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Hammond G, Waken RJ, Johnson DY, Towfighi A, Joynt Maddox KE. Racial Inequities Across Rural Strata in Acute Stroke Care and In-Hospital Mortality: National Trends Over 6 Years. Stroke 2022; 53:1711-1719. [PMID: 35172607 PMCID: PMC9324215 DOI: 10.1161/strokeaha.121.035006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 11/19/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are glaring racial and rural-urban inequities in stroke outcomes. The objective of this study was to determine whether there were recent changes to trends in racial inequities in stroke treatment and in-hospital mortality, and whether racial inequities differed across rural strata. METHODS Retrospective analysis of Black and White patients >18 years old admitted to US acute care hospitals with a primary discharge diagnosis of stroke (unweighted N=652 836) from the National Inpatient Sample from 2012 to 2017. Rural residence was classified by county as urban, town, or rural. The primary outcomes were intravenous thrombolysis and endovascular therapy use among patients with acute ischemic stroke, and in-hospital mortality for all stroke patients. Logistic regression models were run for each outcome adjusting for age, comorbidities, primary payer, and ZIP code median income. RESULTS The sample was 53% female, 81% White, and 19% Black. Black patients from rural areas had the lowest odds of receiving intravenous thrombolysis (adjusted odds ratio [aOR], 0.43 [95% CI, 0.37-0.50]) and endovascular therapy (aOR, 0.60 [0.46-0.78]), compared with White urban patients. Black rural patients were the least likely to be discharged home after a stroke compared with White/urban patients (aOR, 0.79 [0.75-0.83]), this was true for Black patients across the urban-rural spectrum when compared with Whites. Black patients from urban areas had lower mortality than White patients from urban areas (aOR, 0.87 [0.84-0.91]), while White patients from rural areas (aOR, 1.14 [1.10-1.19]) had the highest mortality of all groups. CONCLUSIONS Black patients living in rural areas represent a particularly high-risk group for poor access to advanced stroke care and impaired poststroke functional status. Rural White patients have the highest in-hospital mortality. Clinical and policy interventions are needed to improve access and reduce inequities in stroke care and outcomes.
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Affiliation(s)
- Gmerice Hammond
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
| | - RJ Waken
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
| | - Daniel Y. Johnson
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
| | - Amytis Towfighi
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Karen E. Joynt Maddox
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
- Center for Health Economics and Policy, Institute for Public Health at Washington University, St. Louis, MO
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Prick JCM, Zonjee VJ, van Schaik SM, Dahmen R, Garvelink MM, Brouwers PJAM, Saxena R, Keus SHJ, Deijle IA, van Uden-Kraan CF, van der Wees PJ, Van den Berg-Vos RM. Experiences with information provision and preferences for decision making of patients with acute stroke. PATIENT EDUCATION AND COUNSELING 2022; 105:1123-1129. [PMID: 34462248 DOI: 10.1016/j.pec.2021.08.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/23/2021] [Accepted: 08/21/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE The aim of this study was to gain insight into experiences of patients with acute stroke regarding information provision and their preferred involvement in decision-making processes during the initial period of hospitalisation. METHODS A sequential explanatory design was used in two independent cohorts of patients with stroke, starting with a survey after discharge from hospital (cohort 1) followed by observations and structured interviews during hospitalisation (cohort 2). Quantitative data were analysed descriptively. RESULTS In total, 72 patients participated in this study (52 in cohort 1 and 20 in cohort 2). During hospitalisation, the majority of the patients were educated about acute stroke and their treatment. Approximately half of the patients preferred to have an active role in the decision-making process, whereas only 21% reported to be actively involved. In cohort 2, 60% of the patients considered themselves capable to carefully consider treatment options. CONCLUSIONS Active involvement in the acute decision-making process is preferred by approximately half of the patients with acute stroke and most of them consider themselves capable of doing so. However, they experience a limited degree of actual involvement. PRACTICE IMPLICATIONS Physicians can facilitate patient engagement by explicitly emphasising when a decision has to be made in which the patient's opinion is important.
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Affiliation(s)
- J C M Prick
- Department of Neurology, OLVG, Amsterdam, The Netherlands; Santeon, Utrecht, The Netherlands.
| | - V J Zonjee
- Department of Neurology, OLVG, Amsterdam, The Netherlands
| | - S M van Schaik
- Department of Neurology, OLVG, Amsterdam, The Netherlands
| | - R Dahmen
- Amsterdam Rehabilitation Research Center/Reade, Amsterdam, The Netherlands
| | - M M Garvelink
- Department of Value Based Healthcare, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - P J A M Brouwers
- Department of Neurology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - R Saxena
- Department of Neurology, Maasstad Ziekenhuis, Rotterdam, The Netherlands
| | - S H J Keus
- Department of Quality and Improvement, OLVG, Amsterdam, The Netherlands
| | - I A Deijle
- Department of Quality and Improvement, OLVG, Amsterdam, The Netherlands
| | | | - P J van der Wees
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - R M Van den Berg-Vos
- Department of Neurology, OLVG, Amsterdam, The Netherlands; Department of Neurology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
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Strowd RE, Dunbar EM, Gan HK, Kurz S, Jordan JT, Mandel JJ, Mohile NA, Nevel KS, Taylor JW, Ullrich NJ, Welch MR, Wasilewski A, Mrugala MM. Practical guidance for telemedicine use in neuro-oncology. Neurooncol Pract 2022; 9:91-104. [PMID: 35371525 PMCID: PMC8965064 DOI: 10.1093/nop/npac002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
While the COVID-19 pandemic has catalyzed the expansion of telemedicine into nearly every specialty of medicine, few articles have summarized current practices and recommendations for integrating virtual care in the practice of neuro-oncology. This article identifies current telemedicine practice, provides practical guidance for conducting telemedicine visits, and generates recommendations for integrating virtual care into neuro-oncology practice. Practical aspects of telemedicine are summarized including when to use and not use telemedicine, how to conduct a virtual visit, who to include in the virtual encounter, unique aspects of telehealth in neuro-oncology, and emerging innovations.
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Affiliation(s)
- Roy E Strowd
- Department of Neurology and Internal Medicine, Wake Forest Baptist Comprehensive Cancer Center, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | | | - Hui K Gan
- Medical Oncology, Austin Hospital, Heidelberg, Melbourne, Australia
| | - Sylvia Kurz
- Brain and Spine Tumor Center at the Perlmutter Cancer Center, Department of Neurology, New York University Grossman School of Medicine, New York, New York, USA
| | - Justin T Jordan
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jacob J Mandel
- Baylor College of Medicine, Department of Neurology and Neurosurgery, Houston, Texas, USA
| | - Nimish A Mohile
- Department of Neurology and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Kathryn S Nevel
- Indiana University School of Medicine and Indiana University Health, Brain Tumor Center, Department of Neurology, Indianapolis, Indiana, USA
| | - Jennie W Taylor
- Department of Neurology and Neurological Surgery, University of California, San Francisco, California, USA
| | - Nicole J Ullrich
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary R Welch
- Columbia University Vagelos College of Physicians and Surgeons, Herbert Irving Comprehensive Cancer Center, New York-Presbyterian Hospital, New York, New York, USA
| | | | - Maciej M Mrugala
- Mayo Clinic College of Medicine and Science, Mayo Clinic, Phoenix/Scottsdale, Arizona, USA
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Skidmore ER, Shih M. Stroke Rehabilitation: Recent Progress and Future Promise. OTJR-OCCUPATION PARTICIPATION AND HEALTH 2022; 42:175-181. [PMID: 35341386 DOI: 10.1177/15394492221082630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Significant advancements in acute stroke medical management have changed stroke rehabilitation. In addition, an ever-changing health care ecosystem and heightened awareness of continued and new challenges requires that the occupational therapy profession consider new, innovative, and pragmatic approaches to measurement, intervention, and health services research, and clinical practice. The profession must elevate the focus and rigor of research examining occupation and participation after stroke, and their associations with health. Intervention research must progress beyond early phase pilot studies to a robust collection of meaningful large multisite studies that demonstrate the effectiveness of our interventions and the effectiveness of wide-scale implementation to ensure quality and consistent delivery of evidence-based practices in occupational therapy. These studies must address the accessibility of these practices for all people who have sustained stroke, and particularly those people who are most vulnerable to inaccessible stroke rehabilitation service delivery systems.
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Glober N, Supples M, Persaud S, Kim D, Liao M, Glidden M, O’Donnell D, Tainter C, Boustani M, Alexander A. A novel emergency medical services protocol to improve treatment time for large vessel occlusion strokes. PLoS One 2022; 17:e0264539. [PMID: 35213646 PMCID: PMC8880856 DOI: 10.1371/journal.pone.0264539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 02/11/2022] [Indexed: 01/01/2023] Open
Abstract
In many systems, patients with large vessel occlusion (LVO) strokes experience delays in transport to thrombectomy-capable centers. This pilot study examined use of a novel emergency medical services (EMS) protocol to expedite transfer of patients with LVOs to a comprehensive stroke center (CSC). From October 1, 2020 to February 22, 2021, Indianapolis EMS piloted a protocol, in which paramedics, after transporting a patient with a possible stroke remained at the patient's bedside until released by the emergency department or neurology physician. In patients with possible LVO, EMS providers remained at the bedside until the clinical assessment and CT angiography (CTA) were complete. If indicated, the paramedics at bedside transferred the patient, via the same ambulance, to a nearby thrombectomy-capable CSC with which an automatic transfer agreement had been arranged. This five-month mixed methods study included case-control assessment of use of the protocol, number of transfers, safety during transport, and time saved in transfer compared to emergent transfers via conventional interfacility transfer agencies. In qualitative analysis EMS providers, and ED physicians and neurologists at both sending and receiving institutions, completed e-mail surveys on the process, and offered suggestions for process improvement. Responses were coded with an inductive content analysis approach. The protocol was used 42 times during the study period; four patients were found to have LVOs and were transferred to the CSC. There were no adverse events. Median time from decision-to-transfer to arrival at the CSC was 27.5 minutes (IQR 24.5-29.0), compared to 314.5 minutes (IQR 204.0-459.3) for acute non-stroke transfers during the same period. Major themes of provider impressions included: incomplete awareness of the protocol, smooth process, challenges when a stroke alert was activated after EMS left the hospital, greater involvement of EMS in patient care, and comments on communication and efficiency. This pilot study demonstrated the feasibility, safety, and efficiency of a novel approach to expedite endovascular therapy for patients with LVOs.
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Affiliation(s)
- Nancy Glober
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
- * E-mail:
| | - Michael Supples
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Sarah Persaud
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - David Kim
- Department of Emergency Medicine, Stanford University, Santa Clara County, California, United States of America
| | - Mark Liao
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Michele Glidden
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Dan O’Donnell
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Christopher Tainter
- Department of Anesthesiology Critical Care, University of California at San Diego, San Diego, California, United States of America
| | - Malaz Boustani
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Andreia Alexander
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
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A Scoping Review of Non-Pharmacological, Non-Surgical Secondary Prevention Strategies in Ischaemic Stroke and TIA in National Stroke Guidelines and Clinical Audit Documents. Healthcare (Basel) 2022; 10:healthcare10030481. [PMID: 35326959 PMCID: PMC8954875 DOI: 10.3390/healthcare10030481] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/23/2022] [Accepted: 03/02/2022] [Indexed: 12/22/2022] Open
Abstract
The Stroke Action Plan for Europe (2018–2030) calls for national-level secondary prevention plans that address lifestyle, in addition to prevention medications and surgical interventions. This scoping review examines national stroke care guideline and audit documents across WHO regions to identify non-pharmacological, non-surgical stroke secondary prevention recommendations and associated performance indicators. Using a snowballing methodology, 27 guideline documents met the inclusion criteria. Sixteen (59%) detailed, non-pharmacological, non-surgical stroke secondary prevention-addressing known, modifiable population attributable risk factors, of physical inactivity (N = 11), smoking (N = 11), unsafe alcohol consumption (N = 10), diet (N = 8), weight (N = 5), stress (N = 4) and depression (N = 2). Strategies recommended to address these risk factors were: assessment of stroke risk/risk factors (N = 4); provision of advice and information on reducing lifestyle related risk (N = 16); education and counselling for lifestyle behaviour change (N = 8) and onward referral for specialist management of risk (N = 4). Of the nine stroke audits/registries identified, only three (33%) included non-pharmacological, non-surgical quality indicators of documented provision of advice or information on the following: general lifestyle (N = 2); smoking cessation for current smokers (N = 2); reduction in alcohol consumption, where relevant (N = 1), exercise participation (N = 1) and diet (N = 1). Preventive quality indicators addressing the management of weight, stress or depression were absent. This review highlights current gaps in optimal stroke secondary prevention recommendations and their implementation.
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107
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Hill MD, Warach S, Rostanski SK. Should Primary Stroke Centers Perform Advanced Imaging? Stroke 2022; 53:1423-1430. [PMID: 35227077 DOI: 10.1161/strokeaha.121.033528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michael D Hill
- Departments of Clinical Neurosciences, Community Health Sciences, Medicine, and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (M.D.H.)
| | - Steven Warach
- Department of Neurology, Dell Medical School, University of Texas at Austin (S.W.).,Ascension Healthcare' St. Louis' MO (S.W.)
| | - Sara K Rostanski
- Department of Neurology, NYU Grossman School of Medicine, New York, NY (S.K.R.).,Bellevue Hospital' Manhattan' NY (S.K.R.)
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Tran L, Tran P, Tran L. A cross-sectional analysis of 2017 stroke symptoms recognition at the US regional level. Chronic Illn 2022; 18:119-124. [PMID: 32041414 DOI: 10.1177/1742395320905650] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Stroke symptom recognition is critical in reducing time to treatment, but it is not known whether the increased support for stroke education programs during the last several years has led to an improvement in regional stroke symptom recognition levels since they were last assessed in the mid-2010s. METHODS We used the most current estimates of recognition from the 2017 National Health Interview Survey to examine regional recognition levels for individual stroke symptoms and correct identification of all five stroke symptoms. RESULTS Recognition of individual stroke symptoms was ≥76% in all regions, but correct identification of all stroke symptoms was lower ranging from 68.8 to 70.2%. Recognition of sudden numbness or weakness of face, arm, or leg, especially on one side (Northeast: 94.9%, Midwest: 95.8%, South: 93.8%, West: 94.5%) was the highest and recognition of sudden headache with no known cause (Northeast: 77.6%, Midwest: 76.4%, South: 77.7%, West: 76.5%) was the lowest for all regions. DISCUSSION We observed similar stroke symptom recognition levels in each US region with little improvement since the mid-2010s. Additional effort should be made to increase recognition of sudden headache with no known cause in US regions with current high prevalence of stroke risk factors.
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Affiliation(s)
- Lam Tran
- Department of Biostatistics, Michigan School of Public Health, Ann Arbor, MI, USA
| | - Phoebe Tran
- Department of Chronic Disease Epidemiology, Yale University, New Haven, CT, USA
| | - Liem Tran
- Deparment of Geography, University of Tennessee, Knoxville, TN, USA
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Sharobeam A, Yan B. Advanced imaging in acute ischemic stroke: an updated guide to the hub-and-spoke hospitals. Curr Opin Neurol 2022; 35:24-30. [PMID: 34845146 DOI: 10.1097/wco.0000000000001020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the role of the hub-and-spoke system in acute stroke care, highlight the role of advanced imaging and discuss emerging concepts and trials relevant to the hub-and-spoke model. RECENT FINDINGS The advent of advanced stroke multimodal imaging has provided increased treatment options for patients, particularly in rural and regional areas. When used in the hub-and-spoke model, advanced imaging can help facilitate and triage transfers, appropriately select patients for acute therapy and treat patients who may otherwise be ineligible based on traditional time metrics.Recent, ongoing trials in this area may lead to an even greater range of patients being eligible for acute reperfusion therapy, including mild strokes and patients with large core infarct volumes. SUMMARY Integration of advanced imaging into a hub-and-spoke system, when complemented with other systems including telemedicine, improves access to acute stroke care for patients in regional and rural areas.
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Affiliation(s)
- Angelos Sharobeam
- Melbourne Brain Centre, The Royal Melbourne Hospital, Parkville, Australia
- School of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville
- Victorian Stroke Telemedicine Service, Ambulance Victoria, Australia
| | - Bernard Yan
- Melbourne Brain Centre, The Royal Melbourne Hospital, Parkville, Australia
- School of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville
- Neurointervention Service, The Royal Melbourne Hospital, Parkville, Australia
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111
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Olszewski C, Thomson S, Strauss L, Graham R, Ezzeddine M, Dodenhoff K, Ambrosini A, Smith LD, Silla L, Schreiber A, Caraci C, Guzik A, Strowd RE. Patient Experiences With Ambulatory Telehealth in Neurology: Results of a Mixed-Methods Study. Neurol Clin Pract 2022; 11:484-496. [PMID: 34992956 DOI: 10.1212/cpj.0000000000001072] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/28/2021] [Indexed: 01/01/2023]
Abstract
Objective To assess patient experiences with rapid implementation of ambulatory telehealth during the coronavirus disease 2019 (COVID-19) pandemic. Methods A mixed-methods study was performed to characterize the patients' experience with neurology telehealth visits during the first 8 weeks of the COVID-19 response. Consecutive patients who completed a telehealth visit were contacted by telephone. Assenting patients completed a survey quantifying satisfaction with the visit followed by a semistructured telephone interview. Qualitative data were analyzed using the principles of thematic analysis. Results A total of 2,280 telehealth visits were performed, and 753 patients (33%) were reached for postvisit feedback. Of these, 47% of visits were by video and 53% by telephone. Satisfaction was high, with 77% of patients reporting that all needs were met, although only 51% would consider telehealth in the future. Qualitative themes were constructed, suggesting that positive patient experiences were associated not only with the elimination of commute time and associated costs but also with a positive physician interaction. Negative patient experiences were associated with the inability to complete the neurologic examination. Overall, patients tended to view telehealth as a tool that should augment, and not replace, in-person visits. Conclusion In ambulatory telehealth, patients valued convenience, safety, and physician relationship. Barriers were observed but can be addressed.
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Affiliation(s)
- Carly Olszewski
- Wake Forest School of Medicine (CO, ST, KD, AA, LDS, L. Silla, AS), Wake Forest Baptist Health, Winston Salem, NC; and Department of Neurology (L. Strauss, RG, ME, CC, AG, RES), Wake Forest Baptist Health, Winston Salem, NC
| | - Sharon Thomson
- Wake Forest School of Medicine (CO, ST, KD, AA, LDS, L. Silla, AS), Wake Forest Baptist Health, Winston Salem, NC; and Department of Neurology (L. Strauss, RG, ME, CC, AG, RES), Wake Forest Baptist Health, Winston Salem, NC
| | - Lauren Strauss
- Wake Forest School of Medicine (CO, ST, KD, AA, LDS, L. Silla, AS), Wake Forest Baptist Health, Winston Salem, NC; and Department of Neurology (L. Strauss, RG, ME, CC, AG, RES), Wake Forest Baptist Health, Winston Salem, NC
| | - Rachel Graham
- Wake Forest School of Medicine (CO, ST, KD, AA, LDS, L. Silla, AS), Wake Forest Baptist Health, Winston Salem, NC; and Department of Neurology (L. Strauss, RG, ME, CC, AG, RES), Wake Forest Baptist Health, Winston Salem, NC
| | - Mustapha Ezzeddine
- Wake Forest School of Medicine (CO, ST, KD, AA, LDS, L. Silla, AS), Wake Forest Baptist Health, Winston Salem, NC; and Department of Neurology (L. Strauss, RG, ME, CC, AG, RES), Wake Forest Baptist Health, Winston Salem, NC
| | - Kristen Dodenhoff
- Wake Forest School of Medicine (CO, ST, KD, AA, LDS, L. Silla, AS), Wake Forest Baptist Health, Winston Salem, NC; and Department of Neurology (L. Strauss, RG, ME, CC, AG, RES), Wake Forest Baptist Health, Winston Salem, NC
| | - Alexander Ambrosini
- Wake Forest School of Medicine (CO, ST, KD, AA, LDS, L. Silla, AS), Wake Forest Baptist Health, Winston Salem, NC; and Department of Neurology (L. Strauss, RG, ME, CC, AG, RES), Wake Forest Baptist Health, Winston Salem, NC
| | - Laura Daniela Smith
- Wake Forest School of Medicine (CO, ST, KD, AA, LDS, L. Silla, AS), Wake Forest Baptist Health, Winston Salem, NC; and Department of Neurology (L. Strauss, RG, ME, CC, AG, RES), Wake Forest Baptist Health, Winston Salem, NC
| | - Laura Silla
- Wake Forest School of Medicine (CO, ST, KD, AA, LDS, L. Silla, AS), Wake Forest Baptist Health, Winston Salem, NC; and Department of Neurology (L. Strauss, RG, ME, CC, AG, RES), Wake Forest Baptist Health, Winston Salem, NC
| | - Allysen Schreiber
- Wake Forest School of Medicine (CO, ST, KD, AA, LDS, L. Silla, AS), Wake Forest Baptist Health, Winston Salem, NC; and Department of Neurology (L. Strauss, RG, ME, CC, AG, RES), Wake Forest Baptist Health, Winston Salem, NC
| | - Caroline Caraci
- Wake Forest School of Medicine (CO, ST, KD, AA, LDS, L. Silla, AS), Wake Forest Baptist Health, Winston Salem, NC; and Department of Neurology (L. Strauss, RG, ME, CC, AG, RES), Wake Forest Baptist Health, Winston Salem, NC
| | - Amy Guzik
- Wake Forest School of Medicine (CO, ST, KD, AA, LDS, L. Silla, AS), Wake Forest Baptist Health, Winston Salem, NC; and Department of Neurology (L. Strauss, RG, ME, CC, AG, RES), Wake Forest Baptist Health, Winston Salem, NC
| | - Roy E Strowd
- Wake Forest School of Medicine (CO, ST, KD, AA, LDS, L. Silla, AS), Wake Forest Baptist Health, Winston Salem, NC; and Department of Neurology (L. Strauss, RG, ME, CC, AG, RES), Wake Forest Baptist Health, Winston Salem, NC
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Firmawati E, Setyopanoto I, Pangastuti HS. Mobile Health Application to Support Family Caregivers in Recurrent Stroke Prevention: Scoping Review. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2021.7859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND OF THE STUDY: Caregivers play a vital role in continuum care for stroke patients. Involvement of caregivers in stroke care was important. With the advancement of information technology and the rapid growth worldwide in cell-phone use and internet connectivity, additional evidence may be needed in the use of mobile applications to support caregivers in stroke care.
AIM OF THE STUDY: The aims of this review was to identify existing mobile application designed to support family caregivers of people with stroke disease.
METHODOLOGY: A scoping review study framework was carried out in this study, using the EBSCO, Cochrane, PubMed, ProQuest, and Science Direct databases using search keywords: ‘family caregiver’, ‘mobile health application’, and ‘recurrent stroke or secondary stroke prevention’. This review examined studies published between January 2011 and December 2020. Of a total of 728 papers found, 9 journals were selected. RESULTS: The results founded three categories and their attendant sub-categories. The categories was caregivers support, involvement caregivers in stroke care, and barriers. The majority of mobile application was used to provide video education for caregivers. Caregivers involved in stroke care including emotional care, nutrition, exercise, and recurrent stroke prevention. Poor connection was the most barrier in using mobile application.
CONCLUSION: Mobile application can support caregivers in stroke care. Healthcare providers are expected to utilize mobile applications in helping caregivers in post-stroke care.
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Tatlisumak T, Putaala J. General Stroke Management and Stroke Units. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00055-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Jahan R, Saver JL. Endovascular Treatment of Acute Ischemic Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00067-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Czap AL, Harmel P, Audebert H, Grotta JC. Stroke Systems of Care and Impact on Acute Stroke Treatment. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00051-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Gropen TI, Ivankova NV, Beasley M, Hess EP, Mittman B, Gazi M, Minor M, Crawford W, Floyd AB, Varner GL, Lyerly MJ, Shoemaker CC, Owens J, Wilson K, Gray J, Kamal S. Trauma Communications Center Coordinated Severity-Based Stroke Triage: Protocol of a Hybrid Type 1 Effectiveness-Implementation Study. Front Neurol 2021; 12:788273. [PMID: 34938265 PMCID: PMC8686821 DOI: 10.3389/fneur.2021.788273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Mechanical thrombectomy (MT) can improve the outcomes of patients with large vessel occlusion (LVO), but a minority of patients with LVO are treated and there are disparities in timely access to MT. In part, this is because in most regions, including Alabama, the emergency medical service (EMS) transports all patients with suspected stroke, regardless of severity, to the nearest stroke center. Consequently, patients with LVO may experience delayed arrival at stroke centers with MT capability and worse outcomes. Alabama's trauma communications center (TCC) coordinates EMS transport of trauma patients by trauma severity and regional hospital capability. Our aims are to develop a severity-based stroke triage (SBST) care model based on Alabama's trauma system, compare the effectiveness of this care pathway to current stroke triage in Alabama for improving broad, equitable, and timely access to MT, and explore stakeholder perceptions of the intervention's feasibility, appropriateness, and acceptability. Methods: This is a hybrid type 1 effectiveness-implementation study with a multi-phase mixed methods sequential design and an embedded observational stepped wedge cluster trial. We will extend TCC guided stroke severity assessment to all EMS regions in Alabama; conduct stakeholder interviews and focus groups to aid in development of region and hospital specific prehospital and inter-facility stroke triage plans for patients with suspected LVO; implement a phased rollout of TCC Coordinated SBST across Alabama's six EMS regions; and conduct stakeholder surveys and interviews to assess context-specific perceptions of the intervention. The primary outcome is the change in proportion of prehospital stroke system patients with suspected LVO who are treated with MT before and after implementation of TCC Coordinated SBST. Secondary outcomes include change in broad public health impact before and after implementation and stakeholder perceptions of the intervention's feasibility, appropriateness, and acceptability using a mixed methods approach. With 1200 to 1300 total observations over 36 months, we have 80% power to detect a 15% improvement in the primary endpoint. Discussion: This project, if successful, can demonstrate how the trauma system infrastructure can serve as the basis for a more integrated and effective system of emergency stroke care.
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Affiliation(s)
- Toby I Gropen
- Division of Cerebrovascular Disease, The University of Alabama at Birmingham, Birmingham, AL, United States
| | | | - Mark Beasley
- The University of Alabama at Birmingham, Birmingham, AL, United States
| | - Erik P Hess
- Vanderbilt University Medical Center, Nashville, TN, United States
| | - Brian Mittman
- Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Melissa Gazi
- The University of Alabama at Birmingham, Birmingham, AL, United States
| | - Michael Minor
- The University of Alabama at Birmingham, Birmingham, AL, United States
| | - William Crawford
- The Office of Emergency Medical Services, Alabama Department of Public Health, Montgomery, AL, United States
| | - Alice B Floyd
- The Office of Emergency Medical Services, Alabama Department of Public Health, Prattville, AL, United States
| | - Gary L Varner
- The Office of Emergency Medical Services, Alabama Department of Public Health, Montgomery, AL, United States
| | - Michael J Lyerly
- The University of Alabama at Birmingham, Birmingham, AL, United States
| | | | - Jackie Owens
- Mobile Infirmary Medical Center, Mobile, AL, United States
| | - Kent Wilson
- The Office of Emergency Medical Services, Alabama Department of Public Health, Prattville, AL, United States
| | - Jamie Gray
- The Office of Emergency Medical Services, Alabama Department of Public Health, Montgomery, AL, United States
| | - Shaila Kamal
- The University of Alabama at Birmingham, Birmingham, AL, United States
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Allen M, Pearn K, Ford GA, White P, Rudd AG, McMeekin P, Stein K, James M. National implementation of reperfusion for acute ischaemic stroke in England: How should services be configured? A modelling study. Eur Stroke J 2021; 7:28-40. [PMID: 35300255 PMCID: PMC8921787 DOI: 10.1177/23969873211063323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 10/25/2021] [Accepted: 10/29/2021] [Indexed: 11/21/2022] Open
Abstract
Objectives To guide policy when planning thrombolysis (IVT) and thrombectomy (MT) services for acute stroke in England, focussing on the choice between ‘mothership’ (direct conveyance to an MT centre) and ‘drip-and-ship’ (secondary transfer) provision and the impact of bypassing local acute stroke centres. Design Outcome-based modelling study. Setting 107 acute stroke centres in England, 24 of which provide IVT and MT (IVT/MT centres) and 83 provide only IVT (IVT-only units). Participants 242,874 emergency admissions with acute stroke over 3 years (2015–2017). Intervention Reperfusion delivered by drip-and-ship, mothership or ‘hybrid’ models; impact of additional travel time to directly access an IVT/MT centre by bypassing a more local IVT-only unit; effect of pre-hospital selection for large artery occlusion (LAO). Main outcome measures Population benefit from reperfusion, time to IVT and MT, admission numbers to IVT-only units and IVT/MT centres. Results Without pre-hospital selection for LAO, 94% of the population of England live in areas where the greatest clinical benefit, assuming unknown patient status, accrues from direct conveyance to an IVT/MT centre. However, this policy produces unsustainable admission numbers at these centres, with 78 out of 83 IVT-only units receiving fewer than 300 admissions per year (compared to 3 with drip-and-ship). Implementing a maximum permitted additional travel time to bypass an IVT-only unit, using a pre-hospital test for LAO, and selecting patients based on stroke onset time, all help to mitigate the destabilising effect but there is still some significant disruption to admission numbers, and improved selection of patients suitable for MT selectively reduces the number of patients who would receive IVT at IVT-only centres, challenging the sustainability of IVT expertise in IVT-only centres. Conclusions Implementation of reperfusion for acute stroke based solely on achieving the maximum population benefit potentially leads to destabilisation of the emergency stroke care system. Careful planning is required to create a sustainable system, and modelling may be used to help planners maximise benefit from reperfusion while creating a sustainable emergency stroke care system.
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Affiliation(s)
- Michael Allen
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Kerry Pearn
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Gary A Ford
- Radcliffe Department of Medicine, Oxford University and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Phil White
- Translational and Clinical Research Institute, Newcastle University and Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Anthony G Rudd
- Kings College London and Guy’s and St Thomas, NHS Foundation Trust, London, UK
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle Upon Tyne, UK
| | - Ken Stein
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Martin James
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
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Zadorozny EV, Guyette FX, Flickinger KL, Martin-Gill C, Amoah K, Artist O, Mohammed A, Condle JP, Callaway CW, Elmer J, Coppler PJ. Time to specialty care and mortality after cardiac arrest. Am J Emerg Med 2021; 50:618-624. [PMID: 34879476 DOI: 10.1016/j.ajem.2021.09.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/03/2021] [Accepted: 09/10/2021] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Out of hospital cardiac arrest (OHCA) patients are often transported to the closest emergency department (ED) or cardiac center for initial stabilization and may be transferred for further care. We investigated the effects of delay to transfer on in hospital mortality at a receiving facility. METHODS We included OHCA patients transported from the ED by a single critical care transport service to a quaternary care facility between 2010 and 2018. We calculated dwell time as time from arrest to critical care transport team contact. We abstracted demographics, arrest characteristics, and interventions started prior to transport arrival. For the primary analysis, we used logistic regression to determine the association of dwell time and in-hospital mortality. As secondary outcomes we investigated for associations of dwell time and mortality within 24 h of arrival, proximate cause of death among decedents, arterial pH and lactate on arrival, sum of worst SOFA subscales within 24 h of arrival, and rearrest during interfacility transport. RESULTS We included 572 OHCA patients transported from an outside ED to our facility. Median dwell time was 113 (IQR = 85-159) minutes. Measured in 30 min epochs, increasing dwell time was not associated with in-hospital mortality, 24-h mortality, cause of death and initial pH, but was associated with lower 24-h SOFA score (p = 0.01) and lower initial lactate (p = 0.03). Rearrest during transport was rare (n = 29, 5%). Dwell time was associated with lower probability of rearrest during transport (OR = 0.847, (95% CI 0.68-1.01), p = 0.07). CONCLUSIONS Dwell time was not associated with in-hospital mortality. Rapid transport may be associated with risk of rearrest. Prospective data are needed to clarify optimal patient stabilization and transport strategies.
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Affiliation(s)
- Eva V Zadorozny
- University of Pittsburgh School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Francis X Guyette
- University of Pittsburgh School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Katharyn L Flickinger
- University of Pittsburgh School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Christian Martin-Gill
- University of Pittsburgh School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Kaia Amoah
- Howard University College of Medicine, Washington, DC, USA
| | - Onaje Artist
- Howard University College of Medicine, Washington, DC, USA
| | | | - Joseph P Condle
- University of Pittsburgh School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Clifton W Callaway
- University of Pittsburgh School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Jonathan Elmer
- University of Pittsburgh School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA; University of Pittsburgh School of Medicine, Department of Critical Care Medicine, Pittsburgh, Pennsylvania, USA; University of Pittsburgh School of Medicine, Department of Neurology, Pittsburgh, Pennsylvania, USA
| | - Patrick J Coppler
- University of Pittsburgh School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA.
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Hayden EM, Davis C, Clark S, Joshi AU, Krupinski EA, Naik N, Ward MJ, Zachrison KS, Olsen E, Chang BP, Burner E, Yadav K, Greenwald PW, Chandra S. Telehealth in emergency medicine: A consensus conference to map the intersection of telehealth and emergency medicine. Acad Emerg Med 2021; 28:1452-1474. [PMID: 34245649 PMCID: PMC11150898 DOI: 10.1111/acem.14330] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/18/2021] [Accepted: 06/23/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Telehealth has the potential to significantly change the specialty of emergency medicine (EM) and has rapidly expanded in EM during the COVID pandemic; however, it is unclear how EM should intersect with telehealth. The field lacks a unified research agenda with priorities for scientific questions on telehealth in EM. METHODS Through the 2020 Society for Academic Emergency Medicine's annual consensus conference, experts in EM and telehealth created a research agenda for the topic. The multiyear process used a modified Delphi technique to develop research questions related to telehealth in EM. Research questions were excluded from the final research agenda if they did not meet a threshold of at least 80% of votes indicating "important" or "very important." RESULTS Round 1 of voting included 94 research questions, expanded to 103 questions in round 2 and refined to 36 questions for the final vote. Consensus occurred with a final set of 24 important research questions spanning five breakout group topics. Each breakout group domain was represented in the final set of questions. Examples of the questions include: "Among underserved populations, what are mechanisms by which disparities in emergency care delivery may be exacerbated or ameliorated by telehealth" (health care access) and "In what situations should the quality and safety of telehealth be compared to in-person care and in what situations should it be compared to no care" (quality and safety). CONCLUSION The primary finding from the process was the breadth of gaps in the evidence for telehealth in EM and telehealth in general. Our consensus process identified priority research questions for the use of and evaluation of telehealth in EM to fill the current knowledge gaps. Support should be provided to answer the research questions to guide the evidenced-based development of telehealth in EM.
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Affiliation(s)
- Emily M Hayden
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher Davis
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sunday Clark
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Aditi U Joshi
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Neel Naik
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Erica Olsen
- Department of Emergency Medicine, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Bernard P Chang
- Department of Emergency Medicine, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Elizabeth Burner
- Department of Emergency Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Kabir Yadav
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Peter W Greenwald
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Shruti Chandra
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
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Lobo EH, Abdelrazek M, Grundy J, Kensing F, Livingston PM, Rasmussen LJ, Islam SMS, Frølich A. Caregiver Engagement in Stroke Care: Opportunities and Challenges in Australia and Denmark. Front Public Health 2021; 9:758808. [PMID: 34900907 PMCID: PMC8661098 DOI: 10.3389/fpubh.2021.758808] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 11/04/2021] [Indexed: 01/01/2023] Open
Abstract
Globally, there is a rise in incident cases of stroke, particularly in low- and middle-income countries, due to obesity-related and lifestyle risk factors, including health issues such as high cholesterol, diabetes and hypertension. Since the early 20th century, stroke mortality has declined due to proper management of the risk factors and improved treatment practices. However, despite the decline in mortality, there is an increase in the levels of disability that requires long-term support. In countries such as Australia and Denmark, where most care is provided within the community; family members, generally spouses, assume the role of caregiver, with little to no preparation that affects the quality of care provided to the person living with stroke. While past research has highlighted aspects to improve caregiver preparedness of stroke and its impact on care; health planning, recovery, and public health policies rarely consider these factors, reducing engagement and increasing uncertainty. Hence, there is a need to focus on improving strategies during recovery to promote caregiver engagement. In this study, we, therefore, try to understand the needs of the caregiver in stroke that limit engagement, and processes employed in countries such as Australia and Denmark to provide care for the person with stroke. Based on our understanding of these factors, we highlight the potential opportunities and challenges to promote caregiving engagement in these countries.
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Affiliation(s)
- Elton H. Lobo
- School of Information Technology, Deakin University, Geelong, VIC, Australia
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Mohamed Abdelrazek
- School of Information Technology, Deakin University, Geelong, VIC, Australia
| | - John Grundy
- Faculty of Information Technology, Monash University, Clayton, VIC, Australia
| | - Finn Kensing
- Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | | | - Lene J. Rasmussen
- Department of Cellular and Molecular Medicine, University of Copenhagen, Copenhagen, Denmark
- Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | | | - Anne Frølich
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Innovation and Research Centre for Multimorbidity, Slagelse Hospital, Region Zealand, Denmark
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Bulwa Z, Chen M. Stroke Center Designations, Neurointerventionalist Demand, and the Finances of Stroke Thrombectomy in the United States. Neurology 2021; 97:S17-S24. [PMID: 34785600 DOI: 10.1212/wnl.0000000000012780] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 11/24/2020] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW This article aims to provide an update on the designation of stroke centers, neurointerventionalist demand, and cost-effectiveness of stroke thrombectomy in the United States. RECENT FINDINGS There are now more than 1,660 stroke centers certified by national accrediting bodies in the United States, 306 of which are designated as thrombectomy-capable or comprehensive stroke centers. Considering the amount of nationally certified centers and the number of patients with acute stroke eligible for thrombectomy, each center would be responsible for 64 to 104 thrombectomies per year. As a result, there is a growing demand placed on neurointerventionalists, who have the ability to alter the trajectory of large vessel occlusive strokes. Numbers needed to achieve functional independence after stroke thrombectomy at 90 days range from 3.2 to 7.4 patients in the early time window and 2.8 to 3.6 patients in the extended time window in appropriately selected candidates. With the low number needed to treat, in a variety of valued-based calculations and cost-effectiveness analyses, stroke thrombectomy has proved to be both clinically effective and cost-effective. SUMMARY Advancements in the early recognition and treatment of stroke have been paralleled by a remodeling of health care systems to ensure best practices in a timely manner. Stroke center-accrediting bodies provide oversight to safeguard these standards. As successful trial data from high volume centers transform into real-world experience, we must continue to re-evaluate cost-effectiveness, strike a balance between sufficient case volumes to maintain clinical excellence vs the burden and burnout associated with call responsibilities, and improve access to care for all.
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Affiliation(s)
- Zachary Bulwa
- From the Departments of Neurology (Z.B.) and Neurosurgery (M.C.), Rush University Medical Center, Chicago, IL.
| | - Michael Chen
- From the Departments of Neurology (Z.B.) and Neurosurgery (M.C.), Rush University Medical Center, Chicago, IL
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Camicia M, Lutz B, Summers D, Klassman L, Vaughn S. Nursing's Role in Successful Stroke Care Transitions Across the Continuum: From Acute Care Into the Community. Stroke 2021; 52:e794-e805. [PMID: 34727736 DOI: 10.1161/strokeaha.121.033938] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Facilitating successful care transitions across settings is a key nursing competency. Although we have achieved improvements in acute stroke care, similar advances in stroke care transitions in the postacute and return to community phases have lagged far behind. In the current delivery system, care transitions are often ineffective and inefficient resulting in unmet needs and high rates of unnecessary complications and avoidable hospital readmissions. Nurses must use evidence-based approaches to prepare stroke survivors and their family caregivers for postdischarge self-management, rehabilitation, and recovery. The purpose of this article is to provide evidence on the important nursing roles in stroke care and transition management across the care continuum, discuss cross-setting issues in stroke care, and provide recommendations to leverage nursing's impact in optimizing outcomes for stroke survivors and their family unit across the continuum. To optimize nursing's influence in facilitating safe, effective, and efficient care transitions for stroke survivors and their family caregivers across the continuum we have the following recommendations (1) establish a system of coordinated and seamless comprehensive stroke care across the continuum and into the community; (2) implement a stroke nurse liaison role that provides consultant case management for the episode of care across all settings/services for improved consistency, communication and follow-up care; (3) implement a validated caregiver assessment tool to systematically assess gaps in caregiver preparedness and develop a tailored caregiver/family care plan that can be implemented to improve caregiver preparedness; (4) use evidence-based teaching and communication methods to optimize stroke survivor/caregiver learning; and (5) use technology to advance stroke nursing care. Nurses must leverage their substantial influence over the health care delivery system to achieve these improvements in stroke care delivery to improve the health and lives of stroke survivors and their families.
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Affiliation(s)
- Michelle Camicia
- Kaiser Foundation Rehabilitation Center, Kaiser Permanente, Vallejo, CA (M.C.)
| | | | | | - Lynn Klassman
- Advocate Lutheran General Hospital, Park Ridge, IL (L.K.)
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Bushnell CD, Kucharska-Newton AM, Jones SB, Psioda MA, Johnson AM, Daras LC, Halladay JR, Prvu Bettger J, Freburger JK, Gesell SB, Coleman SW, Sissine ME, Wen F, Hunt GP, Rosamond WD, Duncan PW. Hospital Readmissions and Mortality Among Fee-for-Service Medicare Patients With Minor Stroke or Transient Ischemic Attack: Findings From the COMPASS Cluster-Randomized Pragmatic Trial. J Am Heart Assoc 2021; 10:e023394. [PMID: 34730000 PMCID: PMC9075395 DOI: 10.1161/jaha.121.023394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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 Mortality and hospital readmission rates may reflect the quality of acute and postacute stroke care. Our aim was to investigate if, compared with usual care (UC), the COMPASS-TC (Comprehensive Post-Acute Stroke Services Transitional Care) intervention (INV) resulted in lower all-cause and stroke-specific readmissions and mortality among patients with minor stroke and transient ischemic attack discharged from 40 diverse North Carolina hospitals from 2016 to 2018. Methods and Results Using Medicare fee-for-service claims linked with COMPASS cluster-randomized trial data, we performed intention-to-treat analyses for 30-day, 90-day, and 1-year unplanned all-cause and stroke-specific readmissions and all-cause mortality between INV and UC groups, with 90-day unplanned all-cause readmissions as the primary outcome. Effect estimates were determined via mixed logistic or Cox proportional hazards regression models adjusted for age, sex, race, stroke severity, stroke diagnosis, and documented history of stroke. The final analysis cohort included 1069 INV and 1193 UC patients (median age 74 years, 80% White, 52% women, 40% with transient ischemic attack) with median length of hospital stay of 2 days. The risk of unplanned all-cause readmission was similar between INV versus UC at 30 (9.9% versus 8.7%) and 90 days (19.9% versus 18.9%), respectively. No significant differences between randomization groups were seen in 1-year all-cause readmissions, stroke-specific readmissions, or mortality. Conclusions In this pragmatic trial of patients with complex minor stroke/transient ischemic attack, there was no difference in the risk of readmission or mortality with COMPASS-TC relative to UC. Our study could not conclusively determine the reason for the lack of effectiveness of the INV. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02588664.
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Affiliation(s)
| | - Anna M Kucharska-Newton
- Department of Epidemiology College of Public Health University of Kentucky Lexington KY.,Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Sara B Jones
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Matthew A Psioda
- Department of Biostatistics Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Anna M Johnson
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | | | - Jacqueline R Halladay
- Department of Family Medicine University of North Carolina School of Medicine Chapel Hill NC
| | | | - Janet K Freburger
- Department of Physical Therapy School of Health and Rehabilitation Sciences University of Pittsburgh PA
| | - Sabina B Gesell
- Division of Public Health Sciences Department of Social Sciences and Health Policy Wake Forest School of Medicine Winston-Salem NC
| | - Sylvia W Coleman
- Department of Neurology Wake Forest Baptist Health Winston-Salem NC
| | - Mysha E Sissine
- Department of Neurology Wake Forest Baptist Health Winston-Salem NC
| | - Fang Wen
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Gary P Hunt
- Cecil G Sheps Center for Health Services Research University of North Carolina at Chapel Hill NC
| | - Wayne D Rosamond
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Pamela W Duncan
- Department of Neurology Wake Forest Baptist Health Winston-Salem NC
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Freburger JK, Pastva AM, Coleman SW, Peter KM, Kucharska-Newton AM, Johnson AM, Psioda MA, Duncan PW, Bushnell CD, Rosamond WD, Jones SB. Skilled Nursing and Inpatient Rehabilitation Facility Use by Medicare Fee-for-Service Beneficiaries s Discharged Home following a Stroke: Findings from the COMPASS Trial. Arch Phys Med Rehabil 2021; 103:882-890.e2. [PMID: 34740596 DOI: 10.1016/j.apmr.2021.10.015] [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: 07/19/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 11/02/2022]
Abstract
OBJECTIVES To examine the effect of a comprehensive transitional care model on the utilization of skilled nursing facility (SNF) and inpatient rehabilitation facility (IRF) care in the 12 months after acute care discharge home following stroke; and to identify predictors of experiencing a SNF or IRF admission following discharge home after stroke. DESIGN Cluster randomized pragmatic trial Setting: 41 acute care hospitals in North Carolina. PARTICIPANTS 2,262 Medicare fee-for-service beneficiaries with transient ischemic attack or stroke discharged home. The sample was 80.3% White and 52.1% female, with a mean (standard deviation [SD]) age of 74.9 (10.2) years and a mean (SD) NIH stroke scale score of 2.3 (3.7). INTERVENTION Comprehensive transitional care model (COMPASS-TC) which consisted of a 2-day follow-up phone call from the post-acute care coordinator (PAC) and 14-day in-person visit with the PAC and advanced practice provider. MAIN OUTCOME MEASURES Time to first SNF or IRF and SNF or IRF admission (yes/no) in the 12 months following discharge home. All analyses utilized multivariable mixed models including a hospital-specific random effect to account for the non-independence of measures within hospital. Intent to treat analyses using Cox proportional hazards regression assessed the effect of COMPASS-TC on time to SNF/IRF admission. Logistic regression was used to identify clinical and non-clinical predictors of SNF/IRF admission. RESULTS Only 34% of patients in the intervention arm received COMPASS-TC per protocol. COMPASS-TC was not associated with a reduced hazard of a SNF/ IRF admission in the 12 months post-discharge (HR=1.20 [0.95 - 1.52]) compared to usual care. This estimate was robust to additional covariate adjustment (HR=1.23 [0.93-1.64]). Both clinical and non-clinical factors (i.e., insurance, geography) were predictors of SNF/IRF use. CONCLUSIONS COMPASS-TC was not consistently incorporated into real-world clinical practice. The use of a comprehensive transitional care model for patients discharged home after stroke was not associated with SNF or IRF admissions in a 12-month follow-up period. Non-clinical factors predictive of SNF/IRF use suggest potential issues with access to this type of care.
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Affiliation(s)
- Janet K Freburger
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Bridgeside Point 1, Suite 210, 100 Technology Dr, Pittsburgh, PA 15219-3130.
| | - Amy M Pastva
- Duke University School of Medicine, DUMC Box 104002, 311 Trent Drive, Durham, NC, 27710
| | - Sylvia W Coleman
- Department of Neurology, Wake Forest Baptist Health, Medical Center Blvd, Winston-Salem, NC, 27157
| | - Kennedy M Peter
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599
| | - Anna M Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599; Department of Epidemiology, College of Public Health, University of Kentucky, 111 Washington Ave, Lexington, KY, 40536
| | - Anna M Johnson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599
| | - Matthew A Psioda
- Department of Biostatistics, Gillings School of Global Public Health, 135 University of North Carolina at Chapel Hill, Dauer Dr, Chapel Hill, NC 27599
| | - Pamela W Duncan
- Department of Neurology, Wake Forest Baptist Health, Medical Center Blvd, Winston-Salem, NC, 27157
| | - Cheryl D Bushnell
- Department of Neurology, Wake Forest Baptist Health, Medical Center Blvd, Winston-Salem, NC, 27157
| | - Wayne D Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599
| | - Sara B Jones
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599
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Hanchate AD, Qi D, Stopyra JP, Paasche-Orlow MK, Baker WE, Feldman J. Potential bypassing of nearest emergency department by EMS transports. Health Serv Res 2021; 57:300-310. [PMID: 34723392 DOI: 10.1111/1475-6773.13903] [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: 05/04/2021] [Revised: 10/21/2021] [Accepted: 10/24/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Guidelines recommend emergency medical services (EMS) patients to be transported to the nearest appropriate emergency department (ED). Our objective was to estimate the prevalence of EMS transport to an ED other than the nearest ED ("potential bypassing"). DATA SOURCES Illinois Prehospital Patient Care Report Data of EMS transports (July 2019 to December 2019). DATA COLLECTION/EXTRACTION METHODS We identified all EMS ground transports with an advanced life-support (ALS) paramedic to an ED for patients aged 21 years and older. Using street address of incident location, we performed geocoding and driving route analyses and obtained estimated driving distance and time to the destination ED and alternative EDs. MAIN OUTCOME AND MEASURES Our main outcomes were dichotomous indicators of potential bypassing of the nearest ED based on distance and time. As secondary outcomes we examined potential bypassing indicators based on excess driving distance and time. STUDY DESIGN We used Poisson regression models to obtain adjusted relative rates of potential bypassing indicators by acuity level, primary impression, patient demographics and geographic characteristics. PRINCIPAL FINDINGS Our study cohort of 361,051 EMS transports consisted of 5.8% critical, 37.2% emergent and 57.0% low acuity cases transported to 222 EDs. The observed rate of potential bypassing was approximately 34% of cases for each acuity level. Treating the cardiovascular primary impression code group as the reference case, we found small to no differences in potential bypassing rates across other primary impression code groups of all acuity levels, with the exception of critical acuity trauma cases for which potential bypassing rate was 64% higher (incidence rate ratio = 1.64, 95% confidence interval, 1.54-1.74). Compared to zip codes with one ED within a 5-mile vicinity, potential bypassing was higher in areas with no ED or multiple EDs within a 5-mile vicinity. CONCLUSION Approximately one-third of EMS transports potentially bypassed the nearest ED. EMS transport destination may be motivated by factors other than proximity.
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Affiliation(s)
- Amresh D Hanchate
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Danyang Qi
- SuperMap International Limited, Beijing, China
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Michael K Paasche-Orlow
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - William E Baker
- Department of Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - James Feldman
- Department of Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
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126
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Fisher RJ, Chouliara N, Byrne A, Cameron T, Lewis S, Langhorne P, Robinson T, Waring J, Geue C, Paley L, Rudd A, Walker MF. Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
In England, the provision of early supported discharge is recommended as part of an evidence-based stroke care pathway.
Objectives
To investigate the effectiveness of early supported discharge services when implemented at scale in practice and to understand how the context within which these services operate influences their implementation and effectiveness.
Design
A mixed-methods study using a realist evaluation approach and two interlinking work packages was undertaken. Three programme theories were tested to investigate the adoption of evidence-based core components, differences in urban and rural settings, and communication processes.
Setting and interventions
Early supported discharge services across a large geographical area of England, covering the West and East Midlands, the East of England and the North of England.
Participants
Work package 1: historical prospective patient data from the Sentinel Stroke National Audit Programme collected by early supported discharge and hospital teams. Work package 2: NHS staff (n = 117) and patients (n = 30) from six purposely selected early supported discharge services.
Data and main outcome
Work package 1: a 17-item early supported discharge consensus score measured the adherence to evidence-based core components defined in an international consensus document. The effectiveness of early supported discharge was measured with process and patient outcomes and costs. Work package 2: semistructured interviews and focus groups with NHS staff and patients were undertaken to investigate the contextual determinants of early supported discharge effectiveness.
Results
A variety of early supported discharge service models had been adopted, as reflected by the variability in the early supported discharge consensus score. A one-unit increase in early supported discharge consensus score was significantly associated with a more responsive early supported discharge service and increased treatment intensity. There was no association with stroke survivor outcome. Patients who received early supported discharge in their stroke care pathway spent, on average, 1 day longer in hospital than those who did not receive early supported discharge. The most rural services had the highest service costs per patient. NHS staff identified core evidence-based components (e.g. eligibility criteria, co-ordinated multidisciplinary team and regular weekly multidisciplinary team meetings) as central to the effectiveness of early supported discharge. Mechanisms thought to streamline discharge and help teams to meet their responsiveness targets included having access to a social worker and the quality of communications and transitions across services. The role of rehabilitation assistants and an interdisciplinary approach were facilitators of delivering an intensive service. The rurality of early supported discharge services, especially when coupled with capacity issues and increased travel times to visit patients, could influence the intensity of rehabilitation provision and teams’ flexibility to adjust to patients’ needs. This required organising multidisciplinary teams and meetings around the local geography. Findings also highlighted the importance of good leadership and communication. Early supported discharge staff highlighted the need for collaborative and trusting relationships with patients and carers and stroke unit staff, as well as across the wider stroke care pathway.
Limitations
Work package 1: possible influence of unobserved variables and we were unable to determine the effect of early supported discharge on patient outcomes. Work package 2: the pragmatic approach led to ‘theoretical nuggets’ rather than an overarching higher-level theory.
Conclusions
The realist evaluation methodology allowed us to address the complexity of early supported discharge delivery in real-world settings. The findings highlighted the importance of context and contextual features and mechanisms that need to be either addressed or capitalised on to improve effectiveness.
Trial registration
Current Controlled Trials ISRCTN15568163.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 22. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rebecca J Fisher
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
| | - Niki Chouliara
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
| | - Adrian Byrne
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
| | - Trudi Cameron
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
| | - Sarah Lewis
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Thompson Robinson
- Department of Cardiovascular Sciences and National Institute for Health Research Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Justin Waring
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Claudia Geue
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Lizz Paley
- Sentinel Stroke National Audit Programme, King’s College London, London, UK
| | - Anthony Rudd
- Sentinel Stroke National Audit Programme, King’s College London, London, UK
| | - Marion F Walker
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
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Dowbiggin PL, Infinger AE, Purick GT, Swanson DR, Asimos A, Rhoten JB, VonCannon S, Dometrovich M, Studnek JR. Prehospital Evaluation of the FAST-ED as a Secondary Stroke Screen to Identify Large Vessel Occlusion Strokes. PREHOSP EMERG CARE 2021; 26:333-338. [PMID: 34524065 DOI: 10.1080/10903127.2021.1979701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) was developed to identify Large Vessel Occlusion Strokes (LVOS) presenting out of hospital, although there is limited prospective research validating its use in this setting. This study evaluated the test characteristics of the FAST-ED to identify LVOS when used as a secondary stroke screen in the prehospital environment. Secondary analysis compared the performance of the CPSS and the FAST-ED in identifying an LVOS. Methods: This prospective, observational study was conducted from April 2018 to December 2019 in a municipal EMS system with all ALS ambulance response. The FAST-ED was implemented as a secondary screening tool for emergent stroke patients who had at least one positive Cincinnati Prehospital Stroke Screen (CPSS) item. CPSS and FAST-ED scores were extracted from prehospital electronic care reports, while the presence of LVOS was extracted from hospital records. Results: A total 1,359 patients were enrolled; 55.3% female, 47.5% white, with a mean age of 69.4 (SD 15.8). In this cohort, 11.3% of patients experienced an LVOS. The mean FAST-ED for a patient experiencing an LVOS was 5.33 (95%CI 4.97-5.69) compared to 3.06 (95%CI 2.95-3.12) (p < 0.001). A score of greater or equal to 4 yielded the highest combination of sensitivity (77.78%) and specificity (65.34%) with positive likelihood ratio 2.24 (95% CI 2.00-2.52) and negative likelihood ratio 0.34 (95% CI 0.25-0.46). Area under the ROC curve was 0.77 (95%CI 0.73, 0.81). A CPSS with all three items positive demonstrated a sensitivity of 73.20% and 69.57% specificity, with an ROC area of 0.73 (95% CI 0.70-0.77). When comparing a FAST-ED ≥4 to a CPSS of all positive items, there was no significant difference in sensitivity (p > 0.05), and the FAST-ED had a significantly lower specificity than the CPSS (p < 0.005). Conclusion: As stroke care advances, EMS agencies must consider their destination triage needs. This study suggests agencies must consider the use of single versus secondary scales, and to determine the ideal sensitivity and specificity for their system.
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128
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Martins SCO, Lavados P, Secchi TL, Brainin M, Ameriso S, Gongora-Rivera F, Sacks C, Cantú-Brito C, Alvarez Guzman TF, Pérez-Romero GE, Muñoz Collazos M, Barboza MA, Arauz A, Abanto Argomedo C, Novarro-Escudero N, Amorin Costabile HI, Crosa R, Camejo C, Mernes R, Maldonado N, Mora Cuervo DL, Pontes Neto OM, Silva GS, Carbonera LA, de Souza AC, de Sousa EDG, Flores A, Melgarejo D, Santos Carquin IR, Hoppe A, de Carvalho JJF, Mont'Alverne F, Amaya P, Bayona H, Navia González VH, Duran JC, Urrutia VC, Araujo DV, Feigin VL, Nogueira RG. Fighting Against Stroke in Latin America: A Joint Effort of Medical Professional Societies and Governments. Front Neurol 2021; 12:743732. [PMID: 34659101 PMCID: PMC8517273 DOI: 10.3389/fneur.2021.743732] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/30/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Stroke is one of the leading causes of death in Latin America, a region with countless gaps to be addressed to decrease its burden. In 2018, at the first Latin American Stroke Ministerial Meeting, stroke physician and healthcare manager representatives from 13 countries signed the Declaration of Gramado with the priorities to improve the region, with the commitment to implement all evidence-based strategies for stroke care. The second meeting in March 2020 reviewed the achievements in 2 years and discussed new objectives. This paper will review the 2-year advances and future plans of the Latin American alliance for stroke. Method: In March 2020, a survey based on the Declaration of Gramado items was sent to the neurologists participants of the Stroke Ministerial Meetings. The results were confirmed with representatives of the Ministries of Health and leaders from the countries at the second Latin American Stroke Ministerial Meeting. Results: In 2 years, public stroke awareness initiatives increased from 25 to 75% of countries. All countries have started programs to encourage physical activity, and there has been an increase in the number of countries that implement, at least partially, strategies to identify and treat hypertension, diabetes, and lifestyle risk factors. Programs to identify and treat dyslipidemia and atrial fibrillation still remained poor. The number of stroke centers increased from 322 to 448, all of them providing intravenous thrombolysis, with an increase in countries with stroke units. All countries have mechanical thrombectomy, but mostly restricted to a few private hospitals. Pre-hospital organization remains limited. The utilization of telemedicine has increased but is restricted to a few hospitals and is not widely available throughout the country. Patients have late, if any, access to rehabilitation after hospital discharge. Conclusion: The initiative to collaborate, exchange experiences, and unite societies and governments to improve stroke care in Latin America has yielded good results. Important advances have been made in the region in terms of increasing the number of acute stroke care services, implementing reperfusion treatments and creating programs for the detection and treatment of risk factors. We hope that this approach can reduce inequalities in stroke care in Latin America and serves as a model for other under-resourced environments.
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Affiliation(s)
- Sheila Cristina Ouriques Martins
- Hospital Moinhos de Vento, Porto Alegre, Brazil.,Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Brazilian Stroke Network, Porto Alegre, Brazil.,World Stroke Organization, Geneva, Switzerland
| | - Pablo Lavados
- Clinica Alemana, Universidad del Desarollo, Santiago, Chile
| | - Thaís Leite Secchi
- Hospital Moinhos de Vento, Porto Alegre, Brazil.,Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Brazilian Stroke Network, Porto Alegre, Brazil
| | - Michael Brainin
- World Stroke Organization, Geneva, Switzerland.,Department of Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems an der Donau, Austria
| | - Sebastian Ameriso
- Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia, Buenos Aires, Argentina
| | - Fernando Gongora-Rivera
- Servicio de Neurología - Unidad Neurovascular, Hospital Universitario José Eleuterio González, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico.,Instituto de Neurología y Neurocirugía, Centro Médico Zambrano Hellion, Tec Salud, San Pedro Garza García, Mexico.,Centro de Investigación y Desarrollo en Ciencias de la Salud, Universidad Aiutónoma de Nuevo León, Monterrey, Mexico
| | - Claudio Sacks
- Department of Neurology, Universidad del Valparaiso, Valparaiso, Chile
| | - Carlos Cantú-Brito
- Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Mexico City, Mexico
| | - Tony Fabian Alvarez Guzman
- Hospital Regional Manuela Beltran, Socorro, Colombia.,Asociación Colombiana de Neurología, Bogotá, Colombia
| | - Germán Enrique Pérez-Romero
- Asociación Colombiana de Neurología, Bogotá, Colombia.,Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, Colombia.,Fundación Hospital San Carlos, Bogotá, Colombia
| | | | - Miguel A Barboza
- Hospital Dr. Rafael A. Calderon, Neuroscience Department, San José, Costa Rica
| | - Antonio Arauz
- Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Clínica de Enfermedad Vascular Cerebral, Ciudad de México, Mexico
| | - Carlos Abanto Argomedo
- Departamento de Enfermedades Neurovasculares, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | | | | | | | | | - Ricardo Mernes
- Hospital de Clinicas, Faculdad de Medicina, Universidad Nacional de Asuncion, San Lorenzo, Paraguay
| | - Nelson Maldonado
- Hospital Central del Instituto de Previsión Social, Asunción, Paraguay
| | | | - Octávio Marques Pontes Neto
- Brazilian Stroke Network, Porto Alegre, Brazil.,Universidad San Francisco de Quito, Hospital de los Valles, Quito, Ecuador.,Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Gisele Sampaio Silva
- Brazilian Stroke Network, Porto Alegre, Brazil.,Brazilian Stroke Society, São Paulo, Brazil.,Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil.,Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Ana Claudia de Souza
- Hospital Moinhos de Vento, Porto Alegre, Brazil.,Brazilian Stroke Network, Porto Alegre, Brazil
| | | | - Alan Flores
- Hospital de Clinicas, Faculdad de Medicina, Universidad Nacional de Asuncion, San Lorenzo, Paraguay
| | - Donoban Melgarejo
- Hospital de Clinicas, Faculdad de Medicina, Universidad Nacional de Asuncion, San Lorenzo, Paraguay.,Hospital Central del Instituto de Previsión Social, Asunción, Paraguay
| | - Irving R Santos Carquin
- Emergency Hospital Public Assistance, Santiago, Chile.,Faculty of Medicine, University of Chile, Santiago, Chile.,Ministry of Health, Santiago, Chile
| | - Arnold Hoppe
- Clinica Alemana, Universidad del Desarollo, Santiago, Chile.,Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
| | | | - Francisco Mont'Alverne
- Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile.,Sociedade Brazileira de Neurorradiologia Diagnóstica e Terapêutica, São Paulo, Brazil
| | - Pablo Amaya
- Servicio de Neurología - Unidad Neurovascular, Hospital Universitario José Eleuterio González, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico.,Asociación Colombiana de Neurología, Bogotá, Colombia.,Fundación Valle del Lili, Cali, Colombia
| | - Hernan Bayona
- Asociación Colombiana de Neurología, Bogotá, Colombia.,Fundación Santa Fé de Bogotá, Bogotá, Colombia
| | | | | | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Denizar Vianna Araujo
- Ministry of Health, Brasília, Brazil.,Faculdade de Ciências Médicas da Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Valery L Feigin
- National Institute for Stroke and Applied Neurosciences, School of Public Health and Psychosocial Studies, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Raul G Nogueira
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University, Atlanta, GA, United States
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129
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Maeda M, Fukuda H, Matsuo R, Ago T, Kitazono T, Kamouchi M. Regional Disparity of Reperfusion Therapy for Acute Ischemic Stroke in Japan: A Retrospective Analysis of Nationwide Claims Data from 2010 to 2015. J Am Heart Assoc 2021; 10:e021853. [PMID: 34622661 PMCID: PMC8751889 DOI: 10.1161/jaha.121.021853] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background We aimed to determine whether a regional disparity exists in usage of reperfusion therapy (intravenous recombinant tissue plasminogen activator [IV rt‐PA] and endovascular thrombectomy [EVT]) and post‐reperfusion 30‐day mortality in patients with acute ischemic stroke, and which regional factors are associated with their usage. Methods and Results We retrospectively investigated 69 948 patients (mean age±SD, 74.9±12.0 years; women, 41.4%) with acute ischemic stroke treated with reperfusion therapy between April 2010 and March 2016 in Japan using nationwide claims data. Regional disparity was evaluated using Gini coefficients for age‐ and sex‐adjusted usage of reperfusion therapy and 30‐day post‐reperfusion in‐hospital death ratio in 47 administrative regions. The association between regional factors and reperfusion therapy usage was evaluated with fixed‐effects regression models. During the study period, Gini coefficients showed low inequality (0.11–0.15) for use of IV rt‐PA monotherapy and IV rt‐PA and/or EVT and extreme inequality (0.49) for EVT usage in 2010, which became moderate inequality (0.25) by 2015. The densities of stroke centers and endovascular specialists, as well as market concentration, were associated with increased usage of reperfusion therapy whereas the proportion of rural residents and delayed ambulance transport were negatively associated with usage. Inequality in the standardized death ratio after EVT was extreme (0.86) in 2010 but became moderate (0.29) by 2015; inequality was low to moderate (0.17–0.23) for IV rt‐PA monotherapy and IV rt‐PA and/or EVT. Conclusions Scrutinizing existing data sources revealed regional disparity in reperfusion therapy for acute ischemic stroke and its associated regional factors in Japan.
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Affiliation(s)
- Megumi Maeda
- Department of Health Care Administration and ManagementGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Haruhisa Fukuda
- Department of Health Care Administration and ManagementGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
- Center for Cohort StudiesGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Ryu Matsuo
- Department of Health Care Administration and ManagementGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
- Department of Medicine and Clinical ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Tetsuro Ago
- Department of Medicine and Clinical ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Takanari Kitazono
- Center for Cohort StudiesGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
- Department of Medicine and Clinical ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Masahiro Kamouchi
- Department of Health Care Administration and ManagementGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
- Center for Cohort StudiesGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
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130
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Chen J, Black I, Nichols D, Chen T, Sandison M, Casas R, Lum PS. Pilot Test of Dosage Effects in HEXORR II for Robotic Hand Movement Therapy in Individuals With Chronic Stroke. FRONTIERS IN REHABILITATION SCIENCES 2021; 2. [PMID: 35419565 PMCID: PMC9004134 DOI: 10.3389/fresc.2021.728753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Impaired use of the hand in functional tasks remains difficult to overcome in many individuals after a stroke. This often leads to compensation strategies using the less-affected limb, which allows for independence in some aspects of daily activities. However, recovery of hand function remains an important therapeutic goal of many individuals, and is often resistant to conventional therapies. In prior work, we developed HEXORR I, a robotic device that allows practice of finger and thumb movements with robotic assistance. In this study, we describe modifications to the device, now called HEXORR II, and a clinical trial in individuals with chronic stroke. Fifteen individuals with a diagnosis of chronic stroke were randomized to 12 or 24 sessions of robotic therapy. The sessions involved playing several video games using thumb and finger movement. The robot applied assistance to extension movement that was adapted based on task performance. Clinical and motion capture evaluations were performed before and after training and again at a 6-month followup. Fourteen individuals completed the protocol. Fugl-Meyer scores improved significantly at the 6 month time point compared to baseline, indicating reductions in upper extremity impairment. Flexor hypertonia (Modified Ashworth Scale) also decreased significantly due to the intervention. Motion capture found increased finger range of motion and extension ability after the intervention that continued to improve during the followup period. However, there was no change in a functional measure (Action Research Arm Test). At the followup, the high dose group had significant gains in hand displacement during a forward reach task. There were no other significant differences between groups. Future work with HEXORR II should focus on integrating it with functional task practice and incorporating grip and squeezing tasks. Trial Registration:ClinicalTrials.gov, NCT04536987. Registered 3 September 2020 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/record/NCT04536987.
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Affiliation(s)
- Ji Chen
- Department of Mechanical Engineering, University of the District of Columbia, Washington, DC, United States
- Department of Biomedical Engineering, The Catholic University of America, Washington, DC, United States
| | - Iian Black
- MedStar National Rehabilitation Network, Washington, DC, United States
- Biomedical Engineering Department, Florida International University, Miami, FL, United States
| | - Diane Nichols
- MedStar National Rehabilitation Network, Washington, DC, United States
| | - Tianyao Chen
- Department of Biomedical Engineering, The Catholic University of America, Washington, DC, United States
| | - Melissa Sandison
- Department of Biomedical Engineering, The Catholic University of America, Washington, DC, United States
- MedStar National Rehabilitation Network, Washington, DC, United States
| | - Rafael Casas
- Department of Biomedical Engineering, The Catholic University of America, Washington, DC, United States
- MedStar National Rehabilitation Network, Washington, DC, United States
| | - Peter S. Lum
- Department of Biomedical Engineering, The Catholic University of America, Washington, DC, United States
- MedStar National Rehabilitation Network, Washington, DC, United States
- *Correspondence: Peter S. Lum
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131
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Zachrison KS, Sharma R, Wang Y, Mehrotra A, Schwamm LH. National Trends in Telestroke Utilization in a US Commercial Platform Prior to the COVID-19 Pandemic. J Stroke Cerebrovasc Dis 2021; 30:106035. [PMID: 34419836 PMCID: PMC8494566 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 07/21/2021] [Accepted: 08/01/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Most data on telestroke utilization come from single academic hub-and-spoke telestroke networks. Our objective was to describe characteristics of telestroke consultations among a national sample of telestroke sites on one of the most commonly used common vendor platforms, prior to the COVID-19 public health emergency. MATERIALS AND METHODS A commercial telestroke vendor provided data on all telestroke consultations by two specialist provider groups from 2013-2019. Kendall's τ β nonparametric test was utilized to assess time trends. Generalized linear models were used to assess the association between hospital consult utilization and alteplase use adjusting for hospital characteristics. RESULTS Among 67,736 telestroke consultations to 132 spoke sites over the study period, most occurred in the emergency department (90%) and for stroke indications (final clinical diagnoses: TIA 13%, ischemic stroke 39%, hemorrhagic stroke 2%, stroke mimics 46%). Stroke severity was low (median NIHSS 2, IQR 0-6). Alteplase was recommended for 23% of ischemic stroke patients. From 2013 to 2019, times from ED arrival to NIHSS, CT scan, imaging review, consult, and alteplase administration all decreased (p<0.05 for all), while times from consult start to alteplase recommendation and bolus increased (p<0.01 for both). Transfer was recommended for 8% of ischemic stroke patients. Number of patients treated with alteplase per hospital increased with increasing number of consults and hospital size and was also associated with US region in unadjusted and adjusted analyses. Longer duration of hospital participation in the network was associated with shorter hospital median door-to-needle time for alteplase delivery (39 min shorter per year, p=0.04). CONCLUSIONS Among spoke sites using a commercial telestroke platform over a seven-year time horizon, times to consult start and alteplase bolus decreased over time. Similar to academic networks, duration of telestroke participation in this commercial network was associated with faster alteplase delivery, suggesting practice improves performance.
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Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States.
| | - Richa Sharma
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Yulun Wang
- TelaDoc Health, Harrison, NY, United States
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, MA, United States
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
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132
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Haight T, Tabaac B, Patrice KA, Phipps MS, Butler J, Johnson B, Aycock A, Toral L, Yarbrough KL, Schrier C, Lawrence E, Goldszmidt A, Marsh EB, Urrutia VC. The Maryland Acute Stroke Emergency Medical Services Routing Pilot: Expediting Access to Thrombectomy for Stroke. Front Neurol 2021; 12:663472. [PMID: 34539541 PMCID: PMC8445030 DOI: 10.3389/fneur.2021.663472] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 08/06/2021] [Indexed: 12/24/2022] Open
Abstract
Background: Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke caused by large vessel occlusion, but is not available at all stroke centers. Transfers between hospitals lead to treatment delays. Transport directly to a facility capable of MT based on a prehospital stroke severity scale score has been recommended, if transportation time is less than 30 min. Aims: We hypothesized that an Emergency Medical Services (EMS) routing algorithm for stroke, using the Los Angeles Motor Scale (LAMS) in the field, would improve time from last known well to MT, without causing patients to miss the IV Thrombolysis (IVT) window. Methods: An EMS algorithm in the Baltimore metro area using the LAMS was implemented. Patients suspected of having an acute stroke were assessed by EMS using the LAMS. Patients scoring 4 or higher and within 20 h from last known well, were transported directly to a Thrombectomy Center, if transport could be completed within 30 min. The algorithm was evaluated retrospectively with prospectively collected data at the Thrombectomy Centers. The primary outcome variables were proportion of patients with suspected stroke rerouted by EMS, proportion of rerouted ischemic stroke patients receiving MT, time to treatment, and whether the IVT window was missed. Results: A total of 303 patients were rerouted out of 2459 suspected stroke patients over a period of 6 months. Of diverted patients, 47% had acute ischemic stroke. Of these, 48% received an acute stroke treatment: 16.8% IVT, 17.5% MT, and 14% MT+IVT. Thrombectomy occurred 119 min earlier in diverted patients compared to patients transferred from other hospitals (P = 0.006). 55.3% of diverted patients undergoing MT and 38.2% of patients transferred from hospital to hospital were independent at 90 days (modified Rankin score 0–2) (P = 0.148). No patient missed the time window for IVT due to the extra travel time. Conclusions: In this retrospective analysis of prospectively acquired data, implementation of a pre-hospital clinical screening score to detect patients with suspected acute ischemic stroke due to large vessel occlusion was feasible. Rerouting patients directly to a Thrombectomy Center, based on the EMS algorithm, led to a shorter time to thrombectomy.
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Affiliation(s)
- Taylor Haight
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Burton Tabaac
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kelly-Ann Patrice
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Michael S Phipps
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Jaime Butler
- The Johns Hopkins Hospital, Baltimore, MD, United States
| | - Brenda Johnson
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,The Johns Hopkins Hospital, Baltimore, MD, United States
| | - Anna Aycock
- Maryland Institute for Emergency Medical Services System (MIEMSS), Baltimore, MD, United States
| | - Linda Toral
- Sinai Hospital, Baltimore, MD, United States
| | | | - Chad Schrier
- University of Maryland Medical Center, Baltimore, MD, United States
| | - Erin Lawrence
- Johns Hopkins Bayview Medical Center, Baltimore, MD, United States
| | | | - Elisabeth B Marsh
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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133
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van Meenen LCC, Riedijk F, Stolp J, van der Veen B, Halkes PHA, van der Ree TC, Majoie CBLM, Roos YBWEM, Smeekes MD, Coutinho JM. Pre- and Interhospital Workflow Times for Patients With Large Vessel Occlusion Stroke Transferred for Endovasvular Thrombectomy. Front Neurol 2021; 12:730250. [PMID: 34512538 PMCID: PMC8428365 DOI: 10.3389/fneur.2021.730250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/06/2021] [Indexed: 01/01/2023] Open
Abstract
Background: Patients with large vessel occlusion (LVO) stroke are often initially admitted to a primary stroke center (PSC) and subsequently transferred to a comprehensive stroke center (CSC) for endovascular thrombectomy (EVT). This interhospital transfer delays initiation of EVT. To identify potential workflow improvements, we analyzed pre- and interhospital time metrics for patients with LVO stroke who were transferred from a PSC for EVT. Methods: We used data from the regional emergency medical services and our EVT registry. We included patients with LVO stroke who were transferred from three nearby PSCs for EVT (2014–2021). The time interval between first alarm and arrival at the CSC (call-to-CSC time) and other time metrics were calculated. We analyzed associations between various clinical and workflow-related factors and call-to-CSC time, using multivariable linear regression. Results: We included 198 patients with LVO stroke. Mean age was 70 years (±14.9), median baseline NIHSS was 14 (IQR: 9–18), 136/198 (69%) were treated with intravenous thrombolysis, and 135/198 (68%) underwent EVT. Median call-to-CSC time was 162 min (IQR: 137–190). In 133/155 (86%) cases, the ambulance for transfer to the CSC was dispatched with the highest level of urgency. This was associated with shorter call-to-CSC time (adjusted β [95% CI]: −27.6 min [−51.2 to −3.9]). No clinical characteristics were associated with call-to-CSC time. Conclusion: In patients transferred from a PSC for EVT, median call-to-CSC time was over 2.5 h. The highest level of urgency for dispatch of ambulances for EVT transfers should be used, as this clearly decreases time to treatment.
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Affiliation(s)
- Laura C C van Meenen
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Frank Riedijk
- Emergency Medical Services North-Holland North, Alkmaar, Netherlands
| | - Jeffrey Stolp
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Bas van der Veen
- Department of Neurology, Noordwest Ziekenhuisgroep, Alkmaar, Netherlands
| | | | | | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Martin D Smeekes
- Emergency Medical Services North-Holland North, Alkmaar, Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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134
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Zachrison KS, Richard JV, Wilcock A, Zubizaretta JR, Schwamm LH, Uscher-Pines L, Mehrotra A. Association of Hospital Telestroke Adoption With Changes in Initial Hospital Presentation and Transfers Among Patients With Stroke and Transient Ischemic Attacks. JAMA Netw Open 2021; 4:e2126612. [PMID: 34554236 PMCID: PMC8461501 DOI: 10.1001/jamanetworkopen.2021.26612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
IMPORTANCE It has been proposed that the implementation of telestroke services (a web-based approach to using video telecommunication to treat patients with stroke before hospital admission) changes where patients with stroke symptoms receive care, but this proposal has not been rigorously assessed. OBJECTIVE To assess whether the implementation of telestroke services is associated with changes in where and how patients initially present with stroke symptoms, in their decision to be transferred to another hospital, and which hospitals they are transferred to. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study compared changes in stroke systems of care between a sample of 593 US hospitals that adopted telestroke during the period from 2009 to 2016 but were not comprehensive stroke centers, major teaching hospitals, or thrombectomy-capable hospitals vs 593 matched control hospitals without telestroke based on rural location, critical access hospital status, bed size, primary stroke center status, presence of hospital alternatives in the community, hospital stroke volume, census region, and ownership. With the use of data on 100% of Medicare fee-for-service beneficiaries, all stroke and transient ischemic attack admissions from 2008 to 2018 were identified. EXPOSURES For each hospital pair (telestroke plus matched control), the telestroke hospital's implementation date and difference-in-differences approach were used to quantify the association between telestroke implementation and changes in care from 2 years before implementation to 2 years after implementation. Models also controlled for differences in observed patient characteristics. MAIN OUTCOMES AND MEASURES Hospital stroke volume, patients' ambulance transport distance to initial hospital, hospital case mix, interhospital transfer proportion, and size of the receiving hospital for transferred patients. RESULTS Of the 669 telestroke hospitals and 2143 potential control hospitals, 593 hospital pairs were matched; in each category, 261 hospitals (44.0%) were located in a rural area, 179 (30.2%) were primary stroke centers, and 130 (21.9%) were critical access hospitals. The changes in the preimplementation to postimplementation period were similar at telestroke and control hospitals in mean annual stroke volume (telestroke hospitals, decreased from 79.6 to 76.3 patients; control hospitals, decreased from 78.8 to 75.5 patients [-3.3 patients per year for both; difference-in-differences, 0.009; P ≥ .99]). Similarly, no differences were seen in ambulance transport distance, case mix, interhospital transfers, or bed size of receiving hospitals among transferred patients. CONCLUSIONS AND RELEVANCE This study suggests that, across a national sample of hospitals implementing telestroke, no association between telestroke adoption and changes in stroke systems of care were found.
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Affiliation(s)
- Kori S. Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | - Jessica V. Richard
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Andrew Wilcock
- Department of Family Medicine, University of Vermont College of Medicine, Burlington
| | - Jose R. Zubizaretta
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston
| | | | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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135
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Adapting Clinical Practice of Thrombolysis for Acute Ischemic Stroke Beyond 4.5 Hours: A Review of the Literature. J Stroke Cerebrovasc Dis 2021; 30:106059. [PMID: 34464927 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/23/2021] [Accepted: 08/11/2021] [Indexed: 12/16/2022] Open
Abstract
Several clinical trials have demonstrated that advanced neuroimaging can select patients for recanalization therapy in an extended time window. The favorable functional outcomes and safety profile of these studies have led to the incorporation of neuroimaging in endovascular treatment guidelines, and most recently, also extended to decision making on thrombolysis. Two randomized clinical trials have demonstrated that patients who are not amenable to endovascular thrombectomy within 4.5 hours from symptoms discovery or beyond 4.5 hours from the last-known-well time may also be safely treated with intravenous thrombolysis and have a clinical benefit above the risk of safety concerns. With the growing aging population, increased stroke incidence in the young, and the impact of evolving medical practice, healthcare and stroke systems of care need to adapt continuously to provide evidence-based care efficiently. Therefore, understanding and incorporating appropriate screening strategies is critical for the prompt recognition of potentially eligible patients for extended-window intravenous thrombolysis. Here we review the clinical trial evidence for thrombolysis for acute ischemic stroke in the extended time window and provide a review of new enrolling clinical trials that include thrombolysis intervention beyond the 4.5 hour window.
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Ifejika NL, Wiegand J, Harbold H, Botello AA, Babalola BA, Venkatachalam AM, Novakovic R, Cannell MB. The "Network Effect" on Interfacility Transfers Among Regional Stroke Certified Hospitals. J Stroke Cerebrovasc Dis 2021; 30:106056. [PMID: 34450478 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/09/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION AND PURPOSE Timely inter-facility transfer of thrombectomy-eligible patients is a mainstay of Stroke Systems of Care. We investigated transfer patterns among stroke certified hospitals in the Dallas-Fort Worth (DFW) Metroplex (19 counties, 9,286 sq mi, > 7.7 million people), by hospital network and stroke center status. METHODS We conducted a North Central Texas Trauma Regional Advisory Council (NCTTRAC) Stroke Regional Care Survey at all 44 centers involved in the treatment of MT-eligible ischemic stroke patients between June-September 2019, with a response rate of 100%. All hospitals identified network status, stroke designation - Acute Stroke Ready Hospital (ASRH), Primary Stroke Center (PSC), Comprehensive Stroke Center (CSC) - and geographic location. Stroke Assessment and Large Vessel Occlusion (LVO) screening tool use was evaluated. The distance between the sending and receiving facility was calculated using GPS coordinates. If the closest CSC was not used, the average distance between the selected and the closest CSC was geospatially mapped via R statistical analysis software (Vienna, Austria) gmapsdistance package. RESULTS Of the 44 facilities, 6 were ASRHs, 27 were PSCs, 11 were CSCs. Seventy-seven percent (n=34) belonged to one of four hospital networks. All facilities used stroke assessment tools; 57% completed LVO screening. There was significant heterogeneity in inter-facility transfer patterns with no regional standardization. Seventeen percent of ASRHs (n=1) and 56% of PSCs (n=15) conducted inter-facility transfers using ground transportation via EMS. Sixty percent of non-network facilities transferred to the closest CSC. Of the remaining 40%, the average distance between the closest and the selected CSC was 1.5 miles (min max 0.2-2.9 miles). Seventeen percent of network facilities transferred to the closest CSC. Among the remaining 83%, the average distance between the closest and the selected CSC was 4.1 miles (min-max 1-8 miles). CONCLUSIONS Non-network facility status increased the likelihood of transfer to the closest Comprehensive Stroke Center. Transfer distance variability among network facilities may contribute to delays in reperfusion therapy.
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Affiliation(s)
- Nneka L Ifejika
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9055, United States; Department of Neurology, UT Southwestern Medical Center, Dallas, TX, United States; Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, United States.
| | - Jared Wiegand
- University of Texas Health Science Center at Houston School of Public Health, Dallas, TX, United States.
| | - Hunter Harbold
- Parker County Hospital District, Weatherford, TX, United States.
| | - Adrian A Botello
- North Central Texas Trauma Regional Advisory Council, Arlington, TX, United States.
| | - Babatunde A Babalola
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9055, United States.
| | | | - Roberta Novakovic
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, United States; Department of Radiology, UT Southwestern Medical Center, Dallas, TX, United States.
| | - Michael B Cannell
- University of Texas Health Science Center at Houston School of Public Health, Dallas, TX, United States; Department of Internal Medicine, Division of Geriatric Medicine, UT Southwestern Medical Center, Dallas, TX, United States.
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Alexandrov AW, Arthur AS, Bryndziar T, Swatzell VM, Dusenbury W, Hardage K, McCormick S, Rhudy JP, Maleki AHZ, Singh S, Krishnaiah B, Nearing K, Rubin MN, Malkoff MD, McKendry C, Metter EJ, Alexandrov AV. High-resolution CT with arch/neck/head CT angiography on a mobile stroke unit. J Neurointerv Surg 2021; 14:623-627. [PMID: 34433646 DOI: 10.1136/neurintsurg-2021-017697] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 07/06/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Mobile stroke units (MSUs) performance dependability and diagnostic yield of 16-slice, ultra-fast CT with auto-injection angiography (CTA) of the aortic arch/neck/circle of Willis has not been previously reported. METHODS We performed a prospective observational study of the first-of-its kind MSU equipped with high resolution, 16-slice CT with multiphasic CTA. Field CT/CTA was performed on all suspected stroke patients regardless of symptom severity or resolution. Performance dependability, efficiency and diagnostic yield over 365 days was quantified. RESULTS 1031 MSU emergency activations occurred; of these, 629 (61%) were disregarded with unrelated diagnoses, and 402 patients transported: 245 (61%) ischemic or hemorrhagic stroke, 17 (4%) transient ischemic attack, 140 (35%) other neurologic emergencies. Total time from non-contrast CT/CTA start to images ready for viewing was 4.0 (IQR 3.5-4.5) min. Hemorrhagic stroke totaled 24 (10%): aneurysmal subarachnoid hemorrhage 3, hemorrhagic infarct 1, and 20 intraparenchymal hemorrhages (median intracerebral hemorrhage score was 2 (IQR 1-3), 4 (20%) spot sign positive). In 221 patients with ischemic stroke, 73 (33%) received alteplase with 31.5% treated within 60 min of onset. CTA revealed large vessel occlusion in 66 patients (30%) of which 9 (14%) were extracranial; 27 (41%) underwent thrombectomy with onset to puncture time averaging 141±90 min (median 112 (IQR 90-139) min) with full emergency department (ED) bypass. No imaging needed to be repeated for image quality; all patients were triaged correctly with no inter-hospital transfer required. CONCLUSIONS MSU use of advanced imaging including multiphasic head/neck CTA is feasible, offers high LVO yield and enables full ED bypass.
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Affiliation(s)
| | - Adam S Arthur
- Neurosurgery, UTHSC COM, Memphis, Tennessee, USA.,Vascular Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
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Elijovich L, Dornbos Iii D, Nickele C, Alexandrov A, Inoa-Acosta V, Arthur AS, Hoit D. Automated emergent large vessel occlusion detection by artificial intelligence improves stroke workflow in a hub and spoke stroke system of care. J Neurointerv Surg 2021; 14:704-708. [PMID: 34417344 DOI: 10.1136/neurintsurg-2021-017714] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/17/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Emergent large vessel occlusion (ELVO) acute ischemic stroke is a time-sensitive disease. OBJECTIVE To describe our experience with artificial intelligence (AI) for automated ELVO detection and its impact on stroke workflow. METHODS We conducted a retrospective chart review of code stroke cases in which VizAI was used for automated ELVO detection. Patients with ELVO identified by VizAI were compared with patients with ELVO identified by usual care. Details of treatment, CT angiography (CTA) interpretation by blinded neuroradiologists, and stroke workflow metrics were collected. Univariate statistical comparisons and linear regression analysis were performed to quantify time savings for stroke metrics. RESULTS Six hundred and eighty consecutive code strokes were evaluated by AI; 104 patients were diagnosed with ELVO during the study period. Forty-five patients with ELVO were identified by AI and 59 by usual care. Sixty-nine mechanical thrombectomies were performed.Median time from CTA to team notification was shorter for AI ELVOs (7 vs 26 min; p<0.001). Door to arterial puncture was faster for transfer patients with ELVO detected by AI versus usual care transfer patients (141 vs 185 min; p=0.027). AI yielded a time savings of 22 min for team notification and a 23 min reduction in door to arterial puncture for transfer patients. CONCLUSIONS AI automated alerts can be incorporated into a comprehensive stroke center hub and spoke system of care. The use of AI to detect ELVO improves clinically meaningful stroke workflow metrics, resulting in faster treatment times for mechanical thrombectomy.
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Affiliation(s)
- Lucas Elijovich
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN, USA .,Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - David Dornbos Iii
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Christopher Nickele
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Andrei Alexandrov
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Violiza Inoa-Acosta
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN, USA.,Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Daniel Hoit
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Sciences Center, Memphis, TN, USA
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Araki H, Uchida K, Yoshimura S, Kurisu K, Shime N, Sakamoto S, Aoki S, Ichinose N, Kajihara Y, Tominaga A, Naka H, Mizoue T, Sumida M, Hirotsune N, Nomura E, Matsushige T, Kanazawa J, Kato Y, Kawamoto Y, Kuroki K, Morimoto T. Effect of region-wide use of prehospital stroke triage scale on management of patients with acute stroke. J Neurointerv Surg 2021; 14:677-682. [PMID: 34413244 PMCID: PMC9209665 DOI: 10.1136/neurintsurg-2021-017863] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/03/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Prehospital stroke triage scales help with the decision to transport patients with suspected stroke to suitable hospitals. OBJECTIVE To explore the effect of the region-wide use of the Japan Urgent Stroke Triage (JUST) score, which can predict several types of stroke: large vessel occlusion (LVO), intracranial hemorrhage (ICH), subarachnoid hemorrhage (SAH), and cerebral infarction other than LVO (CI). METHODS We implemented the JUST score and conducted a retrospective and prospective multicenter cohort study at 13 centers in Hiroshima from April 1, 2018, to March 31, 2020. We investigated the success rate of the first request to the hospital, on-scene time, and transport time to hospital. We evaluated the door-to-puncture time, puncture-to-reperfusion time, and 90-day outcome among patients with final diagnoses of LVO. RESULTS The cohort included 5141 patients (2735 before and 2406 after JUST score implementation). Before JUST score implementation, 1269 strokes (46.4%) occurred, including 140 LVO (5.1%), 394 ICH (14.4%), 120 SAH (4.4%), and 615 CI (22.5%). The JUST score was used in 1484 (61.7%) of the 2406 patients after implementation, which included 1267 (52.7%) cases of stroke (186 LVO (7.7%), 405 ICH (16.8%), 109 SAH (4.5%), and 567 CI (23.6%)). Success rate of the first request to the hospital significantly increased after JUST score implementation (76.3% vs 79.7%, p=0.004). JUST score implementation significantly shortened the door-to-puncture time (84 vs 73 min, p=0.03), but the prognosis remained unaltered among patients with acute LVO. CONCLUSIONS Use of prehospital stroke triage scales improved prehospital management and preparation time of intervention among patients with acute stroke.
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Affiliation(s)
- Hayato Araki
- Department of Neurosurgery, Araki Neurosurgical Hospital, Hiroshima, Japan.,Department of Neurosurgery, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.,Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kaoru Kurisu
- Department of Neurosurgery, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Shigeyuki Sakamoto
- Department of Neurosurgery, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Shiro Aoki
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | | | - Yosuke Kajihara
- Department of Neurosurgery, Itsukaichi Memorial Hospital, Hiroshima, Japan
| | - Atsushi Tominaga
- Department of Neurosurgery and Neuroendovascular Therapy, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Hiromitsu Naka
- Department of Neurology, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Tatsuya Mizoue
- Department of Neurosurgery, Suiseikai Kajikawa Hospital, Hiroshima, Japan
| | - Masayuki Sumida
- Department of Neurosurgery, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Nobuyuki Hirotsune
- Department of Neurological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Eiichi Nomura
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Toshinori Matsushige
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | | | - Yukio Kato
- Department of Neurosurgery, Saiseikai Hiroshima Hospital, Aki-gun, Japan
| | | | - Kazuhiko Kuroki
- Department of Neurosurgery, JA Hiroshima General Hospital, Hatsukaichi, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
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Cruz MJ, Nieblas-Bedolla E, Young CC, Feroze AH, Williams JR, Ellenbogen RG, Levitt MR. United States Medicolegal Progress and Innovation in Telemedicine in the Age of COVID-19: A Primer for Neurosurgeons. Neurosurgery 2021; 89:364-371. [PMID: 34133724 PMCID: PMC8344865 DOI: 10.1093/neuros/nyab185] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 04/03/2021] [Indexed: 01/14/2023] Open
Abstract
Telemedicine has received increased attention in recent years as a potential solution to expand clinical capability and patient access to care in many fields, including neurosurgery. Although patient and physician attitudes are rapidly shifting toward greater telemedicine use in light of the COVID-19 pandemic, there remains uncertainty about telemedicine's regulatory future. Despite growing evidence of telemedicine's utility, there remain a number of significant medicolegal barriers to its mass adoption and wider implementation. Herein, we examine recent progress in state and federal regulations in the United States governing telemedicine's implementation in quality of care, finance and billing, privacy and confidentiality, risk and liability, and geography and interstate licensure, with special attention to how these concern teleneurosurgical practice. We also review contemporary topics germane to the future of teleneurosurgery, including the continued expansion of reciprocity in interstate licensure, expanded coverage for homecare services for chronic conditions, expansion of Center for Medicare and Medicaid Services reimbursements, and protections of store-and-forward technologies. Additionally, we discuss recent successes in teleneurosurgery, stroke care, and rehabilitation as models for teleneurosurgical best practices. As telemedicine technology continues to mature and its expanse grows, neurosurgeons' familiarity with its benefits, limitations, and controversies will best allow for its successful adoption in our field to maximize patient care and outcomes.
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Affiliation(s)
- Michael J Cruz
- School of Medicine, University of Washington, Seattle, Washington, USA
| | | | - Christopher C Young
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Abdullah H Feroze
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - John R Williams
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Richard G Ellenbogen
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Stroke and Applied Neurosciences Center, University of Washington, Seattle, Washington, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Stroke and Applied Neurosciences Center, University of Washington, Seattle, Washington, USA
- Department of Radiology, University of Washington, Seattle, Washington, USA
- Department of Mechanical Engineering, University of Washington, Seattle, Washington, USA
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Noser EA, Zhang J, Rahbar MH, Sharrief AZ, Barreto AD, Shaw S, Grotta JC, Savitz SI, Ifejika NL. Leveraging Multimedia Patient Engagement to Address Minority Cerebrovascular Health Needs: Prospective Observational Study. J Med Internet Res 2021; 23:e28748. [PMID: 34397385 PMCID: PMC8398745 DOI: 10.2196/28748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/12/2021] [Accepted: 06/15/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Social inequities affecting minority populations after Hurricane Katrina led to an expansion of environmental justice literature. In August 2017, Hurricane Harvey rainfall was estimated as a 3000- to 20,000-year flood event, further affecting minority populations with disproportionate stroke prevalence. The Stomp Out Stroke initiative leveraged multimedia engagement, creating a patient-centered cerebrovascular health intervention. OBJECTIVE This study aims to address social inequities in cerebrovascular health through the identification of race- or ethnicity-specific health needs and the provision of in-person stroke prevention screening during two community events (May 2018 and May 2019). METHODS Stomp Out Stroke recruitment took place through internet-based channels (websites and social networking). Exclusively through web registration, Stomp Out Stroke participants (aged >18 years) detailed sociodemographic characteristics, family history of stroke, and stroke survivorship. Participant health interests were compared by race or ethnicity using Kruskal-Wallis or chi-square test at an α=.05. A Bonferroni-corrected P value of .0083 was used for multiple comparisons. RESULTS Stomp Out Stroke registrants (N=1401) were 70% (973/1390) female (median age 45 years) and largely self-identified as members of minority groups: 32.05% (449/1401) Hispanic, 25.62% (359/1401) African American, 13.63% (191/1401) Asian compared with 23.63% (331/1401) non-Hispanic White. Stroke survivors comprised 11.55% (155/1401) of our population. A total of 124 stroke caregivers participated. Approximately 36.81% (493/1339) of participants had a family history of stroke. African American participants were most likely to have Medicare or Medicaid insurance (84/341, 24.6%), whereas Hispanic participants were most likely to be uninsured (127/435, 29.2%). Hispanic participants were more likely than non-Hispanic White participants to obtain health screenings (282/449, 62.8% vs 175/331, 52.9%; P=.03). Asian (105/191, 54.9%) and African American (201/359, 55.9%) participants were more likely to request stroke education than non-Hispanic White (138/331, 41.6%) or Hispanic participants (193/449, 42.9%). African American participants were more likely to seek overall health education than non-Hispanic White participants (166/359, 46.2% vs 108/331, 32.6%; P=.002). Non-Hispanic White participants (48/331, 14.5%) were less likely to speak to health care providers than African American (91/359, 25.3%) or Asian participants (54/191, 28.3%). During the 2018 and 2019 events, 2774 health screenings were completed across 12 hours, averaging four health screenings per minute. These included blood pressure (1031/2774, 37.16%), stroke risk assessment (496/2774, 17.88%), bone density (426/2774, 15.35%), carotid ultrasound (380/2774, 13.69%), BMI (182/2774, 6.56%), serum lipids (157/2774, 5.65%), and hemoglobin A1c (102/2774, 3.67%). Twenty multimedia placements using the Stomp Out Stroke webpage, social media, #stompoutstroke, television, iQ radio, and web-based news reached approximately 849,731 people in the Houston area. CONCLUSIONS Using a combination of internet-based recruitment, registration, and in-person assessments, Stomp Out Stroke identified race- or ethnicity-specific health care needs and provided appropriate screenings to minority populations at increased risk of urban flooding and stroke. This protocol can be replicated in Southern US Stroke Belt cities with similar flood risks.
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Affiliation(s)
- Elizabeth Anne Noser
- Institute for Stroke and Cerebrovascular Disease, UTHealth, Houston, TX, United States.,Department of Neurology, McGovern Medical School at UTHealth, Houston, TX, United States
| | - Jing Zhang
- Department of Internal Medicine, Division of Clinical & Translational Sciences, McGovern Medical School at UTHealth, Houston, TX, United States.,Department of Biostatistics and Data Science, UTHealth School of Public Health, Houston, TX, United States
| | - Mohammad Hossein Rahbar
- Institute for Stroke and Cerebrovascular Disease, UTHealth, Houston, TX, United States.,Department of Internal Medicine, Division of Clinical & Translational Sciences, McGovern Medical School at UTHealth, Houston, TX, United States
| | - Anjail Zarinah Sharrief
- Institute for Stroke and Cerebrovascular Disease, UTHealth, Houston, TX, United States.,Department of Neurology, McGovern Medical School at UTHealth, Houston, TX, United States
| | - Andrew David Barreto
- Institute for Stroke and Cerebrovascular Disease, UTHealth, Houston, TX, United States.,Department of Neurology, McGovern Medical School at UTHealth, Houston, TX, United States
| | - Sandi Shaw
- Mischer Neuroscience Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, TX, United States
| | - James Charles Grotta
- Stroke Research and Mobile Stroke Unit, Memorial Hermann Hospital - Texas Medical Center, Houston, TX, United States
| | - Sean Isaac Savitz
- Institute for Stroke and Cerebrovascular Disease, UTHealth, Houston, TX, United States.,Department of Neurology, McGovern Medical School at UTHealth, Houston, TX, United States
| | - Nneka Lotea Ifejika
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, Dallas, TX, United States.,Department of Neurology, UT Southwestern Medical Center, Dallas, TX, United States.,Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, United States
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Ifejika NL, Vahidy FS, Reeves M, Xian Y, Liang L, Matsouaka R, Fonarow GC, Grotta JC. Association Between 2010 Medicare Reform and Inpatient Rehabilitation Access in People With Intracerebral Hemorrhage. J Am Heart Assoc 2021; 10:e020528. [PMID: 34387132 PMCID: PMC8475024 DOI: 10.1161/jaha.120.020528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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 Evidence suggests intracerebral hemorrhage survivors have earlier recovery compared with ischemic stroke survivors. The Centers for Medicare and Medicaid Services prospective payment system instituted documentation rules for inpatient rehabilitation facilities (IRFs) in 2010, with the goal of optimizing patient selection. We investigated whether these requirements limited IRF and increased skilled nursing facility (SNF) use compared with home discharge. Methods and Results Intracerebral hemorrhage discharges to IRF, SNF, or home were estimated using GWTG (Get With The Guidelines) Stroke registry data between January 1, 2008, and December 31, 2015 (n=265 444). Binary hierarchical models determined associations between the 2010 Rule and discharge setting; subgroup analyses evaluated age, geographic region, and hospital type. From January 1, 2008, to December 31, 2009, 45.5% of patients with intracerebral hemorrhage had home discharge, 22.2% went to SNF, and 32.3% went to IRF. After January 1, 2010, there was a 1.06% absolute increase in home discharge, a 0.46% increase in SNF, and a 1.52% decline in IRF. The adjusted odds of IRF versus home discharge decreased 3% after 2010 (adjusted odds ratio [aOR], 0.97; 95% CI, 0.95–1.00). Lower odds of IRF versus home discharge were observed in people aged <65 years (aOR, 0.92; 95% CI, 0.89–0.96), Western states (aOR, 0.89; 95% CI, 0.84–0.95), and nonteaching hospitals (aOR, 0.90; 95% CI, 0.86–0.95). Adjusted odds of SNF versus home discharge increased 14% after 2010 (aOR, 1.14; 95% CI, 1.11–1.18); there were significant associations in all age groups, the Northeast, the South, the Midwest, and teaching hospitals. Conclusions The Centers for Medicare and Medicaid Services 2010 IRF prospective payment system Rule resulted in fewer discharges to IRF and more discharges to SNF in patients with intracerebral hemorrhage. Health policy changes potentially affect access to intensive postacute rehabilitation.
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Affiliation(s)
- Nneka L Ifejika
- Department of Physical Medicine and Rehabilitation UT Southwestern Medical Center Dallas TX.,Department of Neurology UT Southwestern Medical Center Dallas TX.,Department of Population and Data Sciences UT Southwestern Medical Center Dallas TX
| | - Farhaan S Vahidy
- Centers for Outcomes Research Houston Methodist Research Institute Houston TX
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics College of Human Medicine Michigan State University Lansing MI
| | - Ying Xian
- Department of Neurology Duke University Hospital Durham NC.,Duke Clinical Research Institute Durham NC
| | - Li Liang
- Duke Clinical Research Institute Durham NC
| | | | - Gregg C Fonarow
- Division of Cardiology Ahmanson-UCLA Cardiomyopathy CenterUniversity of CaliforniaLos Angeles, Medical Center Los Angeles CA
| | - James C Grotta
- Stroke Research and Mobile Stroke Unit Memorial Hermann Hospital-Texas Medical Center Houston TX
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143
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Pinho J, Quintas-Neves M, Dogan I, Reetz K, Reich A, Costa AS. Incident stroke in patients with Alzheimer's disease: systematic review and meta-analysis. Sci Rep 2021; 11:16385. [PMID: 34385535 PMCID: PMC8361108 DOI: 10.1038/s41598-021-95821-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 07/29/2021] [Indexed: 11/09/2022] Open
Abstract
Vascular mechanisms are increasingly recognized in the pathophysiology of Alzheimer's disease (AD), but less is known about the occurrence of stroke in AD patients. We aimed to quantify the risk of stroke in patients with AD and compare the incidence rates (IR) of stroke in individuals without AD. Systematic search of Embase and MEDLINE between 1970 and 2020. Inclusion criteria: reports with ≥ 50 patients with non-familial AD, which reported the occurrence of stroke (all types) and/or ischemic stroke and/or intracerebral hemorrhage (ICH) during follow-up. Meta-analyses of pooled data using random-effects model were performed. IR were calculated for each study. Incidence rate ratios (IRR) were calculated for studies presenting a control-group without AD. Among 5109 retrieved studies, 29 (0.6%) fulfilled the inclusion criteria, reporting a total of 61,824 AD patients. In AD patients the IR were 15.4/1000 person-years for stroke (all types), 13.0/1000 person-years for ischemic stroke and 3.4/1000 person-years for ICH. When compared to controls without AD, incidence rate for ICH in AD patients was significantly higher (IRR = 1.67, 95%CI 1.43-1.96), but similar for ischemic stroke. Incident stroke is not a rare event in AD population. AD is associated with an increased risk of intracerebral hemorrhage which warrants further clarification.
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Affiliation(s)
- João Pinho
- Department of Neurology, University Hospital RWTH Aachen, Pauwelsst. 30, 52074, Aachen, Germany.
| | - Miguel Quintas-Neves
- Neuroradiology Department, Hospital de Braga, Braga, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B´s-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Imis Dogan
- Department of Neurology, University Hospital RWTH Aachen, Pauwelsst. 30, 52074, Aachen, Germany.,JARA Institute Molecular Neuroscience and Neuroimaging, Juelich Research Center GmbH and RWTH Aachen University, Aachen, Germany
| | - Kathrin Reetz
- Department of Neurology, University Hospital RWTH Aachen, Pauwelsst. 30, 52074, Aachen, Germany.,JARA Institute Molecular Neuroscience and Neuroimaging, Juelich Research Center GmbH and RWTH Aachen University, Aachen, Germany
| | - Arno Reich
- Department of Neurology, University Hospital RWTH Aachen, Pauwelsst. 30, 52074, Aachen, Germany
| | - Ana Sofia Costa
- Department of Neurology, University Hospital RWTH Aachen, Pauwelsst. 30, 52074, Aachen, Germany.,JARA Institute Molecular Neuroscience and Neuroimaging, Juelich Research Center GmbH and RWTH Aachen University, Aachen, Germany
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Between-hospital variability in organ donation after resuscitation from out-of-hospital cardiac arrest. Resuscitation 2021; 167:372-379. [PMID: 34363855 DOI: 10.1016/j.resuscitation.2021.07.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 07/15/2021] [Accepted: 07/22/2021] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Survival and recovery after out-of-hospital cardiac arrest (OHCA) varies between hospitals, with better outcomes associated with high-volume and specialty care. We evaluated if there is a similar relationship with organ donation after OHCA. METHODS We studied a cohort of adults resuscitated from OHCA from 2010 to 2018, treated at one of 112 hospitals served by a regional organ procurement organization (OPO). We obtained hospital-level characteristics from Centers for Medicare and Medicaid Services and Health Resources and Services Administration and obtained patients' clinical information from the OPO health record. We excluded patients with no potential to donate on initial referral. Our primary exposure was treatment at a high-volume hospital (defined >500 eligible cases during the study period) and our primary outcomes were suitability to donate after full medical evaluation, successful organ procurement and organ transplantation. We used mixed effects models to quantify between-hospital variability in the primary outcomes RESULTS: Overall, 9,792 patients were included and 796 (8%) were organ donors. We identified significant between-hospital variation in odds of donation (median odds ratio 1.64 [95% CI 1.42 - 2.02]). Hospital volume explained the greatest proportion of variability. High volume centers had a higher proportion of referrals with potential to donate (16.9 vs 12.2%), actual donation (10.3 vs 6.2%), and successful transplantation (9.4 vs 5.7%). Overall, 2032/7763 (26%) of recovered transplantable organs in this region were procured from OHCA patients. CONCLUSION High volume centers are more likely to refer and procure transplantable organs from patients with non-survivable OHCA.
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Psioda MA, Jones SB, Xenakis JG, D’Agostino RB. Methodological Challenges and Statistical Approaches in the COMprehensive Post-Acute Stroke Services Study. Med Care 2021; 59:S355-S363. [PMID: 34228017 PMCID: PMC8263146 DOI: 10.1097/mlr.0000000000001580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The COMprehensive Post-Acute Stroke Services study was a cluster-randomized pragmatic trial designed to evaluate a comprehensive care transitions model versus usual care. The data collected during this trial were complex and analysis methodology was required that could simultaneously account for the cluster-randomized design, missing patient-level covariates, outcome nonresponse, and substantial nonadherence to the intervention. OBJECTIVE The objective of this study was to discuss an array of complementary statistical methods to evaluate treatment effectiveness that appropriately addressed the challenges presented by the complex data arising from this pragmatic trial. METHODS We utilized multiple imputation combined with inverse probability weighting to account for missing covariate and outcome data in the estimation of intention-to-treat effects (ITT). The ITT estimand reflects the effectiveness of assignment to the COMprehensive Post-Acute Stroke Services intervention compared with usual care (ie, it does not take into account intervention adherence). Per-protocol analyses provide complementary information about the effect of treatment, and therefore are relevant for patients to inform their decision-making. We describe estimation of the complier average causal effect using an instrumental variables approach through 2-stage least squares estimation. For all preplanned analyses, we also discuss additional sensitivity analyses. DISCUSSION Pragmatic trials are well suited to inform clinical practice. Care should be taken to proactively identify the appropriate balance between control and pragmatism in trial design. Valid estimation of ITT and per-protocol effects in the presence of complex data requires application of appropriate statistical methods and concerted efforts to ensure high-quality data are collected.
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Affiliation(s)
- Matthew A. Psioda
- Department of Biostatistics, Collaborative Studies Coordinating Center
| | - Sara B. Jones
- Department of Epidemiology, Gillings School of Global Public Health
| | - James G. Xenakis
- Department of Genetics, University of North Carolina, Chapel Hill
| | - Ralph B. D’Agostino
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
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Gesell SB, Prvu Bettger J, Lawrence RH, Li J, Hoffman J, Lutz BJ, Grudzen C, Johnson AM, Krishnan JA, Hsu LL, Zwart D, Williams MV, Schnipper JL. Implementation of Complex Interventions: Lessons Learned From the Patient-Centered Outcomes Research Institute Transitional Care Portfolio. Med Care 2021; 59:S344-S354. [PMID: 34228016 PMCID: PMC8263141 DOI: 10.1097/mlr.0000000000001591] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite the well-documented risks to patient safety associated with transitions from one care setting to another, health care organizations struggle to identify which interventions to implement. Multiple strategies are often needed, and studying the effectiveness of these complex interventions is challenging. OBJECTIVE The objective of this study was to present lessons learned in implementing and evaluating complex transitional care interventions in routine clinical care. RESEARCH DESIGN Nine transitional care study teams share important common lessons in designing complex interventions with stakeholder engagement, implementation, and evaluation under pragmatic conditions (ie, using only existing resources), and disseminating findings in outlets that reach policy makers and the people who could ultimately benefit from the research. RESULTS Lessons learned serve as a guide for future studies in 3 areas: (1) Delineating the function (intended purpose) versus form (prespecified modes of delivery of the intervention); (2) Evaluating both the processes supporting implementation and the impact of adaptations; and (3) Engaging stakeholders in the design and delivery of the intervention and dissemination of study results. CONCLUSION These lessons can help guide future pragmatic studies of care transitions.
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Affiliation(s)
- Sabina B. Gesell
- Department of Social Sciences and Health Policy
- Department of Implementation Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem
| | - Janet Prvu Bettger
- Duke University School of Medicine, Duke Roybal Center on Aging, Durham, NC
| | - Raymona H. Lawrence
- Department Health Policy and Community Health, Jiann Ping Hsu College of Public Health, Georgia Southern University, Statesboro, GA
| | - Jing Li
- Department of Internal Medicine, Center for Health Services Research (CHSR), University of Kentucky, Lexington, KY
| | - Jeanne Hoffman
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA
| | - Barbara J. Lutz
- School of Nursing, University of North Carolina-Wilmington, Wilmington, NC
| | - Corita Grudzen
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY
| | - Anna M. Johnson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jerry A. Krishnan
- Institute for Healthcare Delivery Design, Office of the Vice Chancellor for Health Affairs
| | - Lewis L. Hsu
- Department of Pediatrics, University of Illinois at Chicago, Chicago, IL
| | - Dorien Zwart
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Mark V. Williams
- Department of Internal Medicine, Center for Health Services Research, University of Kentucky HealthCare, Lexington, KY
| | - Jeffrey L. Schnipper
- Brigham Health Hospital Medicine Unit and Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
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Ganesh A, Ospel JM, Marko M, van Zwam WH, Roos YBWEM, Majoie CBLM, Goyal M. From Three-Months to Five-Years: Sustaining Long-Term Benefits of Endovascular Therapy for Ischemic Stroke. Front Neurol 2021; 12:713738. [PMID: 34381418 PMCID: PMC8350336 DOI: 10.3389/fneur.2021.713738] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/28/2021] [Indexed: 11/28/2022] Open
Abstract
Background and Purpose: During the months and years post-stroke, treatment benefits from endovascular therapy (EVT) may be magnified by disability-related differences in morbidity/mortality or may be eroded by recurrent strokes and non-stroke-related disability/mortality. Understanding the extent to which EVT benefits may be sustained at 5 years, and the factors influencing this outcome, may help us better promote the sustenance of EVT benefits until 5 years post-stroke and beyond. Methods: In this review, undertaken 5 years after EVT became the standard of care, we searched PubMed and EMBASE to examine the current state of the literature on 5-year post-stroke outcomes, with particular attention to modifiable factors that influence outcomes between 3 months and 5 years post-EVT. Results: Prospective cohorts and follow-up data from EVT trials indicate that 3-month EVT benefits will likely translate into lower 5-year disability, mortality, institutionalization, and care costs and higher quality of life. However, these group-level data by no means guarantee maintenance of 3-month benefits for individual patients. We identify factors and associated “action items” for stroke teams/systems at three specific levels (medical care, individual psychosocioeconomic, and larger societal/environmental levels) that influence the long-term EVT outcome of a patient. Medical action items include optimizing stroke rehabilitation, clinical follow-up, secondary stroke prevention, infection prevention/control, and post-stroke depression care. Psychosocioeconomic aspects include addressing access to primary care, specialist clinics, and rehabilitation; affordability of healthy lifestyle choices and preventative therapies; and optimization of family/social support and return-to-work options. High-level societal efforts include improving accessibility of public/private spaces and transportation, empowering/engaging persons with disability in society, and investing in treatments/technologies to mitigate consequences of post-stroke disability. Conclusions: In the longtime horizon from 3 months to 5 years, several factors in the medical and societal spheres could negate EVT benefits. However, many factors can be leveraged to preserve or magnify treatment benefits, with opportunities to share responsibility with widening circles of care around the patient.
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Affiliation(s)
- Aravind Ganesh
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | | | - Martha Marko
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Wim H van Zwam
- Department of Radiology, Maastricht University Medical Centre, Maastricht, Netherlands
| | | | | | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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148
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Corrias G, Mazzotta A, Melis M, Cademartiri F, Yang Q, Suri JS, Saba L. Emerging role of artificial intelligence in stroke imaging. Expert Rev Neurother 2021; 21:745-754. [PMID: 34282975 DOI: 10.1080/14737175.2021.1951234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: The recognition and therapy of patients with stroke is becoming progressively intricate as additional treatment choices become accessible and new associations between disease characteristics and treatment response are incessantly uncovered. Therefore, clinicians must regularly learn new skill, stay up to date with the literature and integrate advances into daily practice. The application of artificial intelligence (AI) to assist clinical decision making could diminish inter-rater variation in routine clinical practice and accelerate the mining of vital data that could expand recognition of patients with stroke, forecast of treatment responses and patient outcomes.Areas covered: In this review, the authors provide an up-to-date review of AI in stroke, analyzing the latest papers on this subject. These have been divided in two main groups: stroke diagnosis and outcome prediction.Expert opinion: The highest value of AI is its capability to merge, select and condense a large amount of clinical and imaging features of a single patient and to associate these with fitted models that have gone through robust assessment and optimization with large cohorts of data to support clinical decision making.
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Affiliation(s)
- Giuseppe Corrias
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), Di Cagliari - Polo Di Monserrato, S.s. 554 Monserrato (Cagliari), Italy
| | - Andrea Mazzotta
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), Di Cagliari - Polo Di Monserrato, S.s. 554 Monserrato (Cagliari), Italy
| | - Marta Melis
- Department of Neurology, Azienda Ospedaliero Universitaria (A.O.U.), Di Cagliari - Cagliari, Italy
| | | | - Qi Yang
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jasjit S Suri
- Stroke Diagnosis and Monitoring Division, AtheroPoint™, Roseville, CA, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), Di Cagliari - Polo Di Monserrato, S.s. 554 Monserrato (Cagliari), Italy
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O' Donoghue M, Boland P, Leahy S, Galvin R, Hayes S. Exploring the perspectives of key stakeholders on the design and delivery of an intervention to rehabilitate people with cognitive deficits post-stroke. HRB Open Res 2021; 3:93. [PMID: 38385122 PMCID: PMC10879761 DOI: 10.12688/hrbopenres.13184.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 02/23/2024] Open
Abstract
Background: Stroke is a leading cause of death and disability worldwide. Cognitive impairment is common post-stroke and can result in negative sequalae such as a lower quality of life, increased carer burden and increased healthcare costs. Despite the prevalence and associated burden of post-stroke cognitive impairment, there is uncertainty regarding the optimum intervention to improve cognitive function post-stroke. By exploring the perspectives of people post-stroke, carers and healthcare professionals on cognitive impairment, this qualitative study aims to inform the design and development of an intervention to rehabilitate cognitive impairment post-stroke. Methods: A qualitative descriptive approach will be applied, using semi-structured interviews with people post-stroke, carers and healthcare professionals. People post-stroke will be recruited via gatekeepers from a local stroke support group and Headway, a brain injury support service. Carers will be recruited via a gatekeeper from a local carers branch. Healthcare professionals will be recruited via gatekeepers from relevant neurological sites and via Twitter. The final number of participants recruited will be guided by information power. Data will be collectively analysed and synthesised using thematic analysis. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines will be used to standardize the conduct and reporting of the research. Conclusions: It is anticipated that exploring the perspectives of people post-stroke, carers and healthcare professionals on cognitive impairment post-stroke will inform the development of an evidence-based optimal intervention to rehabilitate cognitive deficits post-stroke. This study was granted ethical approval from the Faculty of Education and Health Sciences Research Ethics Committee at the University of Limerick. Study findings will be disseminated locally through presentations at stroke support groups, as well as internationally through academic conferences and peer-reviewed journals.
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Affiliation(s)
- Mairéad O' Donoghue
- School of Allied Health, University of Limerick, Limerick, V94 X5K6, Ireland
- Health Research Institute, University of Limerick, Limerick, V94 T9PX, Ireland
- Ageing Research Centre, University of Limerick, Limerick, V94 X5K6, Ireland
| | - Pauline Boland
- School of Allied Health, University of Limerick, Limerick, V94 X5K6, Ireland
- Health Research Institute, University of Limerick, Limerick, V94 T9PX, Ireland
- Ageing Research Centre, University of Limerick, Limerick, V94 X5K6, Ireland
| | - Siobhan Leahy
- School of Allied Health, University of Limerick, Limerick, V94 X5K6, Ireland
- Health Research Institute, University of Limerick, Limerick, V94 T9PX, Ireland
- Ageing Research Centre, University of Limerick, Limerick, V94 X5K6, Ireland
| | - Rose Galvin
- School of Allied Health, University of Limerick, Limerick, V94 X5K6, Ireland
- Health Research Institute, University of Limerick, Limerick, V94 T9PX, Ireland
- Ageing Research Centre, University of Limerick, Limerick, V94 X5K6, Ireland
| | - Sara Hayes
- School of Allied Health, University of Limerick, Limerick, V94 X5K6, Ireland
- Health Research Institute, University of Limerick, Limerick, V94 T9PX, Ireland
- Ageing Research Centre, University of Limerick, Limerick, V94 X5K6, Ireland
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Osakwe ZT, Barrón Y, McDonald MV, Feldman PH. Effect of Nurse Practitioner Interventions on Hospitalizations in the Community Transitions Intervention Trial. Nurs Res 2021; 70:266-272. [PMID: 34160182 PMCID: PMC8231736 DOI: 10.1097/nnr.0000000000000508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite improvements in hypertension treatment in the United States, Black and Hispanic individuals experience poor blood pressure control and have worse hypertension-related outcomes compared to Whites. OBJECTIVE The aim of the study was to determine the effect on hospitalization of supplementing usual home care (UHC) with two hypertension-focused transitional care interventions-one deploying nurse practitioners (NPs) and the other NPs plus health coaches. METHODS We examined post hoc the effect of two hypertension-focused NP interventions on hospitalizations in the Community Transitions Intervention trial-a three-arm, randomized controlled trial comparing the effectiveness of (a) UHC with (b) UHC plus a 30-day NP transitional care intervention or (c) UHC plus NP plus 60-day health coach intervention. RESULTS The study comprised 495 participants: mean age = 66 years; 57% female; 70% Black, non-Hispanic; 30% Hispanic. At the 3- and 12-month follow-up, all three groups showed a significant decrease in the average number of hospitalizations compared to baseline. The interventions were not significantly different from UHC. CONCLUSION The results of this post hoc analysis show that, during the study period, decreases in hospitalizations in the intervention groups were comparable to those in UHC, and deploying NPs provided no detectable value added. Future research should focus on testing ways to optimize UHC services.
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Affiliation(s)
| | - Yolanda Barrón
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, NY
| | - Margaret V. McDonald
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, NY
| | - Penny H. Feldman
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, NY
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