Implementation and evaluation of stroke clinical pathways and the impact on cost of stroke care

Implementation and Evaluation of an Economic Model for Telestroke: Experience from Virtuall, France

Background

Telestroke is recognized as a safe and time-efficient way of treating stroke patients. However, admission centers (spokes) are subject to financial charges which can make them reluctant to join the system. We implemented and assessed an economic model supporting our telestroke system, Virtuall, France, which includes one expert center (hub) and six spokes.

Methods

The model is based on payment for the expertise provided by the hub, distribution of charges related to telemedicine according to the fees perceived by the spokes, and transfer of patients between the spokes and the hub. We performed a cost–benefit analysis for all patients included in Virtuall from January 2014 to December 2015 to assess the economic balance in each center.

Results

321 patients were prospectively included in the study. Application of the economic model resulted in overall financial balance with funding of a dedicated medical service in the hub, and reduced costs directly related to telestroke by an average of 10% in the spokes. The conditions generating the highest costs for the spokes were: a patient returning from the hub for re-hospitalization (mean cost of $1,995/patient); management of patients treated by intravenous thrombolysis without transfer to the hub (mean cost of $2,075/patient). The most favorable financial condition for the spokes remained simple transfer of patients to the hub and no return (mean cost of $329/patient).

Conclusion

We describe an economic model which can be applied to any telestroke system to ensure the optimal balance between hub and spoke centers.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation

BACKGROUND AND PURPOSE

The purpose of this project was to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic cerebrovascular accident (CVA).

METHOD

Using Cochrane Collaboration methods, the Ottawa Methods Group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel, which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a validated and reliable scale.

RESULTS

The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved in post-stroke rehabilitation.

DISCUSSION AND CONCLUSION

The Ottawa Panel recommends the use of therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation in the management of post stroke.

The quality of the evidence base for clinical pathway effectiveness: room for improvement in the design of evaluation trials

Background

The purpose of this article is to report on the quality of the existing evidence base regarding the effectiveness of clinical pathway (CPW) research in the hospital setting. The analysis is based on a recently published Cochrane review of the effectiveness of CPWs.

Methods

An integral component of the review process was a rigorous appraisal of the methodological quality of published CPW evaluations. This allowed the identification of strengths and limitations of the evidence base for CPW effectiveness. We followed the validated Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria for randomized and non-randomized clinical pathway evaluations. In addition, we tested the hypotheses that simple pre-post studies tend to overestimate CPW effects reported.

Results

Out of the 260 primary studies meeting CPW content criteria, only 27 studies met the EPOC study design criteria, with the majority of CPW studies (more than 70 %) excluded from the review on the basis that they were simple pre-post evaluations, mostly comparing two or more annual patient cohorts. Methodologically poor study designs are often used to evaluate CPWs and this compromises the quality of the existing evidence base.

Conclusions

Cochrane EPOC methodological criteria, including the selection of rigorous study designs along with detailed descriptions of CPW development and implementation processes, are recommended for quantitative evaluations to improve the evidence base for the use of CPWs in hospitals.

Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs

BACKGROUND

Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency.

OBJECTIVES

To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs.

SEARCH STRATEGY

We searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care.

MAIN RESULTS

Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 13.65: 95%CI 5.38 to 34.64). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US$ favouring usual care to WMD -4919 US$ favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta-analysis of length of stay and hospital cost results. An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups.

AUTHORS' CONCLUSIONS

Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.

Critical pathways for the management of stroke and intracerebral hemorrhage: a survey of US hospitals

BACKGROUND AND PURPOSE

Thirty-day mortality rates in patients with spontaneous intracerebral hemorrhage (ICH) range from 35% to 50%, with only 10-20% of the survivors regaining functional independence. This high mortality and morbidity argues for the optimization of emergency medical services (EMS), emergency department (ED), and in-patient treatment paradigms. With the development of interventional strategies for ICH, both pharmacologic and surgical, time to treatment will be critical to improving outcomes. Similar to acute ischemic stroke care, proper preparation and role definition will be critical for efficient evaluation and treatment. We studied the existence and structure of ICH management protocols in US hospitals.

METHODS

A national survey of Emergency Medicine physicians was conducted to gather information regarding the existence of stroke and ICH treatment protocols at their institutions.

RESULTS

A clearly established pathway for the management of ischemic stroke exists in most hospitals (78%). By contrast, only 30% of hospitals have a clearly defined pathway for ICH. Thus, while most hospitals are able to perform rapid computed tomography (CT) scans to diagnose ICH, the management of these patients post-CT is more fragmented and variable. Few hospitals have comprehensive protocols that include treatment policies for raised intracranial pressure or formal policies for the transfer of patients to centers with neurocritical care/neurosurgical resources.

RECOMMENDATIONS

Integration of ICH critical pathways into stroke protocols could potentially improve the high mortality and disability associated with this condition and might facilitate ongoing studies of ICH-specific interventions. With stroke neurologists and neurocritical care specialists showing an increasing interest in ICH management, development of critical pathways may allow for a standardized approach to best treatment practices within institutions and networks as evidence grows for new treatments and management strategies. This may also allow a redefinition of the roles of team members, including ED and critical care physicians, neurologists, and neurosurgeons.

Care pathways for acute stroke care and stroke rehabilitation: from theory to evidence

Care pathways aim to promote evidence- and guideline-based care, improve the organisation and efficiency of care, and reduce cost. In the past decade, care pathways have been increasingly implemented as a tool in acute stroke care and stroke rehabilitation. In the most recent Cochrane systematic review, which included three randomised and 12 non-randomised studies, patient management with stroke care pathways was found to have no significant benefit on functional outcome, and patient satisfaction and quality of life might actually be worse. On the other hand, it was associated with a higher proportion of patients receiving investigations and a lower risk of developing certain complications such as infections and readmissions. Overall, the evidence supports the use of care pathways in acute stroke but not stroke rehabilitation. Future developments, including electronic care pathways, patient pathways, and pre-hospital care pathways for hyperacute stroke, will be discussed.

In-hospital care pathways for stroke

BACKGROUND

Stroke care pathways have the potential to promote organised and efficient patient care that is based on best evidence and guidelines, but evidence to support their use is unclear.

OBJECTIVES

We aimed to assess the effects of care pathways, compared with standard medical care, among patients with acute stroke who had been admitted to hospital.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched in June 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2003), MEDLINE (1975 to June 2003), EMBASE (1980 to June 2003), CINAHL (1982 to June 2003), ISI Proceedings: Science & Technology (1990 to November 2003), and HealthSTAR (1994 to May 2001). We also handsearched the Journal of Integrated Care Pathways (2001 to 2003), formerly Journal of Managed Care (1997 to 1998) and Journal of Integrated Care (1998 to 2001). Reference lists of articles were searched.

SELECTION CRITERIA

We considered randomised controlled trials and non-randomised studies that compared care pathway care with standard medical care.

DATA COLLECTION AND ANALYSIS

One reviewer selected studies for inclusion and the other independently checked the decisions. Two reviewers independently assessed the methodological quality of the studies. One reviewer extracted the data and the other checked the extracted data.

MAIN RESULTS

Three randomised controlled trials (340 patients) and 12 non-randomised studies (4081 patients) were included. There was significant statistical heterogeneity in the analysis of many of the outcomes. We found no significant difference between care pathway and control groups in terms of death or discharge destination. Patients managed with a care pathway were: (a) more dependent at discharge (P = 0.04); (b) less likely to suffer a urinary tract infection (Odds Ratio (OR) 0.51, 95% Confidence Interval (CI) 0.34 to 0.79); (c) less likely to be readmitted (OR 0.11, 95% CI 0.03 to 0.39); and (d) more likely to have neuroimaging (OR 2.42, 95% CI 1.12 to 5.25). Evidence from randomised trials suggested that patient satisfaction and quality of life were significantly lower in the care pathway group (P = 0.02 and P < 0.005 respectively).

REVIEWERS' CONCLUSIONS

Use of stroke care pathways may be associated with positive and negative effects. Since most of the results have been derived from non-randomised studies, they are likely to be influenced by potential biases and confounding factors. There is currently insufficient supporting evidence to justify the routine implementation of care pathways for acute stroke management or stroke rehabilitation.

In-hospital care pathways for stroke

BACKGROUND

Stroke care pathways have the potential to promote organised and efficient patient care that is based on best evidence and guidelines, but evidence to support their use is unclear.

OBJECTIVES

We aimed to assess the effects of care pathways, compared with standard medical care, among patients with acute stroke who had been admitted to hospital.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched in June 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2003), MEDLINE (1975 to June 2003), EMBASE (1980 to June 2003), CINAHL (1982 to June 2003), ISI Proceedings: Science & Technology (1990 to November 2003), and HealthSTAR (1994 to May 2001). We also handsearched the Journal of Integrated Care Pathways (2001 to 2003), formerly Journal of Managed Care (1997 to 1998) and Journal of Integrated Care (1998 to 2001). Reference lists of articles were searched.

SELECTION CRITERIA

We considered randomised controlled trials and non-randomised studies that compared care pathway care with standard medical care.

DATA COLLECTION AND ANALYSIS

One reviewer selected studies for inclusion and the other independently checked the decisions. Two reviewers independently assessed the methodological quality of the studies. One reviewer extracted the data and the other checked the extracted data.

MAIN RESULTS

Three randomised controlled trials (340 patients) and 12 non-randomised studies (4081 patients) were included. There was significant statistical heterogeneity in the analysis of many of the outcomes. We found no significant difference between care pathway and control groups in terms of death or discharge destination. Patients managed with a care pathway were: (a) more dependent at discharge (P = 0.04); (b) less likely to suffer a urinary tract infection (Odds Ratio (OR) 0.51, 95% Confidence Interval (CI) 0.34 to 0.79); (c) less likely to be readmitted (OR 0.11, 95% CI 0.03 to 0.39); and (d) more likely to have neuroimaging (OR 2.42, 95% CI 1.12 to 5.25). Evidence from randomised trials suggested that patient satisfaction and quality of life were significantly lower in the care pathway group (P = 0.02 and P < 0.005 respectively).

REVIEWERS' CONCLUSIONS

Use of stroke care pathways may be associated with positive and negative effects. Since most of the results have been derived from non-randomised studies, they are likely to be influenced by potential biases and confounding factors. There is currently insufficient supporting evidence to justify the routine implementation of care pathways for acute stroke management or stroke rehabilitation.

Modern stroke unit

The modern stroke unit is making significant contributions to the care of stroke victims and is proving to be an effective, cost-saving enterprise. The precise factors that contribute to the efficacy of these units have yet to be identified, but a combination of protocolized approaches to patient care, critical paths, a focus of expertise, and heightened index of suspicion for comorbidities all probably play a role. This article outlines the basic features of a modern stroke unit and surveys the literature on stroke unit outcomes.

Does a clinical pathway improve the quality of care for sickle cell anemia?

BACKGROUND

Clinical pathways are often implemented to improve care, yet their effect on quality of care and outcomes is often not evaluated. The Johns Hopkins Children's Center instituted a clinical pathway in early 1996 to improve the care for pediatric sickle cell vaso-occlusive crisis (VOC) and used a retrospective before-after study to describe how quality of care and outcomes changed after introduction of the pathway.

RESULTS

Physicians used the pathway in 43% of eligible admissions, with use decreasing over time. Patients on the pathway were more likely to receive each of its required elements than those not on the pathway (odds ratios [OR] 1.15-2.49). After pathway implementation, even patients not on the pathway were more likely to receive incentive spirometry than those admitted before pathway availability (OR 1.40). Pathway use was associated with longer length of stay (LOS) and time to oral pain medication, while readmission rates did not change.

DISCUSSION

Use of a clinical pathway improved quality of care by increasing compliance with specific care elements, with mixed results on outcomes. Pathways may improve care for all patients, including nonpathway-treated patients, by influencing underlying practice patterns. Quality improvement committees must regularly monitor outcomes after pathway implementation to evaluate the need for pathway reinforcement and refinement.

In-hospital care pathways for stroke

BACKGROUND

Care within a stroke unit reduces death or dependency after stroke. However, studies have found significant variations in clinical practice, access to stroke unit care, organisation of patient care, and clinical outcome. Stroke care pathways have been introduced as a method to promote organised and efficient patient care that is based on best evidence and guidelines.

OBJECTIVES

We aimed to assess the effects of care pathways, as compared to standard medical care, among patients with acute stroke who had been admitted to hospital.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Specialised Trials Register (last searched in May 2001), the Cochrane Controlled Trials Register (Issue 4, 2000), MEDLINE (1975-2000), EMBASE (1980-2000), CINAHL (1982-2000), the Index to Scientific and Technical Proceedings (ISTP, May 2001), and HealthSTAR (May 2001). We also handsearched the Journal of Managed Care (1997 to 1998), which was later renamed the Journal of Integrated Care (1998 to 2001). Reference lists of articles were searched.

SELECTION CRITERIA

We considered randomised controlled trials and non-randomised studies (quasi-randomised trials, comparative studies, controlled and uncontrolled before and after studies, and interrupted time series) that compared care pathway care with standard medical care.

DATA COLLECTION AND ANALYSIS

One reviewer selected studies for inclusion and the other independently checked the decisions. Two reviewers independently assessed the methodological quality of the studies. One reviewer extracted the data and the other checked the extracted data. Data from randomised and non-randomised studies were analysed separately. We found significant statistical heterogeneity in the analysis of two outcomes (computed tomography brain scanning and duration of stay).

MAIN RESULTS

There were three randomised controlled trials (total of 340 patients) and seven non-randomised studies (total of 1673 patients) that compared care pathway care with standard medical care. We found no difference between care pathway and control groups in terms of death, dependency, or discharge destination. Evidence from mainly non-randomised studies suggests that patients managed using a care pathway may be: a) less likely to suffer a urinary tract infection (OR 0.38, CI 0.18 to 0.79), b) less likely to be readmitted (OR 0.11, CI 0.03 to 0.39), and c) more likely to have a computed tomography brain scan (OR 3.66, CI 1.45 to 9.27) or carotid duplex study (OR 2.45, CI 1.3 to 4.61). Evidence from randomised trials suggests that patient satisfaction and quality of life may be significantly lower in the care pathway group (P=0.02 and P<0.005 respectively).

REVIEWER'S CONCLUSIONS

The use of care pathways to manage stroke patients in hospital may be associated with both positive and negative effects on the process of care and clinical outcomes. Since most of the results have been derived from non-randomised studies, they are likely to be influenced by potential biases and confounding factors. There is currently insufficient supporting evidence to justify routine implementation of care pathways for acute stroke management or stroke rehabilitation.

Characteristics of academic medical centers and ischemic stroke outcomes

BACKGROUND AND PURPOSE

Data supporting the efficacy of stroke center characteristics are limited.

METHODS

A questionnaire detailing stroke treatment practices was sent to 42 academic medical centers in the University Health Systems Consortium. In-hospital mortality of all emergency department admissions for ischemic stroke at these institutions was evaluated in a database of discharge abstracts during 1997-1999. Institutional characteristics were evaluated as predictors of in-hospital mortality after adjustment for age, sex, race, hospital treatment volume of ischemic stroke, and admission status (emergent, urgent, elective). Length of stay (LOS), total hospital charges, and frequency of tissue plasminogen activator (tPA) administration were evaluated as secondary outcomes. We used a multivariable method called generalized estimating equations, which broadens confidence intervals to adjust for clustering of variables at institutions.

RESULTS

Thirty-two institutions completed the questionnaire, and 29 of these were included in the database of discharge abstracts. In-hospital deaths occurred in 758 (7.0%) of the 10 880 ischemic stroke patients admitted through the emergency department. In-hospital deaths were less frequent at hospitals with a vascular neurologist (odds ratio [OR] 0.51; 95% CI, 0.36 to 0.74; P<0.0001) and at those with guidelines stating that only neurologists could administer tPA (OR, 0.65; 95% CI, 0.49 to 0.88; P=0.004). There was a trend toward fewer deaths at hospitals with a dedicated stroke team available by pager (OR, 0.76; 95% CI, 0.56 to 1.04; P=0.09). The presence of a dedicated neurological intensive care unit, stroke unit, and written clinical pathway for stroke were not significantly associated with in-hospital death. LOS was shorter at hospitals with a vascular neurologist (P=0.01).

CONCLUSIONS

Academic medical centers with a vascular neurologist and those with written guidelines limiting tPA administration to neurologists had lower rates of in-hospital mortality for ischemic stroke patients.

A descriptive study of function in acute motor stroke

The functional independence measure (FIM) instrument was introduced in 1987 and has proven to be a useful tool for measuring disability in different patient populations. The FIM instrument data collected during inpatient rehabilitation for stroke is very informative, as it is voluminous, comprehensive, and has a uniform reporting mechanism. In contrast to inpatient rehabilitation, there is a paucity of FIM instrument data on acute stroke patients. The purpose of this study was to describe functional level of 100 patients within the first 24 hours of acute care admission. The mean total FIM instrument score was 94.05 (SD +/- 19.31, range = 38-120), the mean motor domain subscore was 61 (SD +/- 17.8, range 23-85), and cognitive was 33.4 (SD +/- 3.3, range 15-35). Significant group differences were identified for age, gender, and disposition for total and/or domain subscores. Significant differences in age, gender, employment, and disposition were found for clinical subscales. This study fills a gap in current knowledge, that of baseline total FIM instrument scores, domain subscores, and six clinical subscales on one particular group of stroke patients, those with a primary motor stroke.

Randomized controlled trial of integrated (managed) care pathway for stroke rehabilitation

BACKGROUND AND PURPOSE

Integrated Care Pathway (ICP) is an organized, goal-defined, and time-managed plan that has the potential of facilitating timely interdisciplinary coordination, improving discharge planning, and reducing length of hospital stay.

METHODS

An ICP for stroke rehabilitation based on evidence of best practice, professional standards, and existing infrastructure was developed. Its effectiveness was tested in 152 stroke patients undergoing rehabilitation who were randomized to receive ICP care coordinated by an experienced nurse (n=76) or conventional multidisciplinary care (n=76).

RESULTS

The age, sex, premorbid functional ability, and stroke characteristics of the 2 groups were comparable. There were no differences in mortality rates (10 [13%] versus 6 [8%]), institutionalization (10 [13%] versus 16 [21%]), or length of hospital stay (50+/-19 versus 45+/-23 days) between patients receiving ICP or multidisciplinary care. Patients receiving conventional multidisciplinary care improved significantly faster between 4 and 12 weeks (median change in Barthel Activities of Daily Living Index 6 versus 2; P<0.01) and had higher Quality of Life scores at 12 weeks (65 versus 59; P=0.07) and 6 months (72 versus 63; P<0.005). There were no significant differences in the mean duration of physiotherapy (42.8+/-41.2 versus 39.4+/-36.4 hours) or occupational therapy (8.5+/-7.5 versus 8.0+/-7.5 hours) received between the 2 groups.

CONCLUSIONS

ICP management offered no benefit over conventional multidisciplinary care on a stroke rehabilitation unit. Functional recovery was faster and Quality of Life outcomes better in patients receiving conventional multidisciplinary care.