How should stroke services be organised?

Stroke rehabilitation pathways during the first year: A cost-effectiveness analysis from a cohort of 460 individuals

BACKGROUND

Stroke burden challenges global health, and social and economic policies. Although stroke recovery encompasses a wide range of care, including in-hospital, outpatient, and community-based rehabilitation, there are no published cost-effectiveness studies of integrated post-stroke pathways.

OBJECTIVE

To determine the most cost-effective rehabilitation pathway during the first 12 months after a first-ever stroke.

METHODS

A cohort of people in the acute phase of a first stroke was followed after hospital discharge; 51 % women, mean (SD) age 74.4 (12.9) years, mean National Institute of Health Stroke Scale score 11.7 (8.5) points, and mode modified Rankin Scale score 3 points. We developed a decision tree model of 9 sequences of rehabilitation care organised in 3 stages (3, 6 and 12 months) through a combination of public, semi-public and private entities, considering both the individual and healthcare service perspectives. Health outcomes were expressed as quality-adjusted life years (QALY) over a 1-year time horizon. Costs included healthcare, social care, and productivity losses. Sensitivity analyses were conducted on model input values.

RESULTS

From the individual perspective, pathway 3 (Short-term Inpatient Unit » Community Clinic) was the most cost-effective, followed by pathway 1 (Rehabilitation Centre » Community Clinic). From the healthcare service perspective, pathway 3 was the most cost-effective followed by pathway 7 (Outpatient Hospital » Private Clinic). All other pathways were considered strongly dominated and excluded from the analysis. The total 1-year mean cost ranged between €12104 and €23024 from the individual's perspective and between €10992 and €31319 from the healthcare service perspective.

CONCLUSION

Assuming a willingness-to-pay threshold of one times the national gross domestic product (€20633/QALY), pathway 3 (Short-term Inpatient Unit » Community Clinic) was the most cost-effective strategy from both the individual and healthcare service perspectives. Rehabilitation pathway data contribute to the development of a future integrated care system adapted to different stroke profiles.

From healthcare system to individuals through stroke rehabilitation pathways.Outcomes, information, and satisfaction along 12 months prospective cohort in Portugal

BACKGROUND

The nature and quality of stroke survivor rehabilitation varies throughout Europe, including in Portugal, having not been widely monitored or benchmarked.

OBJECTIVES

This study analyses the stroke care pathway from three perspectives: healthcare system, process, and patient.

METHODS

The study uses data from a one-year single-center prospective cohort of first stroke patients, assessed at baseline, 3, 6, and 12 months. Care pathways and settings were described in terms of organizational model, funding, patient involvement, frequency and intensity and multidisciplinary team. Patient-level information and satisfaction were evaluated using a 10-point numeric rating scale. Kruskal - Wallis and post-hoc tests were used to compare EQ-5D-3 L, National Institute of Health Stroke Scale (NIHSS), Modified Rankin Scale (mRS), Barthel Index, Mini-Mental State Examination scores between pathways and settings.

RESULTS

A total of 391 acute stroke patients, with a mean disability of 3.7 (mRS) and severity of 11.7 (NIHSS) participated. Six pathways and eight settings were described. A lack of compliance between guidelines and care was identified. There were significant differences in the four outcomes between the six pathways (p-values 0.007 to 0.020) suggesting inefficiency and inequalities, with an inadequate level of information and patient satisfaction. After post-hoc analysis, pathways 1 and 2 showed highest outcomes (p-values 0.001 to 0.002). Within settings, short-term units showed high scores, followed by rehabilitation center, outpatient hospital, and community clinic (p-values 0.001 to 0.040).

CONCLUSION

A multilevel characterization of the post-stroke rehabilitation pathway showed a more complete perspective on stroke management which may contribute to future rehabilitation and stroke policies.

Trends of the Incidence of Ischemic Stroke Thrombolysis over Seven Years and One-Year Outcome: A Population-Based Study in Joinville, Brazil

Background

In a population-based setting, we aimed to measure the incidence trends of ischemic stroke (IS) thrombolysis, thrombolysis times, proportion of symptomatic intracerebral hemorrhage (sICH), 30-day case fatality and functional outcomes. We also compared the 12-month functional status between thrombolyzed and nonthrombolyzed patients.

Methods

Using data from the Joinville Population-Based Stroke Registry, we prospectively ascertained a cohort of all thrombolyses done in Joinville citizens, Southern Brazil, from 2005 to 2011. For the definition of sICH we used European Cooperative Acute Stroke Study (ECASS) II criteria.

Results

Over 7 years, 6% (220/3,552) of all IS were thrombolyzed. The thrombolysis incidence increased from 1.4 [95% confidence interval (CI), 0.6-2.9] in 2005 to 9.8 (7.3-12.9) per 100,000 population in 2011 (p < 0.0001). The thrombolysis incidence age-adjusted to the world population in 2011 was 11 (8.2-14.3) per 100,000. Only 30% (50/165) were thrombolyzed within 1 h of arrival at hospital. In 7 days, 6.4% (14/220) had sICH and 57% (8/14) of those died. In the 2009-2011 period, a favorable functional outcome [modified Rankin scale (mRS) 0-1] at 12 months among patients who received thrombolysis was more frequent [mRS 0-1; 36% (38/107)] than among patients who did not receive thrombolysis [mRS 0-1; 24% (131/544); p = 0.016]. The logistic regression showed that thrombolyzed IS patients had a more favorable outcome (mRS 0-1; HR 2.13; 95% CI, 1.2-3.7; p < 0.016) than nonthrombolyzed patients.

Conclusion

In a population setting of a middle income country, the thrombolysis incidence and outcomes were similar to those of other well-structured services. After 1 year, patients thrombolyzed in the 4.5-hour time window had a better outcome. More than proportions, rates provide additional information and could be used to benchmark services against others.

Telerehabilitation services for stroke

BACKGROUND

Telerehabilitation is an alternative way of delivering rehabilitation services. Information and communication technologies are used to facilitate communication between the healthcare professional and the patient in a remote location. The use of telerehabilitation is becoming more viable as the speed and sophistication of communication technologies improve. However, it is currently unclear how effective this model of delivery is relative to rehabilitation delivered face-to-face.

OBJECTIVES

To determine whether the use of telerehabilitation leads to improved ability to perform activities of daily living amongst stroke survivors when compared with (1) in-person rehabilitation (when the clinician and the patient are at the same physical location and rehabilitation is provided face-to-face); or (2) no rehabilitation. Secondary objectives were to determine whether use of telerehabilitation leads to greater independence in self care and domestic life and improved mobility, health-related quality of life, upper limb function, cognitive function or functional communication when compared with in-person rehabilitation and no rehabilitation. Additionally, we aimed to report on the presence of adverse events, cost-effectiveness, feasibility and levels of user satisfaction associated with telerehabilitation interventions.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (November 2012), the Cochrane Effective Practice and Organization of Care Group Trials Register (November 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 11, 2012), MEDLINE (1950 to November 2012), EMBASE (1980 to November 2012) and eight additional databases. We searched trial registries, conference proceedings and reference lists.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of telerehabilitation in stroke. We included studies that compared telerehabilitation with in-person rehabilitation or no rehabilitation. In addition, we synthesised and described the results of RCTs that compared two different methods of delivering telerehabilitation services without an alternative group. We included rehabilitation programmes that used a combination of telerehabilitation and in-person rehabilitation provided that the greater proportion of intervention was provided via telerehabilitation.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials on the basis of prespecified inclusion criteria, extracted data and assessed risk of bias. A third review author moderated any disagreements. The review authors contacted investigators to ask for missing information.

MAIN RESULTS

We included in the review 10 trials involving a total of 933 participants. The studies were generally small, and reporting quality was often inadequate, particularly in relation to blinding of outcome assessors and concealment of allocation. Selective outcome reporting was apparent in several studies. Study interventions and comparisons varied, meaning that in most cases, it was inappropriate to pool studies. Intervention approaches included upper limb training, lower limb and mobility retraining, case management and caregiver support. Most studies were conducted with people in the chronic phase following stroke.

PRIMARY OUTCOME

no statistically significant results for independence in activities of daily living (based on two studies with 661 participants) were noted when a case management intervention was evaluated.

SECONDARY OUTCOMES

no statistically significant results for upper limb function (based on two studies with 46 participants) were observed when a computer programme was used to remotely retrain upper limb function. Evidence was insufficient to draw conclusions on the effects of the intervention on mobility, health-related quality of life or participant satisfaction with the intervention. No studies evaluated the cost-effectiveness of telerehabilitation. No studies reported on the occurrence of adverse events within the studies.

AUTHORS' CONCLUSIONS

We found insufficient evidence to reach conclusions about the effectiveness of telerehabilitation after stroke. Moreover, we were unable to find any randomised trials that included an evaluation of cost-effectiveness. Which intervention approaches are most appropriately adapted to a telerehabilitation approach remain unclear, as does the best way to utilise this approach.

Stroke rehabilitation

Despite improvements in prevention and acute management, stroke remains a common condition and a major cause of permanent disability. For patients who have had a stroke, an effective rehabilitation program is critical to maximize functional recovery and quality of life. Rehabilitation can occur in a number of different physical settings and is often coordinated by a comprehensive interdisciplinary team of professionals. Rehabilitation includes retraining to regain loss of function and teaching compensatory strategies when that is not possible. A number of interesting training approaches have been developed in recent years to supplement more traditional rehabilitation programs. A variety of adaptive devices is available to improve mobility and performance of self-cares, and these devices should be prescribed for appropriate patients. Physicians caring for patients during stroke rehabilitation must be aware of potential medical complications, as well as a number of special problems that may complicate recovery, including dysphagia, urinary incontinence, shoulder pain, spasticity, falls, and poststroke depression. Involvement of the patient and caregivers in the rehabilitation process is essential. It is important to train and educate these individuals in the physical aspects of poststroke care, the expectations for recovery, and secondary stroke prevention. Issues related to community reintegration, including driving and vocational aspects, should be addressed in appropriate patients. Stroke rehabilitation is an important part of the "stroke continuum of care," which includes prevention, acute management, rehabilitation, and secondary prevention.

Economic evidence on integrated care for stroke patients; a systematic review

Introduction

Given the high incidence of stroke worldwide and the large costs associated with the use of health care resources, it is important to define cost-effective and evidence-based services for stroke rehabilitation. The objective of this review was to assess the evidence on the relative cost or cost-effectiveness of all integrated care arrangements for stroke patients compared to usual care. Integrated care was defined as a multidisciplinary tool to improve the quality and efficiency of evidence-based care and is used as a communication tool between professionals to manage and standardize the outcome-orientated care.

Methods

A systematic literature review of cost analyses and economic evaluations was performed. Study characteristics, study quality and results were summarized.

Results

Fifteen studies met the inclusion criteria; six on early-supported discharge services, four on home-based rehabilitation, two on stroke units and three on stroke services. The follow-up per patient was generally short; one year or less. The comparators and the scope of included costs varied between studies.

Conclusions

Six out of six studies provided evidence that the costs of early-supported discharge are less than for conventional care, at similar health outcomes. Home-based rehabilitation is unlikely to lead to cost-savings, but achieves better health outcomes. Care in stroke units is more expensive than conventional care, but leads to improved health outcomes. The cost-effectiveness studies on integrated stroke services suggest that they can reduce costs. For future research we recommend to focus on the moderate and severely affected patients, include stroke severity as variable, adopt a societal costing perspective and include long-term costs and effects.

Factors that influence the stroke care team's effectiveness in reducing the length of hospital stay

BACKGROUND AND PURPOSE

The purpose of this study was to explore the effects of a quality improvement program for improving stroke care and the determinants of success at the team and hospital levels. Method- For 16 months, 23 multidisciplinary stroke service teams participated in a quality improvement collaborative designed to set up stroke services and reduce the length of hospital stay (LOHS). We monitored the LOHS and the discharge delay during the project and measured indicators of well organized stroke services at baseline and after the intervention. A multiple and multilevel regression model was used to relate the outcome variables to the team and hospital characteristics. National LOHS figures served as reference data.

RESULTS

Data regarding 4549 stroke patients were included in the analyses. The LOHS decreased significantly from 18.3 to 13.3 days. The mean LOHS varied substantially (9.2 to 20.9 days) after the intervention. Teams with higher team functioning scores showed lower LOHS scores and higher scores for the indicators of well organized stroke services. Team characteristics explain almost 40% of the variance in LOHS and 53% in the indicators of well organized stroke care.

CONCLUSIONS

Participation in a national quality improvement collaborative effected a significant decrease of the LOHS and a significant increase in the presence of key features of stroke services. Variation in ability to reduce the LOHS and increase key features of stroke services were related to team functioning. The data suggest that the composite of team functioning is pivotal in quality-of-care improvement and may need specific attention in any quality improvement program.

Cost-effectiveness of integrated stroke services

BACKGROUND

Randomized trials have shown that integrating services for acute stroke care may lead to organizational improvements, higher efficiency and better patient outcomes in the acute phase.

AIM

To compare the costs and effects of stroke services in an experimental group of patients compared to a group of patients receiving conventional care.

DESIGN

Prospective non-randomized controlled trial.

METHODS

We compared all consecutively hospitalized stroke patients in three experimental stroke service settings (Delft, Haarlem and Nijmegen, n = 411) with concurrent patients receiving conventional stroke care (n = 187) over 6 months follow-up. Main end-points were total costs per patient and total health-adjusted days per 100 patients as measured by the EuroQol-5D score during follow-up.

RESULTS

Mean total costs per patient were 16,000 Euro (95%CI 14,670 Euro-16,930 Euro): 13,160 Euro in Delft, 16,790 Euro in Haarlem, 20,230 Euro in Nijmegen, and 13,810 Euro in the control regions. Early discharge in Delft saved about 2500 Euro hospital costs per patient. General patient health in Delft was significantly better than in the control regions; Haarlem and Nijmegen showed no difference in health.

DISCUSSION

Our study confirms the potential to improve stroke outcomes in a cost-effective way in Dutch settings. This was seen in the group of patients in Delft, a complete and relatively simple stroke service, but not in two other regions with more complex stroke services. Important factors are reduction of hospital days and, most likely, adequate multidisciplinary rehabilitation.

Integrated care for patients with a stroke in the Netherlands: results and experiences from a national Breakthrough Collaborative Improvement project

Purpose

This article considers the question if measurable improvements are achieved in the quality of care in stroke services by using a Breakthrough collaborative quality improvement model.

Context of case

Despite the availability of explicit criteria, evidence based guidelines, national protocols and examples of best practices; stroke care in the Netherlands did not improve substantially yet. For that reason a national collaborative started in 2002 to improve integrated stroke care in 23 self selected stroke services.

Data sources

Characteristics of sites, teams, aims and changes were assessed by using a questionnaire and monthly self-reports of teams. Progress in achieving significant quality improvement has been assessed on a five point Likert scale (IHI score).

Case description

The stroke services (n=23) formed multidisciplinary teams, which worked together in a collaborative based on the IHI Breakthrough Series Model. Teams received instruction in quality improvement, reviewed self reported performance data, identified bottlenecks and improvement goals, and implemented “potentially better practices” based on criteria from the Edisse study, evidence based guidelines, own ideas and expert opinion.

Conclusion and discussion

Quality of care has been improved in most participating stroke services. Eighty-seven percent of the teams have improved their care significantly on at least one topic. About 34% of the teams have achieved significant improvement on all aims within the time frame of the project. The project has contributed to the further development and spread of integrated stroke care in the Netherlands.