RM, Rison RA. Acute embolic cerebral ischemia as an initial presentation of polycythemia vera: a case report. J Med Case Rep 2013; 7:131. [PMID: 23683307 PMCID: PMC3668271 DOI: 10.1186/1752-1947-7-131] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Accepted: 03/18/2013] [Indexed: 01/14/2023] Open
Abstract
Introduction Patients with polycythemia vera are at high risk for vaso-occlusive events including cerebral ischemia. Although unusual, acute ischemic stroke may be an initial presentation of polycythemia vera. It had been previously assumed that cerebral ischemic events were due to increased blood viscosity and platelet activation within the central nervous system arterial vessels. However, there are now a few isolated case reports of probable micro-embolic events originating from outside of the brain. This suggests unique management issues for these patients. Case presentation We present the case of a 57-year-old right-handed Caucasian male in excellent health who presented to the Emergency Department with acute right-handed clumsiness. Hematologic investigations revealed a hyperviscous state and magnetic resonance imaging was consistent with cerebral emboli. Symptoms rapidly improved with phlebotomy and hydration. Conclusion The etiology of stroke in polycythemic patients is likely to be multifactorial. While hemodilution has been generally discredited for general stroke management, it is potentially beneficial for patients with polycythemia vera and euvolemic hemodilution should be considered for the polycythemic patient with acute cerebral ischemia.
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Affiliation(s)
- Richard M Zoraster
- Clinical Assistant Professor of Neurology, University of Southern California Keck School of Medicine, Medical Director PIH Health Stroke Program, 12401 Washington Boulevard, Whittier, CA, 90602, USA.
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Mullen MT, Kasner SE, Kallan MJ, Kleindorfer DO, Albright KC, Carr BG. Joint commission primary stroke centers utilize more rt-PA in the nationwide inpatient sample. J Am Heart Assoc 2013; 2:e000071. [PMID: 23537806 PMCID: PMC3647273 DOI: 10.1161/jaha.112.000071] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background The Joint Commission began certifying primary stroke centers (PSCs) in December 2003 and provides a standardized definition of stroke center care. It is unknown if PSCs outperform noncertified hospitals. We hypothesized that PSCs would use more recombinant tissue plasminogen activator (rt‐PA) for ischemic stroke than would non‐PSCs. Methods and Results Data were obtained from the Nationwide Inpatient Sample from 2004 to 2009. The analysis was limited to states that publicly reported hospital identity. All patients ≥18 years with a primary diagnosis of acute ischemic stroke were included. Subjects were excluded if the treating hospital was not identified, if it was not possible to determine the temporal relationship between certification and admission, and/or if admitted as a transfer. Rt‐PA was defined by ICD9 procedure code 99.10. All eligibility criteria were met by 323 228 discharges from 26 states. There were 63 145 (19.5%) at certified PSCs. Intravenous rt‐PA was administered to 3.1% overall: 2.2% at non‐PSCs and 6.7% at PSCs. Between 2004 and 2009, rt‐PA administration increased from 1.4% to 3.3% at non‐PSCs and from 6.0% to 7.6% at PSCs. In a multivariable model incorporating year, age, sex, race, insurance, income, comorbidities, DRG‐based disease severity, and hospital characteristics, evaluation at a PSC was significantly associated with rt‐PA utilization (OR, 1.87; 95% CI, 1.61 to 2.16). Conclusions Subjects evaluated at PSCs were more likely to receive rt‐PA than those evaluated at non‐PSCs. This association was significant after adjustment for patient and hospital‐level variables. Systems of care are necessary to ensure stroke patients have rapid access to PSCs throughout the United States.
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Affiliation(s)
- Michael T Mullen
- Department of Neurology, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Lichtman JH, Jones SB, Wang Y, Leifheit-Limson EC, Goldstein LB. Seasonal variation in 30-day mortality after stroke: teaching versus nonteaching hospitals. Stroke 2013; 44:531-3. [PMID: 23299494 DOI: 10.1161/strokeaha.112.670547] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE A systematic review found an association between the July start of internships and residencies and higher mortality rates for hospitalized patients, but data related to stroke are limited. We assessed seasonal variations in 30-day risk-adjusted mortality rates (RAMRs) after ischemic stroke by hospital teaching status. METHODS The analysis included all fee-for-service Medicare beneficiaries aged ≥ 65 years with a primary discharge diagnosis of ischemic stroke (International Classification of Diseases, 9th revision, codes 433, 434, and 436) from 1999 to 2006. Hierarchical linear regression models calculated RAMRs, adjusting for patient demographics and comorbidities. Annual data were combined and reconstructed for time series analyses; RAMRs were calculated for each month. Structural models compared monthly seasonal patterns stratified by hospital teaching status. RESULTS Of 2 824 694 ischemic stroke discharges, 51.7% were from teaching hospitals. There were seasonal patterns within each calendar year, with the highest 30-day RAMR in the winter and the lowest in the summer, but with a smaller peak in July. Thirty-day RAMRs decreased from 1999 to 2006, as did seasonal variations within each calendar year. Seasonal patterns were similar for teaching and nonteaching hospitals. CONCLUSIONS The 30-day RAMR decreased overall, but seasonal patterns were present, with the highest RAMR in January and a smaller peak in July. Because patterns were similar for teaching and nonteaching hospitals, the July peak cannot be explained by the introduction of new trainees in the beginning of the academic year. The reasons for these seasonal patterns warrant further investigation.
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Prvu Bettger JA, Kaltenbach L, Reeves MJ, Smith EE, Fonarow GC, Schwamm LH, Peterson ED. Assessing Stroke Patients for Rehabilitation During the Acute Hospitalization: Findings From the Get With The Guidelines–Stroke Program. Arch Phys Med Rehabil 2013; 94:38-45. [DOI: 10.1016/j.apmr.2012.06.029] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Accepted: 06/01/2012] [Indexed: 11/27/2022]
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Kim DH, Cha JK, Bae HJ, Park HS, Choi JH, Kang MJ, Kim BG, Huh JT, Kim SB. Organized Comprehensive Stroke Center is Associated with Reduced Mortality: Analysis of Consecutive Patients in a Single Hospital. J Stroke 2013; 15:57-63. [PMID: 24324940 PMCID: PMC3779674 DOI: 10.5853/jos.2013.15.1.57] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 01/16/2013] [Accepted: 01/24/2013] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND AND PURPOSE Organized inpatient stroke care is one of the most effective therapies for improving patient outcomes. Many stroke centers have been established to meet this need, however, there are limited data on the effectiveness of these organized comprehensive stroke center (CSC) in the real-world setting. Our aim is to determine whether inpatient care following the establishment of CSC lowers mortality of patients with acute ischemic stroke (AIS). METHODS Based on a prospective stroke registry, we identified AIS patients hospitalized before and after the establishment of a CSC. We observed all-cause mortality within 30 days from time of admission. Logistic regression was used to determine whether the establishment of the CSC affects independently the 30-day all-cause mortality. RESULTS A total of 3,117 consecutive patients with AIS were admitted within seven days after the onset of the symptoms. Unadjusted 30-day mortality was lower for patients admitted to our hospital after the establishment of the CSC than before (5.9% vs. 8.2%, P=0.012). Advanced age, female gender, previous coronary artery disease, non-smoking, stroke subtype, admission on a holiday, referral from other hospitals, high NIHSS on admission, and admission before the establishment of CSC were associated with increased 30-day stroke case fatality. After adjustment for these factors, stroke inpatient care subsequent to the establishment of the CSC was independently associated with lower 30-day mortality (OR, 0.57; 95% CI, 0.412-0.795). CONCLUSIONS Patients treated after the establishment of a CSC had lower 30-mortality rates than ever before, even adjusting for the differences in the baseline characteristics. The present study reveals that organized stroke care in a CSC might improve the outcome after AIS.
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Affiliation(s)
- Dae-Hyun Kim
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
- Busan-Ulsan Regional Cardiocerebrovascular Center, Busan, Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
- Busan-Ulsan Regional Cardiocerebrovascular Center, Busan, Korea
| | - Hyo-Jin Bae
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
- Busan-Ulsan Regional Cardiocerebrovascular Center, Busan, Korea
| | - Hyun-Seok Park
- Busan-Ulsan Regional Cardiocerebrovascular Center, Busan, Korea
| | - Jae-Hyung Choi
- Busan-Ulsan Regional Cardiocerebrovascular Center, Busan, Korea
| | - Myung-Jin Kang
- Busan-Ulsan Regional Cardiocerebrovascular Center, Busan, Korea
| | - Byoung-Gwon Kim
- Busan-Ulsan Regional Cardiocerebrovascular Center, Busan, Korea
| | - Jae-Taeck Huh
- Busan-Ulsan Regional Cardiocerebrovascular Center, Busan, Korea
| | - Sang-Beom Kim
- Busan-Ulsan Regional Cardiocerebrovascular Center, Busan, Korea
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Abstract
Acute ischemic stroke is a time-critical emergency for which thrombolytic therapy is the only medical treatment. Many patients who would benefit from this treatment are deprived of it due to delays. Failure to call for help rapidly is the main obstacle, but even when the call is made in time, the prehospital evaluation, transportation, and emergency department (ED) diagnostics often take too long to treat the patient with thrombolysis. Interventions to reduce pre- and in-hospital delays have been described; although no single intervention is likely to make a major difference, a whole set of interventions needs to be implemented. The intersection of the pre- and in-hospital care is of special importance. With successful protocols and good communication between the emergency medical service and ED, delays can be significantly reduced. On the basis of our experience, 94% of patients can be treated within 60 min of arrival, based largely on using the prehospital time effectively.
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Affiliation(s)
- Atte Meretoja
- Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
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92
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Sheth KN, Terry JB, Nogueira RG, Horev A, Nguyen TN, Fong AK, Gandhi D, Prabhakaran S, Wisco D, Glenn BA, Tayal AH, Ludwig B, Hussain MS, Jovin TG, Clemmons PF, Cronin C, Liebeskind DS, Tian M, Gupta R. Advanced modality imaging evaluation in acute ischemic stroke may lead to delayed endovascular reperfusion therapy without improvement in clinical outcomes. J Neurointerv Surg 2012; 5 Suppl 1:i62-5. [PMID: 23076268 DOI: 10.1136/neurintsurg-2012-010512] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE Advanced neuroimaging techniques may improve patient selection for endovascular stroke treatment but may also delay time to reperfusion. We studied the effect of advanced modality imaging with CT perfusion (CTP) or MRI compared with non-contrast CT (NCT) in a multicenter cohort. MATERIALS AND METHODS This is a retrospective study of 10 stroke centers who select patients for endovascular treatment using institutional protocols. Approval was obtained from each institution's review board as only de-identified information was used. We collected demographic and radiographic data, selected time intervals, and outcome data. ANOVA was used to compare the groups (NCT vs CTP vs MRI). Binary logistic regression analysis was performed to determine factors associated with a good clinical outcome. RESULTS 556 patients were analyzed. Mean age was 66 ± 15 years and median National Institutes of Health Stroke Scale score was 18 (IQR 14-22). NCT was used in 286 (51%) patients, CTP in 190 (34%) patients, and MRI in 80 (14%) patients. NCT patients had significantly lower median times to groin puncture (61 min, IQR (40-117)) compared with CTP (114 min, IQR (81-152)) or MRI (124 min, IQR (87-165)). There were no differences in clinical outcomes, hemorrhage rates, or final infarct volumes among the groups. CONCLUSIONS The current retrospective study shows that multimodal imaging may be associated with delays in treatment without reducing hemorrhage rates or improving clinical outcomes. This exploratory analysis suggests that prospective randomised studies are warranted to support the hypothesis that advanced modality imaging is superior to NCT in improving clinical outcomes.
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Affiliation(s)
- Kevin N Sheth
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Hinchcliff R, Greenfield D, Moldovan M, Westbrook JI, Pawsey M, Mumford V, Braithwaite J. Narrative synthesis of health service accreditation literature. BMJ Qual Saf 2012; 21:979-91. [PMID: 23038406 DOI: 10.1136/bmjqs-2012-000852] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To systematically identify and synthesise health service accreditation literature. METHODS A systematic identification and narrative synthesis of health service accreditation literature published prior to 2012 were conducted. The search identified 122 empirical studies that examined either the processes or impacts of accreditation programmes. Study components were recorded, including: dates of publication; research settings; levels of study evidence and quality using established rating frameworks; and key results. A content analysis was conducted to determine the frequency of key themes and subthemes examined in the literature and identify knowledge-gaps requiring research attention. RESULTS The majority of studies (n=67) were published since 2006, occurred in the USA (n=60) and focused on acute care (n=79). Two thematic categories, that is, 'organisational impacts' and 'relationship to quality measures', were addressed 60 or more times in the literature. 'Financial impacts', 'consumer or patient satisfaction' and 'survey and surveyor issues' were each examined fewer than 15 times. The literature is limited in terms of the level of evidence and quality of studies, but highlights potential relationships among accreditation programmes, high quality organisational processes and safe clinical care. CONCLUSIONS Due to the limitations of the literature, it is not prudent to make strong claims about the effectiveness of health service accreditation. Nonetheless, several critical issues and knowledge-gaps were identified that may help stimulate and inform discussion among healthcare stakeholders. Ongoing effort is required to build upon the accreditation evidence-base by using high quality experimental study designs to examine the processes, effectiveness and financial value of accreditation programmes and their critical components in different healthcare domains.
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Affiliation(s)
- Reece Hinchcliff
- Centre for Clinical Governance Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia.
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Lichtman JH, Leifheit-Limson EC, Jones SB, Wang Y, Goldstein LB. 30-Day risk-standardized mortality and readmission rates after ischemic stroke in critical access hospitals. Stroke 2012; 43:2741-7. [PMID: 22935397 DOI: 10.1161/strokeaha.112.665646] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE The critical access hospital (CAH) designation was established to provide rural residents with local access to emergency and inpatient care. CAHs, however, have poorer short-term outcomes for pneumonia, heart failure, and myocardial infarction compared with other hospitals. We assessed whether 30-day risk-standardized mortality rates (RSMRs) and risk-standardized readmission rates (RSRRs) after ischemic stroke differ between CAHs and non-CAHs. METHODS The study included all fee-for-service Medicare beneficiaries 65 years of age or older with a primary discharge diagnosis of ischemic stroke (International Classification of Diseases, 9th revision codes 433, 434, 436) in 2006. Hierarchical generalized linear models calculated hospital-level RSMRs and RSRRs, adjusting for patient demographics, medical history, and comorbid conditions. Non-CAHs were categorized by hospital volume quartiles and the RSMR and RSRR posterior probabilities in comparison with CAHs were determined using linear regression with Markov chain Monte Carlo simulation. RESULTS There were 10 267 ischemic stroke discharges from 1165 CAHs and 300 114 discharges from 3381 non-CAHs. The RSMRs of CAHs were higher than non-CAHs (11.9%± 1.4% vs 10.9%± 1.7%; P<0.001), but the RSRRs were comparable (13.7%± 0.6% vs 13.7%± 1.4%; P=0.3). The RSMRs for the 2 higher volume quartiles of non-CAHs were lower than CAHs (posterior probability of RSMRs higher than CAHs=0.007 for quartile 3; P<0.001 for quartile 4), but there were no differences for lower volume hospitals; RSRRs did not vary by annual hospital volume. CONCLUSIONS CAHs had higher RSMRs compared with non-CAHs, but readmission rates were similar. The observed differences may be partly explained by patient characteristics and annual hospital volume.
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Affiliation(s)
- Judith H Lichtman
- Section of Chronic Disease Epidemiology, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT 06520-8034, USA.
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McLaughlin N, Laws ER, Oyesiku NM, Katznelson L, Kelly DF. Pituitary Centers of Excellence. Neurosurgery 2012; 71:916-24; discussion 924-6. [DOI: 10.1227/neu.0b013e31826d5d06] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Pituitary tumors and associated neuroendocrine disorders pose significant challenges in diagnostic and therapeutic management. Optimal care of the “pituitary patient” is best provided in a multidisciplinary collaborative environment that includes not only experienced pituitary practitioners in neurosurgery and endocrinology, but also in otorhinolaryngological surgery, radiation oncology, medical oncology, neuro-ophthalmology, diagnostic and interventional neuroradiology, and neuropathology. We provide the background and rationale for recognizing pituitary centers of excellence and suggest a voluntary verification process, similar to that used by the American College of Surgeons for Trauma Center verification. We propose that pituitary centers of excellence should fulfill 3 key missions: (1) provide comprehensive care and support to patients with pituitary disorders; (2) provide residency training, fellowship training, and/or continuing medical education in the management of pituitary and neuroendocrine disease; and (3) contribute to research in pituitary disorders. As this is a preliminary proposal, we recognize several issues that warrant further consideration including center and surgeon practice volume as well as oversight of the verification process.
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Affiliation(s)
- Nancy McLaughlin
- Brain Tumor Center & Pituitary Disorders Program, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California
| | - Edward R. Laws
- Pituitary and Neuroendocrine Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nelson M. Oyesiku
- Pituitary Center and Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Laurence Katznelson
- Pituitary Center and Departments of Neurosurgery and Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Daniel F. Kelly
- Brain Tumor Center & Pituitary Disorders Program, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California
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Krueger H, Lindsay P, Cote R, Kapral MK, Kaczorowski J, Hill MD. Cost Avoidance Associated With Optimal Stroke Care in Canada. Stroke 2012; 43:2198-206. [DOI: 10.1161/strokeaha.111.646091] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hans Krueger
- From the School of Population and Public Health (H.K.), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; H. Krueger & Associates Inc (H.K.), Delta, British Columbia, Canada; Canadian Stroke Network (P.L., M.K.K.), Ottawa, Ontario, Canada; the Institute of Health Policy, Management and Evaluation (P.L., M.K.K.) and the Department of Medicine (M.K.K.), University of Toronto, Toronto, Ontario, Canada; the Department of Neurology and Neurosurgery and Medicine
| | - Patrice Lindsay
- From the School of Population and Public Health (H.K.), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; H. Krueger & Associates Inc (H.K.), Delta, British Columbia, Canada; Canadian Stroke Network (P.L., M.K.K.), Ottawa, Ontario, Canada; the Institute of Health Policy, Management and Evaluation (P.L., M.K.K.) and the Department of Medicine (M.K.K.), University of Toronto, Toronto, Ontario, Canada; the Department of Neurology and Neurosurgery and Medicine
| | - Robert Cote
- From the School of Population and Public Health (H.K.), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; H. Krueger & Associates Inc (H.K.), Delta, British Columbia, Canada; Canadian Stroke Network (P.L., M.K.K.), Ottawa, Ontario, Canada; the Institute of Health Policy, Management and Evaluation (P.L., M.K.K.) and the Department of Medicine (M.K.K.), University of Toronto, Toronto, Ontario, Canada; the Department of Neurology and Neurosurgery and Medicine
| | - Moira K. Kapral
- From the School of Population and Public Health (H.K.), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; H. Krueger & Associates Inc (H.K.), Delta, British Columbia, Canada; Canadian Stroke Network (P.L., M.K.K.), Ottawa, Ontario, Canada; the Institute of Health Policy, Management and Evaluation (P.L., M.K.K.) and the Department of Medicine (M.K.K.), University of Toronto, Toronto, Ontario, Canada; the Department of Neurology and Neurosurgery and Medicine
| | - Janusz Kaczorowski
- From the School of Population and Public Health (H.K.), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; H. Krueger & Associates Inc (H.K.), Delta, British Columbia, Canada; Canadian Stroke Network (P.L., M.K.K.), Ottawa, Ontario, Canada; the Institute of Health Policy, Management and Evaluation (P.L., M.K.K.) and the Department of Medicine (M.K.K.), University of Toronto, Toronto, Ontario, Canada; the Department of Neurology and Neurosurgery and Medicine
| | - Michael D. Hill
- From the School of Population and Public Health (H.K.), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; H. Krueger & Associates Inc (H.K.), Delta, British Columbia, Canada; Canadian Stroke Network (P.L., M.K.K.), Ottawa, Ontario, Canada; the Institute of Health Policy, Management and Evaluation (P.L., M.K.K.) and the Department of Medicine (M.K.K.), University of Toronto, Toronto, Ontario, Canada; the Department of Neurology and Neurosurgery and Medicine
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97
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Panella M, Marchisio S, Brambilla R, Vanhaecht K, Di Stanislao F. A cluster randomized trial to assess the effect of clinical pathways for patients with stroke: results of the clinical pathways for effective and appropriate care study. BMC Med 2012; 10:71. [PMID: 22781160 PMCID: PMC3403956 DOI: 10.1186/1741-7015-10-71] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Accepted: 07/10/2012] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Clinical pathways (CPs) are used to improve the outcomes of acute stroke, but their use in stroke care is questionable, because the evidence on their effectiveness is still inconclusive. The objective of this study was to evaluate whether CPs improve the outcomes and the quality of care provided to patients after acute ischemic stroke. METHODS This was a multicentre cluster-randomized trial, in which 14 hospitals were randomized to the CP arm or to the non intervention/usual care (UC) arm. Healthcare workers in the CP arm received 3 days of training in quality improvement of CPs and in use of a standardized package including information on evidence-based key interventions and indicators. Healthcare workers in the usual-care arm followed their standard procedures. The teams in the CP arm developed their CPs over a 6-month period. The primary end point was mortality. Secondary end points were: use of diagnostic and therapeutic procedures, implementation of organized care, length of stay, re-admission and institutionalization rates after discharge, dependency levels, and complication rates. RESULTS Compared with the patients in the UC arm, the patients in the CP arm had a significantly lower risk of mortality at 7 days (OR = 0.10; 95% CI 0.01 to 0.95) and significantly lower rates of adverse functional outcomes, expressed as the odds of not returning to pre-stroke functioning in their daily life (OR = 0.42; 95 CI 0.18 to 0.98). There was no significant effect on 30-day mortality. Compared with the UC arm, the hospital diagnostic and therapeutic procedures were performed more appropriately in the CP arm, and the evidence-based key interventions and organized care were more applied in the CP arm. CONCLUSIONS CPs can significantly improve the outcomes of patients with ischemic patients with stroke, indicating better application of evidence-based key interventions and of diagnostic and therapeutic procedures. This study tested a new hypothesis and provided evidence on how CPs can work. TRIAL REGISTRATION ClinicalTrials.gov ID: [NCT00673491].
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Affiliation(s)
- Massimiliano Panella
- Department of Clinical and Experimental Medicine, University of Eastern Piedmont, Novara, Italy.
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98
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Abilleira S, Ribera A, Permanyer-Miralda G, Tresserras R, Gallofré M. Noncompliance With Certain Quality Indicators Is Associated With Risk-Adjusted Mortality After Stroke. Stroke 2012; 43:1094-100. [DOI: 10.1161/strokeaha.111.633578] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sònia Abilleira
- From the Stroke Programme (S.A.), Catalan Agency for Health Information, Assessment and Quality (CAHIAQ), Barcelona; CIBER Epidemiología y Salud Pública (CIBERESP); (S.A., A.R., G.P.-M., M.G.); Cardiovascular Epidemiology Unit (A.R., G.P.-M.), Hospital Vall d'Hebron, Barcelona; Stroke Programme (R.T., M.G.), Department of Health, Autonomous Government of Catalonia
| | - Aida Ribera
- From the Stroke Programme (S.A.), Catalan Agency for Health Information, Assessment and Quality (CAHIAQ), Barcelona; CIBER Epidemiología y Salud Pública (CIBERESP); (S.A., A.R., G.P.-M., M.G.); Cardiovascular Epidemiology Unit (A.R., G.P.-M.), Hospital Vall d'Hebron, Barcelona; Stroke Programme (R.T., M.G.), Department of Health, Autonomous Government of Catalonia
| | - Gaietà Permanyer-Miralda
- From the Stroke Programme (S.A.), Catalan Agency for Health Information, Assessment and Quality (CAHIAQ), Barcelona; CIBER Epidemiología y Salud Pública (CIBERESP); (S.A., A.R., G.P.-M., M.G.); Cardiovascular Epidemiology Unit (A.R., G.P.-M.), Hospital Vall d'Hebron, Barcelona; Stroke Programme (R.T., M.G.), Department of Health, Autonomous Government of Catalonia
| | - Ricard Tresserras
- From the Stroke Programme (S.A.), Catalan Agency for Health Information, Assessment and Quality (CAHIAQ), Barcelona; CIBER Epidemiología y Salud Pública (CIBERESP); (S.A., A.R., G.P.-M., M.G.); Cardiovascular Epidemiology Unit (A.R., G.P.-M.), Hospital Vall d'Hebron, Barcelona; Stroke Programme (R.T., M.G.), Department of Health, Autonomous Government of Catalonia
| | - Miquel Gallofré
- From the Stroke Programme (S.A.), Catalan Agency for Health Information, Assessment and Quality (CAHIAQ), Barcelona; CIBER Epidemiología y Salud Pública (CIBERESP); (S.A., A.R., G.P.-M., M.G.); Cardiovascular Epidemiology Unit (A.R., G.P.-M.), Hospital Vall d'Hebron, Barcelona; Stroke Programme (R.T., M.G.), Department of Health, Autonomous Government of Catalonia
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99
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Affiliation(s)
- Edward C. Jauch
- From the Division of Emergency Medicine, Department of Medicine,
Medical University of South Carolina,
Charleston, SC
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100
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Lichtman JH, Jones SB, Leifheit-Limson EC, Wang Y, Goldstein LB. 30-day mortality and readmission after hemorrhagic stroke among Medicare beneficiaries in Joint Commission primary stroke center-certified and noncertified hospitals. Stroke 2011; 42:3387-91. [PMID: 22033986 PMCID: PMC3292255 DOI: 10.1161/strokeaha.111.622613] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Ischemic stroke patients treated at Joint Commission Primary Stroke Center (JC-PSC)-certified hospitals have better outcomes. Data reflecting the impact of JC-PSC status on outcomes after hemorrhagic stroke are limited. We determined whether 30-day mortality and readmission rates after hemorrhagic stroke differed for patients treated at JC-PSC-certified versus noncertified hospitals. METHODS The study included all fee-for-service Medicare beneficiaries aged 65 years or older with a primary discharge diagnosis of subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH) in 2006. Covariate-adjusted logistic and Cox proportional hazards regression assessed the effect of care at a JC-PSC-certified hospital on 30-day mortality and readmission. RESULTS There were 2305 SAH and 8708 ICH discharges from JC-PSC-certified hospitals and 3892 SAH and 22 564 ICH discharges from noncertified hospitals. Unadjusted in-hospital mortality (SAH: 27.5% versus 33.2%, P<0.0001; ICH: 27.9% versus 29.6%, P=0.003) and 30-day mortality (SAH: 35.1% versus 44.0%, P<0.0001; ICH: 39.8% versus 42.4%, P<0.0001) were lower in JC-PSC hospitals, but 30-day readmission rates were similar (SAH: 17.0% versus 17.0%, P=0.97; ICH: 16.0% versus 15.5%, P=0.29). Risk-adjusted 30-day mortality was 34% lower (odds ratio, 0.66; 95% confidence interval, 0.58-0.76) after SAH and 14% lower (odds ratio, 0.86; 95% confidence interval, 0.80-0.92) after ICH for patients discharged from JC-PSC-certified hospitals. There was no difference in 30-day risk-adjusted readmission rates for SAH or ICH based on JC-PSC status. CONCLUSIONS Patients treated at JC-PSC-certified hospitals had lower risk-adjusted mortality rates for both SAH and ICH but similar 30-day readmission rates as compared with noncertified hospitals.
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Affiliation(s)
- Judith H Lichtman
- Department of Epidemiology and Public Health, Yale University School of Medicine, PO Box 208034, New Haven, CT 06520, USA.
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