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Kleinig TJ, McMullan P, Cloud GC, Bladin PC, Ranta A. Hyper-Acute Stroke Systems of Care and Workflow. Curr Neurol Neurosci Rep 2024; 24:495-505. [PMID: 39150649 DOI: 10.1007/s11910-024-01367-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2024] [Indexed: 08/17/2024]
Abstract
PURPOSE OF REVIEW Recent stroke treatment advances have necessitated agile, broad-scale healthcare system redesign, to achieve optimal patient outcomes and access equity. Optimised hyperacute stroke care requires integrated pre-hospital, emergency department, stroke specialist, radiology, neurosurgical and endovascular neurointervention services, guided by a population-wide needs analysis. In this review, we survey system integration efforts, providing case studies, and identify common elements of successful initiatives. RECENT FINDINGS Different regions and nations have evolved varied acute stroke systems depending on geography, population density and workforce. However, common facilitators to these solutions have included stroke unit care as a foundation, government-clinician synergy, pre-hospital pathway coordination, service centralisation, and stroke data guiding system improvement. Further technological advantages will minimize the geographical distance disadvantages and facilitate virtual expertise redistribution to remote areas. Continued treatment advances necessitate an integrated, adaptable, population-wide trans-disciplinary approach. A well-designed clinician-led and government-supported system can facilitate hyperacute care and scaffold future system enhancements.
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Affiliation(s)
- Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, 1 Port Road, Adelaide, South Australia, 5000, Australia.
| | - Patrick McMullan
- Department of Neurology, Royal Adelaide Hospital, 1 Port Road, Adelaide, South Australia, 5000, Australia
| | - Geoffrey C Cloud
- Department of Neurology, Alfred Health, Melbourne, VIC, Australia
- Department of Neuroscience, School of Translational Medicine, Monash University, Melbourne, VIC, Australia
| | | | - Anna Ranta
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
- Department of Medicine, University of Otago, Wellington, New Zealand
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2
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Hengel P, Nimptsch U, Blümel M, Achstetter K, Busse R. Regional variation in access to and quality of acute stroke care: results of Germany's Health System Performance Assessment pilot, 2014-2020. RESEARCH IN HEALTH SERVICES & REGIONS 2024; 3:9. [PMID: 39177921 PMCID: PMC11281753 DOI: 10.1007/s43999-024-00045-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 06/18/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND Health System Performance Assessments (HSPA) and analyses of unwarranted regional variation in health care both aim at identifying strengths and weaknesses of health systems to improve care. Applying HSPA's conceptual approach of interrelated health system dimensions (e.g., access, quality) to regional levels might help to better understand variation in care to reduce inequity and improve performance. METHODS We use four indicators identified and analysed in a pilot study for a German HSPA to assess variation in access to and quality of acute stroke care between Germany's 16 federal states and urban vs. rural regions from 2014 to 2020. Stroke unit (SU) density, share of the population reaching a SU within 30 min by car, share of inpatient stroke cases treated in a hospital with a SU, and inpatient mortality were computed based on hospital quality reports and discharge data covering all acute care hospitals. Inpatient mortality was adjusted for age, sex, stroke type, and comorbidities. RESULTS About 500 SU were identified, i.e., 2.0 per 1,000 inpatient stroke cases. Almost 95% of Germans could reach a SU hospital within 30 min (rural: 90%; urban: 99%; > 88% in all states but one). The share of inpatient stroke cases treated in a SU hospital increased to 93% with a decreasing span between rural (92%) and urban (95%) regions and between states (74-98%). Inpatient mortality stagnated around 8.5% and increased to 9.0% in 2020 (rural: 8.7%; urban: 9.2%; states: 7.0-9.7%, one outlier of 13.3%). CONCLUSIONS The results especially revealed varying performance patterns in access to and quality of acute stroke care between the federal states, indicating different areas for improvement which might be addressed by more targeted policy measures in the future.
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Affiliation(s)
- P Hengel
- Department of Health Care Management, Technische Universität Berlin, Str. des 17. Juni 135, Berlin, 10623, Germany.
| | - U Nimptsch
- Department of Health Care Management, Technische Universität Berlin, Str. des 17. Juni 135, Berlin, 10623, Germany
| | - M Blümel
- Department of Health Care Management, Technische Universität Berlin, Str. des 17. Juni 135, Berlin, 10623, Germany
| | - K Achstetter
- Department of Health Care Management, Technische Universität Berlin, Str. des 17. Juni 135, Berlin, 10623, Germany
| | - R Busse
- Department of Health Care Management, Technische Universität Berlin, Str. des 17. Juni 135, Berlin, 10623, Germany
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Hara K, Kanda M, Kuwabara H, Kobayashi Y, Inoue T. Association between the quantity of stroke care units and the complement of neurosurgical and neurology specialists in Japan: A retrospective study. J Stroke Cerebrovasc Dis 2024; 33:107734. [PMID: 38670322 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107734] [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: 10/03/2023] [Revised: 12/13/2023] [Accepted: 04/23/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Stroke care units provide advanced intensive care for unstable patients with acute stroke. We conducted a survey to clarify the differences in stroke care units between urban and regional cities and the relationship between the number of stroke care unit beds and neurologists. METHODS This retrospective observational study was conducted in 2,857 and 4,184 hospitals in urban and regional cities in 47 provinces of Japan, respectively, between January 2020 and August 2023. Tokyo and ordinance-designated cities in provinces were defined as urban cities, and those without such cities were defined as regional cities. The primary endpoint was the presence or absence of a stroke care unit. RESULTS Multiple linear regression analysis revealed that the presence of stroke care units was significantly associated with the number of neurosurgical specialists. Receiver operating characteristic curve analysis was performed to predict the number of personnel required for stroke care unit installation based on the number of neurosurgical specialists. The area under the receiver operating characteristic curve, Youden index, sensitivity, and specificity were 0.721, 0.483, 0.783, and 0.700, respectively. CONCLUSIONS Our study underscores the indispensability of SCUs in stroke treatment, advocating for a strategic allocation of medical resources, heightened accessibility to neurosurgical specialists, and a concerted effort to address geographic and resource imbalances. The identified cutoff value of 8.99 neurosurgical specialists per 100,000 population serves as a practical benchmark for optimizing SCU establishment, thereby potentially mitigating stroke-related mortality.
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Affiliation(s)
- Kentaro Hara
- Department of Operation Center, National Hospital Organization Nagasaki Medical Center, Nagasaki 856-8562, Japan; Department of Nursing, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8523, Japan; Healthcare Management Research Center, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba 260-8677, Japan
| | - Masato Kanda
- Healthcare Management Research Center, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba 260-8677, Japan; Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba 260-8677, Japan
| | - Hiroyo Kuwabara
- Healthcare Management Research Center, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba 260-8677, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba 260-8677, Japan
| | - Takahiro Inoue
- Healthcare Management Research Center, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba 260-8677, Japan.
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4
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Rudd AG, Zhao J, Ford G, Melifonwu R, Abraham SV, Fisher M, Andersen G, Waters D, Li D, Liu R. Results of an international survey on the status of prehospital care. Int J Stroke 2023; 18:1084-1091. [PMID: 37154607 PMCID: PMC10614170 DOI: 10.1177/17474930231177204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/02/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Prehospital care including recognition of stroke symptoms by the public and professionals combined with an efficient and effective emergency medical service (EMS) is essential to increase access to effective acute stroke care. We undertook a survey to document the status of stroke prehospital care globally. METHODS A survey was distributed via email to the World Stroke Organization (WSO) members. Information was sought on the current status of stroke prehospital delay globally, including (1) ambulance availability and whether payment for use is required, (2) ambulance response times and the proportion of patients arriving at hospital by ambulance, (3) the proportion of patients arriving within 3 h and more than 24 h after symptom, (4) whether stroke care training of paramedics, call handlers, and primary care staff, (5) availability of specialist centers, and (6) the proportion of patients taken to specialist centers. Respondents were also asked to identify the top three changes in prehospital care that would benefit their population. Data were analyzed descriptively at both country and continent level. RESULTS Responses were received from 116 individuals in 43 countries, with a response rate of 4.7%. Most respondents (90%) reported access to ambulances, but 40% of respondents reported payment was required by the patient. Where an ambulance service was available (105 respondents) 37% of respondents reported that less than 50% of patients used an ambulance and 12% less than 20% of patients used an ambulance. Large variations in ambulance response times were reported both within and between countries. Most of the participating high-income countries (HIC) offered a service used by patients, but this was rarely the case for the low- and middle-income countries (LMIC). Time to admission was often much longer in LMIC, and there was less access to stroke training for EMS and primary care staff. CONCLUSIONS Significant deficiencies in stroke prehospital care exist globally especially in LMIC. In all countries, there are opportunities to improve the quality of the service in ways that would likely result in improved outcomes after acute stroke.
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Affiliation(s)
- Anthony G Rudd
- Stroke Research Group and Division for Health & Social Care Research, Kings College London, London, UK
- Coalition of Stroke Taskforces for Stroke
- World Stroke Organisation Taskforce on Prehospital Care, Geneva Switzerland
| | - Jing Zhao
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, China
- World Stroke Organisation Taskforce on Prehospital Care, Geneva Switzerland
| | - Gary Ford
- Radcliffe Department of Medicine, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- World Stroke Organisation Taskforce on Prehospital Care, Geneva Switzerland
| | - Rita Melifonwu
- Department of Nursing Science, Nnamdi Azikiwe University, Awka, Nigeria
- Life after Stroke Centre, Stroke Action Nigeria, Onitsha, Nigeria
- World Stroke Organisation Taskforce on Prehospital Care, Geneva Switzerland
| | - Siju V Abraham
- Department of Emergency Medicine, Jubilee Mission Medical College and Research Institute, Thrissur, India
- World Stroke Organisation Taskforce on Prehospital Care, Geneva Switzerland
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- World Stroke Organisation Taskforce on Prehospital Care, Geneva Switzerland
| | - Grethe Andersen
- Departments Clinical Medicine and Neurology, Aarhus University, Aarhus, Denmark
- World Stroke Organisation Taskforce on Prehospital Care, Geneva Switzerland
| | - David Waters
- Council of Ambulance Authorities, Hilton, SA, Australia
- World Stroke Organisation Taskforce on Prehospital Care, Geneva Switzerland
| | - Dou Li
- Department of Emergency Medicine, Beijing Emergency Medical Center, Beijing, China
- World Stroke Organisation Taskforce on Prehospital Care, Geneva Switzerland
| | - Renyu Liu
- Departments of Anaesthesiology and Critical Care and Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- World Stroke Organisation Taskforce on Prehospital Care, Geneva Switzerland
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Thompson S, Levack W, Douwes J, Girvan J, Abernethy G, Barber PA, Fink J, Gommans J, Davis A, Harwood M, Cadilhac DA, McNaughton H, Feigin V, Wilson A, Denison H, Corbin M, Kim J, Ranta A. Patient, carer and health worker perspectives of stroke care in New Zealand: a mixed methods survey. Disabil Rehabil 2023; 45:2957-2963. [PMID: 36063065 DOI: 10.1080/09638288.2022.2117862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 08/14/2022] [Accepted: 08/21/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE It is important to understand how consumers (person with stroke/family member/carer) and health workers perceive stroke care services. MATERIALS AND METHODS Consumers and health workers from across New Zealand were surveyed on perceptions of stroke care, access barriers, and views on service centralisation. Quantitative data were summarised using descriptive statistics whilst thematic analysis was used for free-text answers. RESULTS Of 149 consumers and 79 health workers invited to complete a survey, 53 consumers (36.5%) and 41 health workers (51.8%) responded. Overall, 40/46 (87%) consumers rated stroke care as 'good/excellent' compared to 24/41 (58.6%) health workers. Approximately 72% of consumers preferred to transfer to a specialised hospital. We identified three major themes related to perceptions of stroke care: 1) 'variability in care by stage of treatment'; 2) 'impact of communication by health workers on care experience'; and 3) 'inadequate post-acute services for younger patients'. Four access barrier themes were identified: 1) 'geographic inequities'; 2) 'knowing what is available'; 3) 'knowledge about stroke and available services'; and 4) 'healthcare system factors'. CONCLUSIONS Perceptions of stroke care differed between consumers and health workers, highlighting the importance of involving both in service co-design. Improving communication, post-hospital follow-up, and geographic equity are key areas for improvement.Implications for rehabilitationProvision of detailed information on stroke recovery and available services in the community is recommended.Improvements in the delivery of post-hospital stroke care are required to optimise stroke care, with options including routine phone follow up appointments and wider development of early supported discharge services.Stroke rehabilitation services should continue to be delivered 'close to home' to allow community integration.Telehealth is a likely enabler to allow specialist urban clinicians to support non-urban clinicians, as well as increasing the availability and access of community rehabilitation.
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Affiliation(s)
| | - William Levack
- Professor and Dean and Head of Campus, University of Otago, Wellington
| | - Jeroen Douwes
- Research Centre for Hauora and Health, Massey University, Wellington, New Zealand
| | | | | | | | - John Fink
- Canterbury District Health Board, Christchurch, New Zealand
| | - John Gommans
- Hawke's Bay District Health Board, Hastings, New Zealand
| | | | | | - Dominique A Cadilhac
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Harry McNaughton
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Valery Feigin
- Auckland University of Technology, Auckland, New Zealand
| | - Andrew Wilson
- Nelson-Marlborough District Health Board, Blenheim, New Zealand
| | - Hayley Denison
- Research Centre for Hauora and Health, Massey University, Wellington, New Zealand
| | - Marine Corbin
- Research Centre for Hauora and Health, Massey University, Wellington, New Zealand
| | - Joosup Kim
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Annemarei Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
- Department of Neurology, Capital & Coast District Health Board, Wellington, New Zealand
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Pareek N, Rees P, Quinn T, Vopelius-Feldt JV, Gallagher S, Mozid A, Johnson T, Gudde E, Simpson R, Glover G, Davies J, Curzen N, Keeble TR. British Cardiovascular Interventional Society Consensus Position Statement on Out-of-Hospital Cardiac Arrest 1: Pathway of Care. Interv Cardiol 2022; 17:e18. [PMID: 36644626 PMCID: PMC9820135 DOI: 10.15420/icr.2022.09] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/10/2022] [Indexed: 11/11/2022] Open
Abstract
Out-of-hospital cardiac arrest (OHCA) affects 80,000 patients per year in the UK; despite improvements in care, survival to discharge remains lower than 10%. NHS England and several societies recommend all resuscitated OHCA patients be directly transferred to a cardiac arrest centre (CAC). However, evidence is limited that all patients benefit from transfer to a CAC, and there are significant organisational, logistic and financial implications associated with such change in policies. Furthermore, there is significant variability in interventional cardiovascular practices for OHCA. Accordingly, the British Cardiovascular Interventional Society established a multidisciplinary group to address variability in practice and provide recommendations for the development of cardiac networks. In this position statement, we recommend: the formal establishment of dedicated CACs; a pathway of conveyance to CACs; and interventional practice to standardise our approach. Further research is needed to understand the role of CACs and which interventions benefit patients with OHCA to support wide-scale changes in networks of care across the UK.
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Affiliation(s)
- Nilesh Pareek
- King's College Hospital NHS Foundation TrustLondon, UK,School of Cardiovascular Medicine and Sciences, British Heart Failure Centre of Excellence, King's College LondonLondon, UK
| | - Paul Rees
- Barts Interventional Group, Barts Heart CentreLondon, UK,Academic Department of Military Medicine, Defence Medical ServicesLondon, UK
| | - Tom Quinn
- Emergency, Cardiovascular and Critical Care Research Group, Kingston University and St. George's, University of LondonLondon, UK
| | | | - Sean Gallagher
- Department of Cardiology, University Hospital of WalesCardiff, UK
| | - Abdul Mozid
- Leeds Teaching Hospitals NHS Foundation TrustLeeds, UK
| | - Tom Johnson
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation TrustUK
| | - Ellie Gudde
- Essex Cardiothoracic Centre, MSE TrustBasildon, Essex, UK,Medical Technology Research Centre, Anglia Ruskin School of MedicineChelmsford, Essex, UK
| | - Rupert Simpson
- Essex Cardiothoracic Centre, MSE TrustBasildon, Essex, UK,Medical Technology Research Centre, Anglia Ruskin School of MedicineChelmsford, Essex, UK
| | - Guy Glover
- Intensive Care Unit, Guy's and St Thomas' NHS Foundation TrustLondon, UK
| | - John Davies
- Essex Cardiothoracic Centre, MSE TrustBasildon, Essex, UK,Medical Technology Research Centre, Anglia Ruskin School of MedicineChelmsford, Essex, UK
| | - Nick Curzen
- Faculty of Medicine, University of SouthamptonSouthampton, UK,Cardiothoracic Care Group, University Hospital SouthamptonSouthampton, UK
| | - Thomas R Keeble
- Essex Cardiothoracic Centre, MSE TrustBasildon, Essex, UK,Medical Technology Research Centre, Anglia Ruskin School of MedicineChelmsford, Essex, UK
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Wood RM, Moss SJ, Murch BJ, Vasilakis C, Clatworthy PL. Optimising acute stroke pathways through flexible use of bed capacity: a computer modelling study. BMC Health Serv Res 2022; 22:1068. [PMID: 35987642 PMCID: PMC9392305 DOI: 10.1186/s12913-022-08433-0] [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: 04/19/2022] [Accepted: 08/10/2022] [Indexed: 11/11/2022] Open
Abstract
Background Optimising capacity along clinical pathways is essential to avoid severe hospital pressure and help ensure best patient outcomes and financial sustainability. Yet, typical approaches, using only average arrival rate and average lengths of stay, are known to underestimate the number of beds required. This study investigates the extent to which averages-based estimates can be complemented by a robust assessment of additional ‘flex capacity’ requirements, to be used at times of peak demand. Methods The setting was a major one million resident healthcare system in England, moving towards a centralised stroke pathway. A computer simulation was developed for modelling patient flow along the proposed stroke pathway, accounting for variability in patient arrivals, lengths of stay, and the time taken for transfer processes. The primary outcome measure was flex capacity utilisation over the simulation period. Results For the hyper-acute, acute, and rehabilitation units respectively, flex capacities of 45%, 45%, and 36% above the averages-based calculation would be required to ensure that only 1% of stroke presentations find the hyper-acute unit full and have to wait. For each unit some amount of flex capacity would be required approximately 30%, 20%, and 18% of the time respectively. Conclusions This study demonstrates the importance of appropriately capturing variability within capacity plans, and provides a practical and economical approach which can complement commonly-used averages-based methods. Results of this study have directly informed the healthcare system’s new configuration of stroke services.
Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08433-0.
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Thompson SG, Barber PA, Gommans JH, Cadilhac DA, Davis A, Fink JN, Harwood M, Levack W, McNaughton HK, Feigin VL, Abernethy V, Girvan J, Kim J, Denison H, Corbin M, Wilson A, Douwes J, Ranta A. Geographic Disparities in Stroke Outcomes and Service Access: A Prospective Observational Study. Neurology 2022; 99:e414-e426. [PMID: 35623890 PMCID: PMC9421775 DOI: 10.1212/wnl.0000000000200526] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 03/01/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES International evidence shows that patients treated at nonurban hospitals experience poorer access to key stroke interventions. Evidence for whether this results in poorer outcomes is conflicting and generally based on administrative or voluntary registry data. The aim of this study was to use prospective high-quality comprehensive nationwide patient-level data to investigate the association between hospital geography and outcomes of patients with stroke and access to best-practice stroke care in New Zealand. METHODS This is a prospective, multicenter, nationally representative observational study involving all 28 New Zealand acute stroke hospitals (18 nonurban) and affiliated rehabilitation and community services. Consecutive adults admitted to the hospital with acute stroke between May 1 and October 31, 2018, were captured. Outcomes included functional outcome (modified Rankin Scale [mRS] score shift analysis), functional independence (mRS score 0-2), quality of life (EuroQol 5-dimension, 3-level health-related quality of life questionnaire), stroke/vascular events, and death at 3, 6, and 12 months and proportion accessing thrombolysis, thrombectomy, stroke units, key investigations, secondary prevention, and inpatient/community rehabilitation. Results were adjusted for age, sex, ethnicity, stroke severity/type, comorbid conditions, baseline function, and differences in baseline characteristics. RESULTS Overall, 2,379 patients were eligible (mean [SD] age 75 [13.7] years; 51.2% male; 1,430 urban, 949 nonurban). Patients treated at nonurban hospitals were more likely to score in a higher mRS score category (greater disability) at 3 (adjusted odds ratio [aOR] 1.28, 95% CI 1.07-1.53), 6 (aOR 1.33, 95% CI 1.07-1.65), and 12 (aOR 1.31, 95% CI 1.06-1.62) months and were more likely to have died (aOR 1.57, 95% CI 1.17-2.12) or experienced recurrent stroke and vascular events at 12 months (aOR 1.94, 95% CI 1.14-3.29 and aOR 1.65, 95% CI 1.09-2.52). Fewer nonurban patients received recommended stroke interventions, including endovascular thrombectomy (aOR 0.25, 95% CI 0.13-0.49), acute stroke unit care (aOR 0.60, 95% CI 0.49-0.73), antiplatelet prescriptions (aOR 0.72, 95% CI 0.58-0.88), ≥60 minutes of daily physical therapy (aOR 0.55, 95% CI 0.40-0.77), and community rehabilitation (aOR 0.69, 95% CI 0.56-0.84). DISCUSSION Patients managed at nonurban hospitals experience poorer stroke outcomes and reduced access to key stroke interventions across the entire care continuum. Efforts to improve access to high quality stroke care in nonurban hospitals should be a priority.
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Affiliation(s)
- Stephanie G Thompson
- From the Department of Medicine (S.G.T., W.L., A.R.), University of Otago, Wellington; Departments of Medicine (P.A.B.) and General Practice (M.H.), Auckland University; Department of Medicine (J.H.G.), Hawke's Bay District Health Board, New Zealand; Department of Medicine (D.A.C., J.K.), School of Clinical Sciences, Monash University, Melbourne, Australia; Department of Medicine (A.D.), Whangarei Hospital; Department of Neurology (J.N.F.), Canterbury District Health Board, Christchurch; Medical Research Institute of New Zealand (H.K.M.), Wellington; Auckland University of Technology (V.L.F.); Stroke Foundation New Zealand (V.A.), Wellington; Consumer Advisor (J.G.); Centre for Public Health and Epidemiology (H.D., M.C., J.D.), Massey University, Wellington; Department of Medicine (A.W.), Wairau Hospital, Blenheim; and Department of Neurology (A.R.), Capital & Coast District Health Board, Wellington, New Zealand
| | - P Alan Barber
- From the Department of Medicine (S.G.T., W.L., A.R.), University of Otago, Wellington; Departments of Medicine (P.A.B.) and General Practice (M.H.), Auckland University; Department of Medicine (J.H.G.), Hawke's Bay District Health Board, New Zealand; Department of Medicine (D.A.C., J.K.), School of Clinical Sciences, Monash University, Melbourne, Australia; Department of Medicine (A.D.), Whangarei Hospital; Department of Neurology (J.N.F.), Canterbury District Health Board, Christchurch; Medical Research Institute of New Zealand (H.K.M.), Wellington; Auckland University of Technology (V.L.F.); Stroke Foundation New Zealand (V.A.), Wellington; Consumer Advisor (J.G.); Centre for Public Health and Epidemiology (H.D., M.C., J.D.), Massey University, Wellington; Department of Medicine (A.W.), Wairau Hospital, Blenheim; and Department of Neurology (A.R.), Capital & Coast District Health Board, Wellington, New Zealand
| | - John H Gommans
- From the Department of Medicine (S.G.T., W.L., A.R.), University of Otago, Wellington; Departments of Medicine (P.A.B.) and General Practice (M.H.), Auckland University; Department of Medicine (J.H.G.), Hawke's Bay District Health Board, New Zealand; Department of Medicine (D.A.C., J.K.), School of Clinical Sciences, Monash University, Melbourne, Australia; Department of Medicine (A.D.), Whangarei Hospital; Department of Neurology (J.N.F.), Canterbury District Health Board, Christchurch; Medical Research Institute of New Zealand (H.K.M.), Wellington; Auckland University of Technology (V.L.F.); Stroke Foundation New Zealand (V.A.), Wellington; Consumer Advisor (J.G.); Centre for Public Health and Epidemiology (H.D., M.C., J.D.), Massey University, Wellington; Department of Medicine (A.W.), Wairau Hospital, Blenheim; and Department of Neurology (A.R.), Capital & Coast District Health Board, Wellington, New Zealand
| | - Dominique A Cadilhac
- From the Department of Medicine (S.G.T., W.L., A.R.), University of Otago, Wellington; Departments of Medicine (P.A.B.) and General Practice (M.H.), Auckland University; Department of Medicine (J.H.G.), Hawke's Bay District Health Board, New Zealand; Department of Medicine (D.A.C., J.K.), School of Clinical Sciences, Monash University, Melbourne, Australia; Department of Medicine (A.D.), Whangarei Hospital; Department of Neurology (J.N.F.), Canterbury District Health Board, Christchurch; Medical Research Institute of New Zealand (H.K.M.), Wellington; Auckland University of Technology (V.L.F.); Stroke Foundation New Zealand (V.A.), Wellington; Consumer Advisor (J.G.); Centre for Public Health and Epidemiology (H.D., M.C., J.D.), Massey University, Wellington; Department of Medicine (A.W.), Wairau Hospital, Blenheim; and Department of Neurology (A.R.), Capital & Coast District Health Board, Wellington, New Zealand
| | - Alan Davis
- From the Department of Medicine (S.G.T., W.L., A.R.), University of Otago, Wellington; Departments of Medicine (P.A.B.) and General Practice (M.H.), Auckland University; Department of Medicine (J.H.G.), Hawke's Bay District Health Board, New Zealand; Department of Medicine (D.A.C., J.K.), School of Clinical Sciences, Monash University, Melbourne, Australia; Department of Medicine (A.D.), Whangarei Hospital; Department of Neurology (J.N.F.), Canterbury District Health Board, Christchurch; Medical Research Institute of New Zealand (H.K.M.), Wellington; Auckland University of Technology (V.L.F.); Stroke Foundation New Zealand (V.A.), Wellington; Consumer Advisor (J.G.); Centre for Public Health and Epidemiology (H.D., M.C., J.D.), Massey University, Wellington; Department of Medicine (A.W.), Wairau Hospital, Blenheim; and Department of Neurology (A.R.), Capital & Coast District Health Board, Wellington, New Zealand
| | - John N Fink
- From the Department of Medicine (S.G.T., W.L., A.R.), University of Otago, Wellington; Departments of Medicine (P.A.B.) and General Practice (M.H.), Auckland University; Department of Medicine (J.H.G.), Hawke's Bay District Health Board, New Zealand; Department of Medicine (D.A.C., J.K.), School of Clinical Sciences, Monash University, Melbourne, Australia; Department of Medicine (A.D.), Whangarei Hospital; Department of Neurology (J.N.F.), Canterbury District Health Board, Christchurch; Medical Research Institute of New Zealand (H.K.M.), Wellington; Auckland University of Technology (V.L.F.); Stroke Foundation New Zealand (V.A.), Wellington; Consumer Advisor (J.G.); Centre for Public Health and Epidemiology (H.D., M.C., J.D.), Massey University, Wellington; Department of Medicine (A.W.), Wairau Hospital, Blenheim; and Department of Neurology (A.R.), Capital & Coast District Health Board, Wellington, New Zealand
| | - Matire Harwood
- From the Department of Medicine (S.G.T., W.L., A.R.), University of Otago, Wellington; Departments of Medicine (P.A.B.) and General Practice (M.H.), Auckland University; Department of Medicine (J.H.G.), Hawke's Bay District Health Board, New Zealand; Department of Medicine (D.A.C., J.K.), School of Clinical Sciences, Monash University, Melbourne, Australia; Department of Medicine (A.D.), Whangarei Hospital; Department of Neurology (J.N.F.), Canterbury District Health Board, Christchurch; Medical Research Institute of New Zealand (H.K.M.), Wellington; Auckland University of Technology (V.L.F.); Stroke Foundation New Zealand (V.A.), Wellington; Consumer Advisor (J.G.); Centre for Public Health and Epidemiology (H.D., M.C., J.D.), Massey University, Wellington; Department of Medicine (A.W.), Wairau Hospital, Blenheim; and Department of Neurology (A.R.), Capital & Coast District Health Board, Wellington, New Zealand
| | - William Levack
- From the Department of Medicine (S.G.T., W.L., A.R.), University of Otago, Wellington; Departments of Medicine (P.A.B.) and General Practice (M.H.), Auckland University; Department of Medicine (J.H.G.), Hawke's Bay District Health Board, New Zealand; Department of Medicine (D.A.C., J.K.), School of Clinical Sciences, Monash University, Melbourne, Australia; Department of Medicine (A.D.), Whangarei Hospital; Department of Neurology (J.N.F.), Canterbury District Health Board, Christchurch; Medical Research Institute of New Zealand (H.K.M.), Wellington; Auckland University of Technology (V.L.F.); Stroke Foundation New Zealand (V.A.), Wellington; Consumer Advisor (J.G.); Centre for Public Health and Epidemiology (H.D., M.C., J.D.), Massey University, Wellington; Department of Medicine (A.W.), Wairau Hospital, Blenheim; and Department of Neurology (A.R.), Capital & Coast District Health Board, Wellington, New Zealand
| | - Harry K McNaughton
- From the Department of Medicine (S.G.T., W.L., A.R.), University of Otago, Wellington; Departments of Medicine (P.A.B.) and General Practice (M.H.), Auckland University; Department of Medicine (J.H.G.), Hawke's Bay District Health Board, New Zealand; Department of Medicine (D.A.C., J.K.), School of Clinical Sciences, Monash University, Melbourne, Australia; Department of Medicine (A.D.), Whangarei Hospital; Department of Neurology (J.N.F.), Canterbury District Health Board, Christchurch; Medical Research Institute of New Zealand (H.K.M.), Wellington; Auckland University of Technology (V.L.F.); Stroke Foundation New Zealand (V.A.), Wellington; Consumer Advisor (J.G.); Centre for Public Health and Epidemiology (H.D., M.C., J.D.), Massey University, Wellington; Department of Medicine (A.W.), Wairau Hospital, Blenheim; and Department of Neurology (A.R.), Capital & Coast District Health Board, Wellington, New Zealand
| | - Valery L Feigin
- From the Department of Medicine (S.G.T., W.L., A.R.), University of Otago, Wellington; Departments of Medicine (P.A.B.) and General Practice (M.H.), Auckland University; Department of Medicine (J.H.G.), Hawke's Bay District Health Board, New Zealand; Department of Medicine (D.A.C., J.K.), School of Clinical Sciences, Monash University, Melbourne, Australia; Department of Medicine (A.D.), Whangarei Hospital; Department of Neurology (J.N.F.), Canterbury District Health Board, Christchurch; Medical Research Institute of New Zealand (H.K.M.), Wellington; Auckland University of Technology (V.L.F.); Stroke Foundation New Zealand (V.A.), Wellington; Consumer Advisor (J.G.); Centre for Public Health and Epidemiology (H.D., M.C., J.D.), Massey University, Wellington; Department of Medicine (A.W.), Wairau Hospital, Blenheim; and Department of Neurology (A.R.), Capital & Coast District Health Board, Wellington, New Zealand
| | - Virginia Abernethy
- From the Department of Medicine (S.G.T., W.L., A.R.), University of Otago, Wellington; Departments of Medicine (P.A.B.) and General Practice (M.H.), Auckland University; Department of Medicine (J.H.G.), Hawke's Bay District Health Board, New Zealand; Department of Medicine (D.A.C., J.K.), School of Clinical Sciences, Monash University, Melbourne, Australia; Department of Medicine (A.D.), Whangarei Hospital; Department of Neurology (J.N.F.), Canterbury District Health Board, Christchurch; Medical Research Institute of New Zealand (H.K.M.), Wellington; Auckland University of Technology (V.L.F.); Stroke Foundation New Zealand (V.A.), Wellington; Consumer Advisor (J.G.); Centre for Public Health and Epidemiology (H.D., M.C., J.D.), Massey University, Wellington; Department of Medicine (A.W.), Wairau Hospital, Blenheim; and Department of Neurology (A.R.), Capital & Coast District Health Board, Wellington, New Zealand
| | - Jacqueline Girvan
- From the Department of Medicine (S.G.T., W.L., A.R.), University of Otago, Wellington; Departments of Medicine (P.A.B.) and General Practice (M.H.), Auckland University; Department of Medicine (J.H.G.), Hawke's Bay District Health Board, New Zealand; Department of Medicine (D.A.C., J.K.), School of Clinical Sciences, Monash University, Melbourne, Australia; Department of Medicine (A.D.), Whangarei Hospital; Department of Neurology (J.N.F.), Canterbury District Health Board, Christchurch; Medical Research Institute of New Zealand (H.K.M.), Wellington; Auckland University of Technology (V.L.F.); Stroke Foundation New Zealand (V.A.), Wellington; Consumer Advisor (J.G.); Centre for Public Health and Epidemiology (H.D., M.C., J.D.), Massey University, Wellington; Department of Medicine (A.W.), Wairau Hospital, Blenheim; and Department of Neurology (A.R.), Capital & Coast District Health Board, Wellington, New Zealand
| | - Joosup Kim
- From the Department of Medicine (S.G.T., W.L., A.R.), University of Otago, Wellington; Departments of Medicine (P.A.B.) and General Practice (M.H.), Auckland University; Department of Medicine (J.H.G.), Hawke's Bay District Health Board, New Zealand; Department of Medicine (D.A.C., J.K.), School of Clinical Sciences, Monash University, Melbourne, Australia; Department of Medicine (A.D.), Whangarei Hospital; Department of Neurology (J.N.F.), Canterbury District Health Board, Christchurch; Medical Research Institute of New Zealand (H.K.M.), Wellington; Auckland University of Technology (V.L.F.); Stroke Foundation New Zealand (V.A.), Wellington; Consumer Advisor (J.G.); Centre for Public Health and Epidemiology (H.D., M.C., J.D.), Massey University, Wellington; Department of Medicine (A.W.), Wairau Hospital, Blenheim; and Department of Neurology (A.R.), Capital & Coast District Health Board, Wellington, New Zealand
| | - Hayley Denison
- From the Department of Medicine (S.G.T., W.L., A.R.), University of Otago, Wellington; Departments of Medicine (P.A.B.) and General Practice (M.H.), Auckland University; Department of Medicine (J.H.G.), Hawke's Bay District Health Board, New Zealand; Department of Medicine (D.A.C., J.K.), School of Clinical Sciences, Monash University, Melbourne, Australia; Department of Medicine (A.D.), Whangarei Hospital; Department of Neurology (J.N.F.), Canterbury District Health Board, Christchurch; Medical Research Institute of New Zealand (H.K.M.), Wellington; Auckland University of Technology (V.L.F.); Stroke Foundation New Zealand (V.A.), Wellington; Consumer Advisor (J.G.); Centre for Public Health and Epidemiology (H.D., M.C., J.D.), Massey University, Wellington; Department of Medicine (A.W.), Wairau Hospital, Blenheim; and Department of Neurology (A.R.), Capital & Coast District Health Board, Wellington, New Zealand
| | - Marine Corbin
- From the Department of Medicine (S.G.T., W.L., A.R.), University of Otago, Wellington; Departments of Medicine (P.A.B.) and General Practice (M.H.), Auckland University; Department of Medicine (J.H.G.), Hawke's Bay District Health Board, New Zealand; Department of Medicine (D.A.C., J.K.), School of Clinical Sciences, Monash University, Melbourne, Australia; Department of Medicine (A.D.), Whangarei Hospital; Department of Neurology (J.N.F.), Canterbury District Health Board, Christchurch; Medical Research Institute of New Zealand (H.K.M.), Wellington; Auckland University of Technology (V.L.F.); Stroke Foundation New Zealand (V.A.), Wellington; Consumer Advisor (J.G.); Centre for Public Health and Epidemiology (H.D., M.C., J.D.), Massey University, Wellington; Department of Medicine (A.W.), Wairau Hospital, Blenheim; and Department of Neurology (A.R.), Capital & Coast District Health Board, Wellington, New Zealand
| | - Andrew Wilson
- From the Department of Medicine (S.G.T., W.L., A.R.), University of Otago, Wellington; Departments of Medicine (P.A.B.) and General Practice (M.H.), Auckland University; Department of Medicine (J.H.G.), Hawke's Bay District Health Board, New Zealand; Department of Medicine (D.A.C., J.K.), School of Clinical Sciences, Monash University, Melbourne, Australia; Department of Medicine (A.D.), Whangarei Hospital; Department of Neurology (J.N.F.), Canterbury District Health Board, Christchurch; Medical Research Institute of New Zealand (H.K.M.), Wellington; Auckland University of Technology (V.L.F.); Stroke Foundation New Zealand (V.A.), Wellington; Consumer Advisor (J.G.); Centre for Public Health and Epidemiology (H.D., M.C., J.D.), Massey University, Wellington; Department of Medicine (A.W.), Wairau Hospital, Blenheim; and Department of Neurology (A.R.), Capital & Coast District Health Board, Wellington, New Zealand
| | - Jeroen Douwes
- From the Department of Medicine (S.G.T., W.L., A.R.), University of Otago, Wellington; Departments of Medicine (P.A.B.) and General Practice (M.H.), Auckland University; Department of Medicine (J.H.G.), Hawke's Bay District Health Board, New Zealand; Department of Medicine (D.A.C., J.K.), School of Clinical Sciences, Monash University, Melbourne, Australia; Department of Medicine (A.D.), Whangarei Hospital; Department of Neurology (J.N.F.), Canterbury District Health Board, Christchurch; Medical Research Institute of New Zealand (H.K.M.), Wellington; Auckland University of Technology (V.L.F.); Stroke Foundation New Zealand (V.A.), Wellington; Consumer Advisor (J.G.); Centre for Public Health and Epidemiology (H.D., M.C., J.D.), Massey University, Wellington; Department of Medicine (A.W.), Wairau Hospital, Blenheim; and Department of Neurology (A.R.), Capital & Coast District Health Board, Wellington, New Zealand
| | - Annemarei Ranta
- From the Department of Medicine (S.G.T., W.L., A.R.), University of Otago, Wellington; Departments of Medicine (P.A.B.) and General Practice (M.H.), Auckland University; Department of Medicine (J.H.G.), Hawke's Bay District Health Board, New Zealand; Department of Medicine (D.A.C., J.K.), School of Clinical Sciences, Monash University, Melbourne, Australia; Department of Medicine (A.D.), Whangarei Hospital; Department of Neurology (J.N.F.), Canterbury District Health Board, Christchurch; Medical Research Institute of New Zealand (H.K.M.), Wellington; Auckland University of Technology (V.L.F.); Stroke Foundation New Zealand (V.A.), Wellington; Consumer Advisor (J.G.); Centre for Public Health and Epidemiology (H.D., M.C., J.D.), Massey University, Wellington; Department of Medicine (A.W.), Wairau Hospital, Blenheim; and Department of Neurology (A.R.), Capital & Coast District Health Board, Wellington, New Zealand.
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Seguin M, Morris M, McKee M, Nolte E. "There's Not Enough Bodies to Do the Demand": An Exploration of Key Stakeholder Views on the Role of Health Service Capacity in Shaping Cancer Outcomes in 7 International Cancer Benchmarking Partnership Countries. Int J Health Policy Manag 2022; 11:1024-1034. [PMID: 33589567 PMCID: PMC9808162 DOI: 10.34172/ijhpm.2020.254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/09/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Differences in cancer survival are shaped by differences in health system capacity in workforce and infrastructure. Part of the International Cancer Benchmarking Partnership (ICBP), this study explored stakeholders' perceptions of the role of health system capacity necessary for cancer care in influencing cancer survival in 7 high-income countries. METHODS We conducted semi-structured interviews with 79 key informants from national, regional, and local tiers of health systems, professional bodies, patient associations, and academic experts in Australia, Canada, Denmark, Ireland, New Zealand, Norway, and the United Kingdom. Data collection was guided by a conceptual model linking characteristics of health systems and cancer survival along the cancer patient journey, from recognition of symptoms at pre-diagnostic stages through to survivorship or death. Data were analysed using a thematic approach. RESULTS We identified 3 themes as important in shaping cancer outcomes: primary care and access to diagnostic evaluation, specialist care and access to treatment, and workforce pertaining to diagnostic and treatment phases. Improved infrastructure for diagnosis and treatment had improved cancer outcomes in all jurisdictions. However, this was seen as insufficient if staffing was inadequate. Consolidation of services and greater surgical specialisation was important in some jurisdictions if accompanied by a reconfiguration of services, in particular the creation of specialist multidisciplinary teams, along with supporting capacity in the wider health system. Staff shortages were commonly cited as reasons why some jurisdictions lagged behind others. CONCLUSION Continued improvement in cancer outcomes will require sustained investment in plans to deliver and maintain the workforce engaged in cancer care and in the infrastructure on which they depend. However, strategic plans must recognise that systems for cancer care do not work in isolation from the rest of the health system and a whole systems approach is essential if we are to improve outcomes for an ageing, increasingly multimorbid population.
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Affiliation(s)
| | | | | | - Ellen Nolte
- Department of Health Services Research & Policy, London School of Hygiene & Topical Medicine, London, UK
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10
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Hargroves D, Lowe D, Wood M, Ray S. Networks for future healthcare. Future Healthc J 2022; 9:118-124. [DOI: 10.7861/fhj.2022-0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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11
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Price CI, White P, Balami J, Bhattarai N, Coughlan D, Exley C, Flynn D, Halvorsrud K, Lally J, McMeekin P, Shaw L, Snooks H, Vale L, Watkins A, Ford GA. Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2022. [DOI: 10.3310/tzty9915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Intravenous thrombolysis and intra-arterial thrombectomy are proven emergency treatments for acute ischaemic stroke, but they require rapid delivery to selected patients within specialist services. National audit data have shown that treatment provision is suboptimal.
Objectives
The aims were to (1) determine the content, clinical effectiveness and day 90 cost-effectiveness of an enhanced paramedic assessment designed to facilitate thrombolysis delivery in hospital and (2) model thrombectomy service configuration options with optimal activity and cost-effectiveness informed by expert and public views.
Design
A mixed-methods approach was employed between 2014 and 2019. Systematic reviews examined enhanced paramedic roles and thrombectomy effectiveness. Professional and service user groups developed a thrombolysis-focused Paramedic Acute Stroke Treatment Assessment, which was evaluated in a pragmatic multicentre cluster randomised controlled trial and parallel process evaluation. Clinicians, patients, carers and the public were surveyed regarding thrombectomy service configuration. A decision tree was constructed from published data to estimate thrombectomy eligibility of the UK stroke population. A matching discrete-event simulation predicted patient benefits and financial consequences from increasing the number of centres.
Setting
The paramedic assessment trial was hosted by three regional ambulance services (in north-east England, north-west England and Wales) serving 15 hospitals.
Participants
A total of 103 health-care representatives and 20 public representatives assisted in the development of the paramedic assessment. The trial enrolled 1214 stroke patients within 4 hours of symptom onset. Thrombectomy service provision was informed by a Delphi exercise with 64 stroke specialists and neuroradiologists, and surveys of 147 patients and 105 public respondents.
Interventions
The paramedic assessment comprised additional pre-hospital information collection, structured hospital handover, practical assistance up to 15 minutes post handover, a pre-departure care checklist and clinician feedback.
Main outcome measures
The primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included day 90 health (poor status was a modified Rankin Scale score of > 2). Economic outputs reported the number of cases treated and cost-effectiveness using quality-adjusted life-years and Great British pounds.
Data sources
National registry data from the Sentinel Stroke National Audit Programme and the Scottish Stroke Care Audit were used.
Review methods
Systematic searches of electronic bibliographies were used to identify relevant literature. Study inclusion and data extraction processes were described using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
Results
The paramedic assessment trial found a clinically important but statistically non-significant reduction in thrombolysis among intervention patients, compared with standard care patients [197/500 (39.4%) vs. 319/714 (44.7%), respectively] (adjusted odds ratio 0.81, 95% confidence interval 0.61 to 1.08; p = 0.15). The rate of poor health outcomes was not significantly different, but was lower in the intervention group than in the standard care group [313/489 (64.0%) vs. 461/690 (66.8%), respectively] (adjusted odds ratio 0.86, 95% confidence interval 0.60 to 1.2; p = 0.39). There was no difference in the quality-adjusted life-years gained between the groups (0.005, 95% confidence interval –0.004 to 0.015), but total costs were significantly lower for patients in the intervention group than for those in the standard care group (–£1086, 95% confidence interval –£2236 to –£13). It has been estimated that, in the UK, 10,140–11,530 patients per year (i.e. 12% of stroke admissions) are eligible for thrombectomy. Meta-analysis of published data confirmed that thrombectomy-treated patients were significantly more likely to be functionally independent than patients receiving standard care (odds ratio 2.39, 95% confidence interval 1.88 to 3.04; n = 1841). Expert consensus and most public survey respondents favoured selective secondary transfer for accessing thrombectomy at regional neuroscience centres. The discrete-event simulation model suggested that six new English centres might generate 190 quality-adjusted life-years (95% confidence interval –6 to 399 quality-adjusted life-years) and a saving of £1,864,000 per year (95% confidence interval –£1,204,000 to £5,017,000 saving per year). The total mean thrombectomy cost up to 72 hours was £12,440, mostly attributable to the consumables. There was no significant cost difference between direct admission and secondary transfer (mean difference –£368, 95% confidence interval –£1016 to £279; p = 0.26).
Limitations
Evidence for paramedic assessment fidelity was limited and group allocation could not be masked. Thrombectomy surveys represented respondent views only. Simulation models assumed that populations were consistent with published meta-analyses, included limited parameters reflecting underlying data sets and did not consider the capital costs of setting up new services.
Conclusions
Paramedic assessment did not increase the proportion of patients receiving thrombolysis, but outcomes were consistent with improved cost-effectiveness at day 90, possibly reflecting better informed treatment decisions and/or adherence to clinical guidelines. However, the health difference was non-significant, small and short term. Approximately 12% of stroke patients are suitable for thrombectomy and widespread provision is likely to generate health and resource gains. Clinician and public views support secondary transfer to access treatment.
Future work
Further evaluation of emergency care pathways will determine whether or not enhanced paramedic assessment improves hospital guideline compliance. Validation of the simulation model post reconfiguration will improve precision and describe wider resource implications.
Trial registration
This trial is registered as ISRCTN12418919 and the systematic review protocols are registered as PROSPERO CRD42014010785 and PROSPERO CRD42015016649.
Funding
The project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 4. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Christopher I Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Phil White
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Joyce Balami
- Department of Stroke Medicine, Norfolk and Norwich University Teaching Hospital NHS Trust, Norwich, UK
| | - Nawaraj Bhattarai
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Diarmuid Coughlan
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Exley
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Darren Flynn
- School of Health & Life Sciences, Teesside University, Middlesbrough, UK
| | - Kristoffer Halvorsrud
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Joanne Lally
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Peter McMeekin
- School of Health, Community and Education Studies, Northumbria University, Newcastle upon Tyne, UK
| | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Snooks
- Centre for Health Information Research and Evaluation, Medical School, Swansea University, Swansea, UK
| | - Luke Vale
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Alan Watkins
- Centre for Health Information Research and Evaluation, Medical School, Swansea University, Swansea, UK
| | - Gary A Ford
- Oxford Academic Health Science Network, Oxford University and Oxford University Hospitals, Oxford, UK
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Walton H, Simpson A, Ramsay AIG, Hudson E, Hunter A, Jones J, Ng PL, Leeson-Beevers K, Bloom L, Kai J, Kerecuk L, Kokocinska M, Sutcliffe AG, Morris S, Fulop NJ. Developing a taxonomy of care coordination for people living with rare conditions: a qualitative study. Orphanet J Rare Dis 2022; 17:171. [PMID: 35443702 PMCID: PMC9020422 DOI: 10.1186/s13023-022-02321-w] [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: 11/24/2021] [Accepted: 04/09/2022] [Indexed: 12/03/2022] Open
Abstract
Background Improving care coordination is particularly important for individuals with rare conditions (who may experience multiple inputs into their care, across different providers and settings). To develop and evaluate strategies to potentially improve care coordination, it is necessary to develop a method for organising different ways of coordinating care for rare conditions. Developing a taxonomy would help to describe different ways of coordinating care and in turn facilitate development and evaluation of pre-existing and new models of care coordination for rare conditions. To the authors’ knowledge, no studies have previously developed taxonomies of care coordination for rare conditions. This research aimed to develop and refine a care coordination taxonomy for people with rare conditions. Methods This study had a qualitative design and was conducted in the United Kingdom. To develop a taxonomy, six stages of taxonomy development were followed. We conducted interviews (n = 30 health care professionals/charity representatives/commissioners) and focus groups (n = 4 focus groups, 22 patients/carers with rare/ultra-rare/undiagnosed conditions). Interviews and focus groups were audio-recorded with consent, and professionally transcribed. Findings were analysed using thematic analysis. Themes were used to develop a taxonomy, and to identify which types of coordination may work best in which situations. To refine the taxonomy, we conducted two workshops (n = 12 patients and carers group; n = 15 professional stakeholder group). Results Our taxonomy has six domains, each with different options. The six domains are: (1) Ways of organising care (local, hybrid, national), (2) Ways of organising those involved in care (collaboration between many or all individuals, collaboration between some individuals, a lack of collaborative approach), (3) Responsibility for coordination (administrative support, formal roles and responsibilities, supportive roles and no responsibility), (4) How often appointments and coordination take place (regular, on demand, hybrid), (5) Access to records (full or filtered access), and (6) Mode of care coordination (face-to-face, digital, telephone). Conclusions Findings indicate that there are different ways of coordinating care across the six domains outlined in our taxonomy. This may help to facilitate the development and evaluation of existing and new models of care coordination for people living with rare conditions. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02321-w.
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Affiliation(s)
- Holly Walton
- Department of Applied Health Research, University College London, Gower Street, London, WC1E 6BT, UK.
| | - Amy Simpson
- Department of Applied Health Research, University College London, Gower Street, London, WC1E 6BT, UK.,Genetic Alliance UK, Creative Works, 7 Blackhorse Lane, London, E17 6DS, UK
| | - Angus I G Ramsay
- Department of Applied Health Research, University College London, Gower Street, London, WC1E 6BT, UK
| | - Emma Hudson
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Amy Hunter
- Genetic Alliance UK, Creative Works, 7 Blackhorse Lane, London, E17 6DS, UK
| | - Jennifer Jones
- Genetic Alliance UK, Creative Works, 7 Blackhorse Lane, London, E17 6DS, UK
| | - Pei Li Ng
- Department of Applied Health Research, University College London, Gower Street, London, WC1E 6BT, UK
| | | | - Lara Bloom
- The Ehlers-Danlos Society and Academic of Patient Engagement and Global Collaboration, Penn State College of Medicine, Hershey, USA
| | - Joe Kai
- Division of Primary Care, School of Medicine, University of Nottingham, Floors 13-15, Tower Building, University Park, Nottingham, NG7 2RD, UK
| | - Larissa Kerecuk
- Birmingham Women's and Children's NHS Foundation Trust, NIHR CRN West Midlands, Birmingham, UK
| | - Maria Kokocinska
- Birmingham Women's and Children's NHS Foundation Trust, NIHR CRN West Midlands, Birmingham, UK
| | - Alastair G Sutcliffe
- UCL and Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Stephen Morris
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, Gower Street, London, WC1E 6BT, UK
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13
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Medina-Rioja R, González-Calderón G, Saldívar-Dávila S, Estrada Saúl A, Gayón-Lombardo E, Somerville-Briones N, Calleja-Castillo JM. Grace Under Pressure: Resiliency of Quality Monitoring of Stroke Care During the Covid-19 Pandemic in Mexico City. Front Neurol 2022; 13:831735. [PMID: 35463140 PMCID: PMC9020365 DOI: 10.3389/fneur.2022.831735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/11/2022] [Indexed: 11/19/2022] Open
Abstract
Stroke is one of the leading causes of death and disability among adults worldwide. The World Health Organization (WHO) officially declared a COVID-19 pandemic on March 11, 2020. The first case in Mexico was confirmed in February 2020, subsequently becoming one of the countries most affected by the pandemic. In 2020, The National Institute of Neurology of Mexico started a Quality assurance program for stroke care, consisting of registering, monitoring and feedback of stroke quality measures through the RES-Q platform. We aim to describe changes in the demand for stroke healthcare assistance at the National Institute of Neurology and Neurosurgery during the pandemic and the behavior of stroke quality metrics during the prepandemic and the pandemic periods. For this study, we analyzed data for acute stroke patients registered in the RES-Q platform, in the prepandemic (November 2019 to February 2020) and pandemic (March-December 2020) periods in two groups, one prior to the pandemic. During the pandemic, there was an increase in the total number of assessed acute stroke patients at our hospital, from 474 to 574. The average time from the onset of symptoms to hospital arrival (Onset to Door Time—OTD) for all stroke patients (thrombolyzed and non-thrombolyzed) increased from 9 h (542 min) to 10.3 h (618.3 min) in the pandemic group. A total of 135 acute stroke patients were enrolled in this registry. We found the following results: Patients in both groups were studied with non-contrast computed tomography (NNCT), computed tomography angiography (CTA), magnetic resonance angiography (MRA), digital subtraction angiography (DSA) or more frequently in the pandemic period (early carotid imaging, Holter monitoring) as needed. Treatment for secondary prevention (antihypertensives, antiplatelets, statins) did not differ. Frequency of performing and documenting the performance of NIHSS scale at arrival and early dysphagia test improved. There was an increase in alteplase use from 21 to 42% (p = 0.03). There was a decrease in door to needle time (46 vs. 39 min p = 0.30). After the implementation of a stroke care protocol and quality monitoring system, acute stroke treatment in our institution has gradually improved, a process that was not thwarted during the COVID-19 pandemic.
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Walton H, Simpson A, Ramsay AIG, Hunter A, Jones J, Ng PL, Leeson-Beevers K, Bloom L, Kai J, Kokocinska M, Sutcliffe AG, Morris S, Fulop NJ. Development of models of care coordination for rare conditions: a qualitative study. Orphanet J Rare Dis 2022; 17:49. [PMID: 35164822 PMCID: PMC8843018 DOI: 10.1186/s13023-022-02190-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/30/2022] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Improving care coordination for people with rare conditions may help to reduce burden on patients and carers and improve the care that patients receive. We recently developed a taxonomy of different ways of coordinating care for rare conditions. It is not yet known which models of care coordination are appropriate in different situations. This study aimed to: (1) explore what types of care coordination may be appropriate in different situations, and (2) use these findings to develop hypothetical models of care coordination for rare conditions. METHODS To explore appropriateness of different types of care coordination, we conducted interviews (n = 30), four focus groups (n = 22) and two workshops (n = 27) with patients, carers, healthcare professionals, commissioners, and charity representatives. Participants were asked about preferences, benefits and challenges, and the factors influencing coordination. Thematic analysis was used to develop hypothetical models of care coordination. Models were refined following feedback from workshop participants. RESULTS Stakeholders prefer models of care that: are nationally centralised or a hybrid of national and local care, involve professionals collaborating to deliver care, have clear roles and responsibilities outlined (including administrative, coordinator, clinical and charity roles), provide access to records and offer flexible appointments (in terms of timing and mode). Many factors influenced coordination, including those relating to the patient (e.g., condition complexity, patient's location and ability to coordinate their own care), the healthcare professional (e.g., knowledge and time), the healthcare environment (e.g., resources) and societal factors (e.g., availability of funding). We developed and refined ten illustrative hypothetical models of care coordination for rare conditions. CONCLUSION Findings underline that different models of care coordination may be appropriate in different situations. It is possible to develop models of care coordination which are tailored to the individual in context. Findings may be used to facilitate planning around which models of care coordination may be appropriate in different services or circumstances. Findings may also be used by key stakeholders (e.g. patient organisations, clinicians and service planners) as a decision-making tool.
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Affiliation(s)
- Holly Walton
- Department of Applied Health Research, University College London, Gower Street, London, WC1E 6BT, UK.
| | - Amy Simpson
- Department of Applied Health Research, University College London, Gower Street, London, WC1E 6BT, UK
- Genetic Alliance UK, Creative Works, 7 Blackhorse Lane, London, E17 6DS, UK
| | - Angus I G Ramsay
- Department of Applied Health Research, University College London, Gower Street, London, WC1E 6BT, UK
| | - Amy Hunter
- Genetic Alliance UK, Creative Works, 7 Blackhorse Lane, London, E17 6DS, UK
| | - Jennifer Jones
- Genetic Alliance UK, Creative Works, 7 Blackhorse Lane, London, E17 6DS, UK
| | - Pei Li Ng
- Department of Applied Health Research, University College London, Gower Street, London, WC1E 6BT, UK
| | | | - Lara Bloom
- Penn State College of Medicine, Hershey, USA
- The Ehlers-Danlos Society, Newyork, USA
| | - Joe Kai
- Division of Primary Care, Centre for Academic Primary Care, NIHR School for Primary Care Research, University of Nottingham, Floors 13-15, Tower Building, University Park, Nottingham, NG7 2RD, UK
| | - Maria Kokocinska
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Alastair G Sutcliffe
- UCL and Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Stephen Morris
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, Gower Street, London, WC1E 6BT, UK
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15
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Vindrola-Padros C, Ramsay AIG, Black G, Barod R, Hines J, Mughal M, Shackley D, Fulop NJ. Inter-organisational collaboration enabling care delivery in a specialist cancer surgery provider network: A qualitative study. J Health Serv Res Policy 2022; 27:211-221. [PMID: 35130097 PMCID: PMC9277336 DOI: 10.1177/13558196211053954] [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: 12/02/2022]
Abstract
Objective To explore the processes, challenges and strategies used to govern and
maintain inter-organisational collaboration between professionals in a
provider network in London, United Kingdom, which implemented major system
change focused on the centralisation of specialist cancer surgery. Methods We used a qualitative design involving interviews with stakeholders
(n = 117), non-participant observations
(n = 163) and documentary analysis (n
= 100). We drew on an existing model of collaboration in healthcare
organisations and expanded this framework by applying it to the analysis of
collaboration in the context of major system change. Results Network provider organisations established shared goals, maintained central
figures who could create and sustain collaboration, and promoted distributed
forms of leadership. Still, organisations continued to encounter barriers or
challenges in relation to developing opportunities for mutual
acquaintanceship across all professional groups; the active sharing of
knowledge, expertise and good practice across the network; the fostering of
trust; and creation of information exchange infrastructures fit for
collaborative purposes. Conclusion Collaborative relationships changed over time, becoming stronger
post-implementation in some areas, but continued to be negotiated where
resistance to the centralisation remained. Future research should explore
the sustainability of these relationships and further unpack how hierarchies
and power relationships shape inter-organisational collaboration.
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Affiliation(s)
- Cecilia Vindrola-Padros
- Senior Research Fellow, Department of Targeted Intervention, University College London, London, UK
| | - Angus I G Ramsay
- Senior Research Fellow, Department of Applied Health Research, University College London, London, UK
| | - Georgia Black
- Principal Research Fellow, Department of Applied Health Research, 4919University College London, London, UK
| | - Ravi Barod
- Consultant Urological Surgeon, Specialist Centre for Kidney Cancer, 4965Royal Free London NHS Foundation Trust, London, UK
| | - John Hines
- Consultant Urological Surgeon and London Cancer Urology Pathway Board Director, Department of Urology, 8964University College London Hospitals NHS Foundation Trust, London, UK
| | - Muntzer Mughal
- Consultant General & Upper Gastrointestinal Surgeon, 8964University College London Hospitals NHS Foundation Trust, London, UK
| | - David Shackley
- Medical Director, Greater Manchester Cancer and Manchester Academic Health Science Centre, Christie NHS Foundation Trust, Manchester, UK
| | - Naomi J Fulop
- Professor of Health Care Organisation and Management, Department of Applied Health Research, University College London, London, UK
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16
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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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17
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Langhorne P. The Stroke Unit Story: Where Have We Been and Where Are We Going? Cerebrovasc Dis 2021; 50:636-643. [PMID: 34547746 DOI: 10.1159/000518934] [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: 05/26/2021] [Accepted: 06/17/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The concept of stroke unit care has been discussed for over 50 years, but it is only in the last 25 years that clear evidence of its effectiveness has emerged to inform these discussions. SUMMARY This review outlines the history of the concept of stroke units to improve recovery after stroke and their evaluation in clinical trials. It describes the first systematic review of stroke unit trials published in 1993, the establishment of a collaborative research group (the Stroke Unit Trialists' Collaboration), the subsequent analyses and updates of the evidence base, and the efforts to implement stroke unit care in routine settings. The final section considers some of the remaining challenges in this area of research and clinical practice. Key Messages: Good quality evidence confirms that stroke patients who are looked after in a stroke unit are more likely to survive and be independent and living at home 1 year after their stroke. The apparent benefits are independent of patient age, sex, stroke type, or initial stroke severity. The benefits are most obvious in units based in a discrete ward (stroke ward). The current challenges include integrating effective stroke units with more recent systems to deliver hyper-acute stroke interventions and implementing stroke units in lower resource regions.
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Affiliation(s)
- Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, Academic Section of Geriatric Medicine, University of Glasgow, Glasgow, United Kingdom
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18
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Ladwig S, Ziegler M, Südmeyer M, Werheid K. The Post-Stroke Depression Risk Scale (PoStDeRiS): Development of an Acute-Phase Prediction Model for Depression 6 Months After Stroke. J Acad Consult Liaison Psychiatry 2021; 63:144-152. [PMID: 34438096 DOI: 10.1016/j.jaclp.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/06/2021] [Accepted: 08/11/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Depression after stroke is common but often undertreated as increasing depression prevalence and decreasing health care contacts diverge after the event. OBJECTIVE To develop an acute-phase prediction scale for prognosis of depression 6 months after stroke. METHODS Participants (N = 226) were consecutively recruited and assessed within the first week after ischemic stroke for history of depression, stroke severity (National Institutes of Health Stroke Scale), and functional independence (Barthel Index). Early depressive symptoms were self-reported via the Patient Health Questionnaire-2 and external-rated by nurses via the Signs of Depression Scale. Six months later, 183 participants were assessed for Diagnostic and Statistical Manual of Mental Disorders, 5th edition diagnosis of depression. Significant predictors of depression were identified in multivariate logistic regression analysis and their coefficients transformed into a risk scale. Measurement precision was identified using receiver operating characteristic curve analysis. RESULTS Depression was diagnosed in 32 (17.5%) participants 6 months after stroke. History of depression, the Barthel Index, and the Patient Health Questionnaire-2 were significant predictors of depression. Transformation of the coefficients yielded the Post-Stroke Depression Risk Scale that demonstrated good discrimination (area under the receiver operating characteristic curve = 0.84; 95% confidence interval = 0.78/0.90). The optimum cutoff showed a sensitivity of 0.81, a specificity of 0.72, a positive predictive value of 0.38, and a negative predictive value of 0.95. CONCLUSIONS The Post-Stroke Depression Risk Scale accurately identifies people in the acute phase with low risk of depression 6 months later, which saves expendable psychiatric interviews in stroke patients. While the sensitivity indicates that recognition of people with later depression is adequate, positive results in the acute phase show low predictivity. Clinical and methodological reasons for these results as well as implications for future research to increase case-finding ability are discussed.
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Affiliation(s)
- Simon Ladwig
- Department of Clinical Neuropsychology, Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany; Department of Neurology, Klinikum Ernst von Bergmann, Potsdam, Germany.
| | - Matthias Ziegler
- Psychological Assessment, Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Martin Südmeyer
- Department of Neurology, Klinikum Ernst von Bergmann, Potsdam, Germany; Department of Neurology, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Katja Werheid
- Department of Clinical Neuropsychology, Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany; Department of Neurology, Klinikum Ernst von Bergmann, Potsdam, Germany
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19
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Galvin KT, Pound C, Cowdell F, Ellis-Hill C, Sloan C, Brooks S, Ersser SJ. A lifeworld theory-led action research process for humanizing services: improving "what matters" to older people to enhance humanly sensitive care. Int J Qual Stud Health Well-being 2021; 15:1817275. [PMID: 33222652 PMCID: PMC7717129 DOI: 10.1080/17482631.2020.1817275] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Purpose: Using a theory-led action research process test applicability of humanizing care theory to better understand what matters to people and assess how the process can improve human dimensions of health care services. Consideration of the value of this process to guide enhancements in humanly sensitive care and investigate transferable benefits of the participatory strategy for improving human dimensions of health care services. Methods: Action research with service users, practitioners and academics, with participatory processes led through the application of theory via a novel Humanizing Care Framework in two diverse clinical settings. Results: Participants engaged in a theory-led participatory process, understood and valued the framework seeing how it relates to own experiences. Comparative analysis of settings identified transferable processes with potential to enhance human dimensions of care more generally. We offer transferable strategy with contextualized practical details of humanizing processes and outcomes that can contribute to portable pathways to enhance dignity in care through application of humanizing care theory in practice. Conclusion: The theoretical framework is a feasible and effective guide to enhance human dimensions of care. Our rigorous participative process facilitates sharing of patient and staff experience, sensitizing practitioners’ understandings and helping develop new ways of providing theoretically robust person-centred care based on lifeworld approaches.
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Affiliation(s)
| | - Carole Pound
- Faculty of Health and Social Sciences, Bournemouth University , Bournemouth, UK
| | - Fiona Cowdell
- Faculty of Health, Education and Life Sciences, Birmingham City University , Bournemouth, UK
| | - Caroline Ellis-Hill
- Faculty of Health and Social Sciences, Bournemouth University , Bournemouth, UK
| | - Claire Sloan
- Academic Unit of Elderly Care and Rehabilitation, University of Bradford , Bradford, UK
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20
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Grimm F, Hodgson K, Brine R, Deeny SR. Hospital admissions from care homes in England during the COVID-19 pandemic: a retrospective, cross-sectional analysis using linked administrative data. Int J Popul Data Sci 2021; 5:1663. [PMID: 34286106 PMCID: PMC8267611 DOI: 10.23889/ijpds.v5i4.1663] [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] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Care home residents have complex healthcare needs but may have faced barriers to accessing hospital treatment during the first wave of the COVID-19 pandemic. OBJECTIVES To examine trends in the number of hospital admissions for care home residents during the first months of the COVID-19 outbreak. METHODS Retrospective analysis of a national linked dataset on hospital admissions for residential and nursing home residents in England (257,843 residents, 45% in nursing homes) between 20 January 2020 and 28 June 2020, compared to admissions during the corresponding period in 2019 (252,432 residents, 45% in nursing homes). Elective and emergency admission rates, normalised to the time spent in care homes across all residents, were derived across the first three months of the pandemic between 1 March and 31 May 2020 and primary admission reasons for this period were compared across years. RESULTS Hospital admission rates rapidly declined during early March 2020 and remained substantially lower than in 2019 until the end of June. Between March and May, 2,960 admissions from residential homes (16.2%) and 3,295 admissions from nursing homes (23.7%) were for suspected or confirmed COVID-19. Rates of other emergency admissions decreased by 36% for residential and by 38% for nursing home residents (13,191 fewer admissions in total). Emergency admissions for acute coronary syndromes fell by 43% and 29% (105 fewer admission) and emergency admissions for stroke fell by 17% and 25% (128 fewer admissions) for residential and nursing home residents, respectively. Elective admission rates declined by 64% for residential and by 61% for nursing home residents (3,762 fewer admissions). CONCLUSIONS This is the first study showing that care home residents' hospital use declined during the first wave of COVID-19, potentially resulting in substantial unmet health need that will need to be addressed alongside ongoing pressures from COVID-19.
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Affiliation(s)
- Fiona Grimm
- The Health Foundation, 8 Salisbury Square, London EC4Y 8AP, UK
| | - Karen Hodgson
- The Health Foundation, 8 Salisbury Square, London EC4Y 8AP, UK
| | - Richard Brine
- The Health Foundation, 8 Salisbury Square, London EC4Y 8AP, UK
| | - Sarah R Deeny
- The Health Foundation, 8 Salisbury Square, London EC4Y 8AP, UK
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21
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Maharaj R, McGuire A, Street A. Association of Annual Intensive Care Unit Sepsis Caseload With Hospital Mortality From Sepsis in the United Kingdom, 2010-2016. JAMA Netw Open 2021; 4:e2115305. [PMID: 34185067 PMCID: PMC8243236 DOI: 10.1001/jamanetworkopen.2021.15305] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Sepsis is associated with a high burden of inpatient mortality. Treatment in intensive care units (ICUs) that have more experience treating patients with sepsis may be associated with lower mortality. OBJECTIVE To assess the association between the volume of patients with sepsis receiving care in an ICU and hospital mortality from sepsis in the UK. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from adult patients with sepsis from 231 UK ICUs between 2010 and 2016. Demographic and clinical data were extracted from the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme database. Data were analyzed from January 1, 2010, to December 31, 2016. EXPOSURES Annual sepsis case volume in an ICU in the year of a patient's admission. MAIN OUTCOMES AND MEASURES Hospital mortality after ICU admission for sepsis assessed using a mixed-effects logistic model in a 3-level hierarchical structure based on the number of individual patients nested in years nested within ICUs. RESULTS Among 273 001 patients included in the analysis, the median age was 66 years (interquartile range, 53-76 years), 148 149 (54.3%) were male, and 248 275 (91.0%) were White. The mean ICNARC-2018 illness severity score was 21.0 (95% CI, 20.9-21.0). Septic shock accounted for 19.3% of patient admissions, and 54.3% of patients required mechanical ventilation. The median annual sepsis volume per ICU was 242 cases (interquartile range, 177-334 cases). The study identified a significant association between the volume of sepsis cases in the ICU and mortality from sepsis; in the logistic regression model, hospital mortality was significantly lower among patients admitted to ICUs in the highest quartile of sepsis volume compared with the lowest quartile (odds ratio [OR], 0.89; 95% CI, 0.82-0.96; P = .002). With volume modeled as a restricted cubic spline, treatment in a larger ICU was associated with lower hospital mortality. A lower annual volume threshold of 215 patients above which hospital mortality decreased significantly was found; 38.8% of patients were treated in ICUs below this threshold volume. There was no significant interaction between ICU volume and severity of illness as described by the ICNARC-2018 score (β [SE], -0.00014 [0.00024]; P = .57). CONCLUSIONS AND RELEVANCE The findings suggest that patients with sepsis in the UK have higher odds of survival if they are treated in an ICU with a larger sepsis case volume. The benefit of a high sepsis case volume was not associated with the severity of the sepsis episode.
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Affiliation(s)
- Ritesh Maharaj
- Department of Health Policy, London School of Economics and Political Science, London, UK
- Department of Critical Care, Kings College Hospital NHS Foundation Trust, London, UK
| | - Alistair McGuire
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Andrew Street
- Department of Health Policy, London School of Economics and Political Science, London, UK
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22
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Dwyer M, Peterson G, Gall S, Kinsman L, Francis K, Ford K, Castley H, Kitsos A, Hilliard T, English J. Regional differences in access to acute ischaemic stroke care and patient outcomes. Intern Med J 2021; 50:965-971. [PMID: 31566867 DOI: 10.1111/imj.14638] [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: 04/29/2019] [Revised: 09/06/2019] [Accepted: 09/07/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Advances in stroke management such as acute stroke units and thrombolysis are not uniformly distributed throughout our population, with rural areas being relatively disadvantaged. It remains unclear, however, whether such disparities have led to corresponding differences in patient outcomes. AIMS To describe the regional differences in acute ischaemic stroke care and outcomes within the Australian state of Tasmania. METHODS A retrospective case note audit was used to assess the care and outcomes of 395 acute ischaemic stroke patients admitted to Tasmania's four major public hospitals. Sixteen care processes were recorded, which covered time-critical treatment, allied health interventions and secondary prevention. Outcome measures were assessed using 30-day mortality and discharge destination, both of which were analysed for differences between urban and rural hospitals using logistic regression. RESULTS No patients in rural hospitals were administered thrombolysis; these hospitals also did not have acute stroke units. With few exceptions, patients' access to the remaining care indicators was comparable between regions. After adjusting for confounders, there were no significant differences between regions in terms of 30-day mortality (odds ratio (OR) = 0.99, 95% confidence interval (CI) 0.46-2.18) or discharge destination (OR = 1.24, 95% CI 0.81-1.91). CONCLUSIONS With the exception of acute stroke unit care and thrombolysis, acute ischaemic stroke care within Tasmania's urban and rural hospitals was broadly similar. No significant differences were found between regions in terms of patient outcomes. Future studies are encouraged to employ larger data sets, which capture a broader range of urban and rural sites and record patient outcomes at extended interval.
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Affiliation(s)
- Mitchell Dwyer
- College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Greg Peterson
- College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Seana Gall
- College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Leigh Kinsman
- School of Nursing and Midwifery, University of Newcastle, Newcastle, New South Wales, Australia
| | - Karen Francis
- College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Karen Ford
- Royal Hobart Hospital, Tasmanian Health Service, Hobart, Tasmania, Australia
| | - Helen Castley
- Royal Hobart Hospital, Tasmanian Health Service, Hobart, Tasmania, Australia
| | - Alex Kitsos
- College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Tamsin Hilliard
- Royal Hobart Hospital, Tasmanian Health Service, Hobart, Tasmania, Australia
| | - Jennifer English
- Royal Hobart Hospital, Tasmanian Health Service, Hobart, Tasmania, Australia
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23
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Deliwala SS, Hussain M, Ponnapalli A, Awuah D, Dawood T, Bachuwa G. Acute confusional state as a prognostic sign of COVID-19 large-vessel occlusion (LVO). BMJ Case Rep 2021; 14:14/2/e240536. [PMID: 33622754 PMCID: PMC7907863 DOI: 10.1136/bcr-2020-240536] [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] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
COVID-19 is well known for its respiratory symptoms, but severe presentations can alter haemostasis, causing acute end-organ damage with poor outcomes. Among its various neurological presentations, cerebrovascular events often present as small-vessel strokes. Although uncommon, in predisposed individuals, large-vessel occlusions (LVOs) can occur as a possible consequence of direct viral action (viral burden or antigenic structure) or virus-induced cytokine storm. Subtle presentations and complicated stroke care pathways continue to exist, delaying timely care. We present a unique case of COVID-19 LVO manifesting as an acute confusional state in an elderly man in April 2020. CT angiography revealed 'de novo' occlusions of the left internal carotid artery and proximal right vertebral artery, effectively blocking anterior and posterior circulations. Delirium can lead to inaccurate stroke scale assessments and prolong initiation of COVID-19 stroke care pathways. Future studies are needed to look into the temporal relationship between confusion and neurological manifestations.
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Affiliation(s)
| | - Murtaza Hussain
- Internal Medicine, Hurley Medical Center, Flint, Michigan, USA
| | | | - Dominic Awuah
- Internal Medicine, Hurley Medical Center, Flint, Michigan, USA
| | - Thair Dawood
- Internal Medicine, Hurley Medical Center, Flint, Michigan, USA
| | - Ghassan Bachuwa
- Internal Medicine, Hurley Medical Center, Flint, Michigan, USA
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24
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Price CI, Shaw L, Islam S, Javanbakht M, Watkins A, McMeekin P, Snooks H, Flynn D, Francis R, Lakey R, Sutcliffe L, McClelland G, Lally J, Exley C, Rodgers H, Russell I, Vale L, Ford GA. Effect of an Enhanced Paramedic Acute Stroke Treatment Assessment on Thrombolysis Delivery During Emergency Stroke Care: A Cluster Randomized Clinical Trial. JAMA Neurol 2021; 77:840-848. [PMID: 32282015 PMCID: PMC7154959 DOI: 10.1001/jamaneurol.2020.0611] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Question Can hospital stroke thrombolysis treatment rates be increased by an enhanced paramedic assessment that includes additional prehospital information collection, a structured hospital handover, practical assistance after handover, a predeparture care checklist, and clinician feedback? Findings In this cluster randomized clinical trial, fewer patients in the intervention group (39.4%) received thrombolysis vs those in the standard care group (44.7%), but there were fewer poor health outcomes (disability or death) after 90 days (intervention group, 64.0% vs standard care group, 66.8%). The results were not statistically significant. Meaning This study found that the enhanced paramedic assessment should not be used to increase thrombolysis volume but may influence the quality of treatment decisions. Importance Rapid thrombolysis treatment for acute ischemic stroke reduces disability among patients who are carefully selected, but service delivery is challenging. Objective To determine whether an enhanced Paramedic Acute Stroke Treatment Assessment (PASTA) intervention increased hospital thrombolysis rates. Design, Setting, and Participants This multicenter, cluster randomized clinical trial took place between December 2015 and July 2018 in 3 ambulance services and 15 hospitals. Clusters were paramedics based within ambulance stations prerandomized to PASTA or standard care. Patients attended by study paramedics were enrolled after admission if a hospital specialist confirmed a stroke and paramedic assessment started within 4 hours of onset. Allocation to PASTA or standard care reflected the attending paramedic’s randomization status. Interventions The PASTA intervention included additional prehospital information collection, a structured hospital handover, practical assistance up to 15 minutes after handover, a predeparture care checklist, and clinician feedback. Standard care reflected national guidelines. Main Outcomes and Measures Primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included time intervals and day 90 health (with poor status defined as a modified Rankin Score >2, to represent dependency or death). Results A total of 11 478 patients were screened following ambulance transportation; 1391 were eligible and approached, but 177 did not consent. Of 1214 patients enrolled (mean [SD] age, 74.7 [13.2] years; 590 women [48.6%]), 500 were assessed by 242 paramedics trained in the PASTA intervention and 714 were assessed by 355 paramedics continuing with standard care. The paramedics trained in the PASTA intervention took a mean of 13.4 (95% CI, 9.4-17.4) minutes longer (P < .001) to complete patient care episodes. There was less thrombolysis among the patients in the PASTA group, but this was not significant (PASTA group, 197 of 500 patients [39.4%] vs the standard care group, 319 of 714 patients [44.7%]; adjusted odds ratio, 0.81 [95% CI, 0.61-1.08]; P = .15). Time from a paramedic on scene to thrombolysis was a mean of 8.5 minutes longer in the PASTA group (98.1 [37.6] minutes) vs the standard care group (89.4 [31.1] minutes; P = .01). Poor health outcomes did not differ significantly but occurred less often among patients in the PASTA group (313 of 489 patients [64.0%]) vs the standard care group (461 of 690 patients [66.8%]; adjusted odds ratio, 0.86 [95% CI, 0.60-1.20]; P = .39). Conclusions and Relevance An enhanced paramedic assessment did not facilitate thrombolysis delivery. The unexpected combination of thrombolysis and health outcomes suggests possible alternative influences on treatment decisions by the intervention, requiring further evaluation. Trial Registration ISRCTN Registry Identifier: ISRCTN12418919
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Affiliation(s)
- Christopher I Price
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Lisa Shaw
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Saiful Islam
- Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Mehdi Javanbakht
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Alan Watkins
- Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, United Kingdom
| | - Helen Snooks
- Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Darren Flynn
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Richard Francis
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Rachel Lakey
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Lou Sutcliffe
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Joanne Lally
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Catherine Exley
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Helen Rodgers
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom.,Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Ian Russell
- Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Luke Vale
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Gary A Ford
- Medical Sciences Division, University of Oxford, Oxford, United Kingdom.,Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
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25
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Christensen H, Pezzella FR. Implementation of the Stroke Action Plan for Europe 2018--2030 during coronavirus disease-2019. Curr Opin Neurol 2021; 34:55-60. [PMID: 33278140 DOI: 10.1097/wco.0000000000000893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE OF REVIEW To describe the background, principles and implementation of the Stroke Action Plan for Europe 2018--2030 (SAP-E) in the perspective of the current COVID-19 pandemic. RECENT FINDINGS SAP-E sets targets for the implementation of evidence-based preventive actions and stroke services to 2030. A recent mapping of stroke care in Europe has documented massive inequalities and even in high-income European countries access to reperfusion therapy and mortality after ischaemic stroke varies significantly. Organized stroke care providing stroke unit care and access to reperfusion therapies reduces mortality and long-term disability. Stroke prevention and care are highly cost-effective. The COVID-19 pandemic has challenged organized care, diverged attention from stroke and necessitated a novel approach to the implementation program because of the continued need for social distancing and reduced travelling. Consequently, meetings, training and engagement will be handled by online resources. SUMMARY Stroke can be prevented and treated but there remain massive inequalities in Europe. SAP-E has set targets for development of stroke care. COVID-19 pandemic has led to further challenges for stroke care and implementation of the Action Plan will rely on online meetings and resources as it is yet unforeseeable when things will return to normal. VIDEO ABSTRACT http://links.lww.com/CONR/A53.
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Affiliation(s)
- Hanne Christensen
- Department of Neurology, Bispebjerg Hospital and University of Copenhagen, Copenhagen, Denmark
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26
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Mueller C, John C, Perera G, Aarsland D, Ballard C, Stewart R. Antipsychotic use in dementia: the relationship between neuropsychiatric symptom profiles and adverse outcomes. Eur J Epidemiol 2021; 36:89-101. [PMID: 32415541 PMCID: PMC7847435 DOI: 10.1007/s10654-020-00643-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 05/02/2020] [Indexed: 12/29/2022]
Abstract
Antipsychotic treatments are associated with safety concerns in people with dementia. The authors aimed to investigate whether risk of adverse outcomes related to antipsychotic prescribing differed according to major neuropsychiatric syndromes-specifically psychosis, agitation, or a combination. A cohort of 10,106 patients with a diagnosis of dementia was assembled from a large dementia care database in South East London. Neuropsychiatric symptoms closest to first dementia diagnosis were determined according to the Health of the Nation Outcome Scales' mental and behavioural problem scores and the sample was divided into four groups: 'agitation and psychosis', 'agitation, but no psychosis', 'psychosis, but no agitation', and 'neither psychosis nor agitation'. Antipsychotic prescription in a one-year window around first dementia diagnosis was ascertained as exposure variable through natural language processing from free text. Cox regression models were used to analyse associations of antipsychotic prescription with all-cause and stroke-specific mortality, emergency hospitalisation and hospitalised stroke adjusting for sixteen potential confounders including demographics, cognition, functioning, as well as physical and mental health. Only in the group 'psychosis, but no agitation' (n = 579), 30% of whom were prescribed an antipsychotic, a significant antipsychotic-associated increased risk of hospitalised stroke was present after adjustment (adjusted hazard ratio (HR) 2.16; 95% confidence interval (CI) 1.09-4.25). An increased antipsychotic-related all-cause (adjusted HR 1.14; 95% CI 1.04-1.24) and stroke-specific mortality risk (adjusted HR 1.28; 95% CI 1.01-1.63) was detected in the whole sample, but no interaction between the strata and antipsychotic-related mortality. In conclusion, the adverse effects of antipsychotics in dementia are complex. Stroke risk may be highest when used in patients presenting with psychosis without agitation, indicating the need for novel interventions for this group.
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Affiliation(s)
- Christoph Mueller
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, UK.
- South London and Maudsley NHS Foundation Trust, London, UK.
| | - Christeena John
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, UK
| | - Gayan Perera
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, UK
| | - Dag Aarsland
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, UK
- Stavanger University Hospital, Centre for Age-Related Disease, Stavanger, Norway
| | - Clive Ballard
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, UK
- University of Exeter Medical School, Exeter, UK
| | - Robert Stewart
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
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27
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Damien C, Cisse F, Ligot N, Toure ML, Konaté M, Barry SD, Saw M, Naeije G. Insights in the pathophysiology of haemorrhagic strokes in a sub-Sahara African country, an epidemiological and MRI study. Trop Med Int Health 2020; 26:166-172. [PMID: 33159424 DOI: 10.1111/tmi.13512] [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: 12/22/2022]
Abstract
OBJECTIVE Intra-cerebral Haemorrhage (ICH) seems more prevalent in sub-Saharan Africa (SSA) than in High-Income Countries (HIC) with poorer clinical outcome. Higher impact of hypertension and/or amyloid angiopathy could account for this disproportion. Here, we sought to (i) retrospectively compare ICH clinical and imaging patterns in Belgium and Guinea and in a subsequent cohort (ii) prospectively compare brain MRI characteristics to seek evidence for a different proportion of amyloid angiopathy patterns. METHODS Ninety one consecutive patients admitted for spontaneous ICH at Brussels Erasme-ULB Hospital and at Conakry Ignace Deen-UGANC were retrospectively compared in terms of ICH volume estimated with the ABC/2 method, clinical characteristics and modified ranking (mRS) score at 30 days. mRS was dichotomised as good outcomes (≤3) and poor outcomes (>3). A prospective cohort of 30 consecutive patients with ICH admitted at CHU Conakry Ignace Deen-UGANC was prospectively included to undergo brain MRI. Results of the Guinean MRI were compared to 30 patients randomly selected from Brussels' initial cohort. Paired Student's t-test and Mann-Whitney u-test were used for group comparisons. RESULTS Age of ICH onset was higher in Belgium (68 ± 17 years vs. 56 ± 14 years, P < 0.01) while ICH volume and 30-day mortality rate were higher in Guinea (20 ml vs. 11 ml, P < 0.01 and mortality 33% vs. 10 %, P < 0.01). ICH burden in survivors in Conakry and Brussels showed respectively good outcomes in 56.7% and 60.4% (P = 0.09) and poor outcomes in 10.3% vs. 29.6% (P < 0.001). MRI analysis of the prospective cohort failed to disclose significant differences regarding brain MRI characteristics. CONCLUSIONS Intra-cerebral Haemorrhage affected patients 15 years younger in Guinea with larger haematoma volumes and higher mortality than in Belgium. MRI findings did not show more prevalent amyloid angiopathy pathology suggesting that better primary prevention of hypertension could positively impact ICH epidemiology in Guinea.
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Affiliation(s)
- C Damien
- Department of Neurology, CUB Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - F Cisse
- Department of Neurology, CHU Ignace Deen, Université Gamal Abdel Nasser Conakry, Conakry, Guinea
| | - N Ligot
- Department of Neurology, CUB Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - M L Toure
- Department of Neurology, CHU Ignace Deen, Université Gamal Abdel Nasser Conakry, Conakry, Guinea
| | - M Konaté
- Department of Neurology, CHU Ignace Deen, Université Gamal Abdel Nasser Conakry, Conakry, Guinea
| | - S D Barry
- Department of Neurology, CHU Ignace Deen, Université Gamal Abdel Nasser Conakry, Conakry, Guinea
| | - M Saw
- Centre de Diagnostic Caisse Nationale de Sécurité Sociale, Conakry, Guinea
| | - G Naeije
- Department of Neurology, CUB Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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28
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Kelham M, Jones TN, Rathod KS, Guttmann O, Proudfoot A, Rees P, Knight CJ, Ozkor M, Wragg A, Jain A, Baumbach A, Mathur A, Jones DA. An observational study assessing the impact of a cardiac arrest centre on patient outcomes after out-of-hospital cardiac arrest (OHCA). EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 9:S67-S73. [PMID: 33241716 DOI: 10.1177/2048872620974606] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) is a major cause of death worldwide. Recent guidelines recommend the centralisation of OHCA services in cardiac arrest centres to improve outcomes. In 2015, two major tertiary cardiac centres in London merged to form a large dedicated tertiary cardiac centre. This study aimed to compare the short-term mortality of patients admitted with an OHCA before-and-after the merger of services had taken place and admission criteria were relaxed, which led to managing OHCA in higher volume. METHODS We retrospectively analysed the data of OHCA patients pre- and post-merger. Baseline demographic and medical characteristics were recorded, along with factors relating to the cardiac arrest. The primary endpoint was in-hospital mortality. RESULTS OHCA patients (N =728; 267 pre- and 461 post-merger) between 2013 and 2018 were analysed. Patients admitted pre-merger were older (65.0 vs. 62.4 years, p=0.027), otherwise there were similar baseline demographic and peri-arrest characteristics. There was a greater proportion of non-acute coronary syndrome-related OHCA admission post-merger (10.1% vs. 23.4%, p=0.0001) and a corresponding decrease in those admitted with ST-elevation myocardial infarction (80.2% vs. 57.0%, p=0.0001) and those treated with percutaneous coronary intervention (78.8% vs. 54.0%, p=0.0001). Despite this, in-hospital mortality was lower post-merger (63.7% vs. 44.3%, p=0.0001), which persisted after adjustment for demographic and arrest-related characteristics using stepwise logistic regression (p=0.036) between the groups. CONCLUSION Despite an increase in non-acute coronary syndrome-related OHCA cases, the formation of a centralised invasive heart centre was associated with improved survival in OHCA patients. This suggests there may be a benefit of a cardiac arrest centre model of care.
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Affiliation(s)
- Matthew Kelham
- Barts Interventional Group, Barts Heart Centre, London, UK
| | | | - Krishnaraj S Rathod
- Barts Interventional Group, Barts Heart Centre, London, UK.,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, UK
| | - Oliver Guttmann
- Barts Interventional Group, Barts Heart Centre, London, UK.,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, UK
| | | | - Paul Rees
- Barts Interventional Group, Barts Heart Centre, London, UK
| | | | - Muhiddin Ozkor
- Barts Interventional Group, Barts Heart Centre, London, UK
| | - Andrew Wragg
- Barts Interventional Group, Barts Heart Centre, London, UK.,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, UK
| | - Ajay Jain
- Barts Interventional Group, Barts Heart Centre, London, UK
| | - Andreas Baumbach
- Barts Interventional Group, Barts Heart Centre, London, UK.,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, UK
| | - Anthony Mathur
- Barts Interventional Group, Barts Heart Centre, London, UK.,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, UK
| | - Daniel A Jones
- Barts Interventional Group, Barts Heart Centre, London, UK.,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, UK
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29
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Langhorne P, Audebert HJ, Cadilhac DA, Kim J, Lindsay P. Stroke systems of care in high-income countries: what is optimal? Lancet 2020; 396:1433-1442. [PMID: 33129394 DOI: 10.1016/s0140-6736(20)31363-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/31/2020] [Accepted: 06/09/2020] [Indexed: 01/19/2023]
Abstract
Stroke is a complex, time-sensitive, medical emergency that requires well functioning systems of care to optimise treatment and improve patient outcomes. Education and training campaigns are needed to improve both the recognition of stroke among the general public and the response of emergency medical services. Specialised stroke ambulances (mobile stroke units) have been piloted in many cities to speed up the diagnosis, triage, and emergency treatment of people with acute stroke symptoms. Hospital-based interdisciplinary stroke units remain the central feature of a modern stroke service. Many have now developed a role in the very early phase (hyperacute units) plus outreach for patients who return home (early supported discharge services). Different levels (comprehensive and primary) of stroke centre and telemedicine networks have been developed to coordinate the various service components with specialist investigations and interventions including rehabilitation. Major challenges include the harmonisation of resources for stroke across the whole patient journey (including the rapid, accurate triage of patients who require highly specialised treatment in comprehensive stroke centres) and the development of technology to improve communication across different parts of a service.
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Affiliation(s)
- Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Royal Infirmary, Glasgow, UK.
| | - Heinrich J Audebert
- Department of Neurology and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Dominique A Cadilhac
- Monash University, Department of Medicine, School of Clinical Sciences at Monash Health, Clayton, VIC, Australia
| | - Joosup Kim
- Monash University, Department of Medicine, School of Clinical Sciences at Monash Health, Clayton, VIC, Australia
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30
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Li L, Pan Y, Wang M, Jing J, Meng X, Jiang Y, Guo C, Jin Z, Wang Y. Trends and predictors of myocardial infarction or vascular death after ischaemic stroke or TIA in China, 2007-2018: insights from China National Stroke Registries. Stroke Vasc Neurol 2020; 6:214-221. [PMID: 33127855 PMCID: PMC8258052 DOI: 10.1136/svn-2020-000503] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/09/2020] [Accepted: 09/24/2020] [Indexed: 11/04/2022] Open
Abstract
Background Although stroke management, primary and secondary preventions have been improved in China last decades, the trends and predictors of major vascular events after ischaemic stroke or transient ischaemic attack (TIA) at national scale are less known. Methods Data were obtained from the three phases of China National Stroke Registry (CNSR), including CNSR-Ⅰ (years 2007–2008), CNSR-Ⅱ (years 2012–2013) and CNSR-III (years 2015–2018). For comparison, patients who were diagnosed as ischaemic stroke or TIA were included. Kaplan-Meier estimates of myocardial infarction (MI) or vascular death were calculated at 1 year. Independent predictors were further assessed with a Cox proportional hazards regression. Results From 2007 to 2018, a total of 50 284 patients with ischaemic stroke or TIA were enrolled in this study. A declining trend was found in 1-year MI or vascular death (p for trend <0.001), while recurrent stroke depicted a U-shape curve with a nadir in 2012–2013 cohort. A similar trend was also observed in patients who were admitted to 26 hospitals in all three CNSRs. In 2015–2018 cohort, only 251 (1.7%; 95% CI 1.5% to 1.9%) MI or vascular death had occurred at 1 year. Older age, previous stroke or TIA, history of coronary artery disease and the National Institutes of Health Stroke Scale >6 were associated with both an increased risk of MI or vascular death and recurrent stroke. While early antiplatelet therapy and lipid-lowering agents at discharge predicted a reduced risk. Conclusion A declining trend and current low incidence of MI or vascular death, rather than recurrent stroke, after ischaemic stroke or TIA were observed in China. Traditional factors were found as independent predictors. These findings suggested there is still much room to improve for stroke management.
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Affiliation(s)
- Long Li
- Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Mengxing Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Caixia Guo
- Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zening Jin
- Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China .,Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China .,China National Clinical Research Center for Neurological Diseases, Beijing, China
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31
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Crawford SM. How to provide specialist services: how do we know when centralisation is a good idea? Postgrad Med J 2020; 97:69-71. [PMID: 33008955 DOI: 10.1136/postgradmedj-2020-138151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/22/2020] [Accepted: 08/30/2020] [Indexed: 11/04/2022]
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32
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Use of public datasets in the examination of multimorbidity: Opportunities and challenges. Mech Ageing Dev 2020; 190:111310. [PMID: 32622995 DOI: 10.1016/j.mad.2020.111310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/01/2020] [Indexed: 01/27/2023]
Abstract
The interrogation of established, large-scale datasets presents great opportunities in health data science for the linkage and mining of potentially disparate resources to create new knowledge in a fast and cost-efficient manner. The number of datasets that can be queried in the field of multimorbidity is vast, ranging from national administrative and audit datasets, large clinical, technical and biological cohorts, through to more bespoke data collections made available by individual organisations and laboratories. However, with these opportunities also come technical and regulatory challenges that require an informed approach. In this review, we outline the potential benefits of using previously collected data as a vehicle for research activity. We illustrate the added value of combining potentially disparate datasets to find answers to novel questions in the field. We focus on the legal, governance and logistical considerations required to hold and analyse data acquired from disparate sources and outline some of the solutions to these challenges. We discuss the infrastructure resources required and the essential considerations in data curation and informatics management, and briefly discuss some of the analysis approaches currently used.
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33
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Simister R, Black GB, Melnychuk M, Ramsay AIG, Baim-Lance A, Cohen DL, Eng J, Xanthopoulou PD, Brown MM, Rudd AG, Morris S, Fulop NJ. Temporal variations in quality of acute stroke care and outcomes in London hyperacute stroke units: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Seven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of the day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units.
Objectives
To investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units, and to identify factors influencing such variations.
Design
This was a prospective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme. Factors influencing variations in care and outcomes were studied through interview and observation data.
Setting
The setting was acute stroke services in London hyperacute stroke units.
Participants
A total of 7094 patients with a primary diagnosis of stroke took part. We interviewed hyperacute stroke unit staff (n = 76), including doctors, nurses, therapists and administrators, and 31 patients and carers. We also conducted non-participant observations of delivery of care at different times of the day and week (n = 45, ≈102 hours).
Intervention
Hub-and-spoke model for care of suspected acute stroke patients in London with performance standards was designed to deliver uniform access to high-quality hyperacute stroke unit care across the week.
Main outcome measures
Indicators of quality of acute stroke care, mortality at 3 days after admission, disability at the end of the inpatient spell and length of stay.
Data sources
Sentinel Stroke National Audit Programme data for all patients in London hyperacute stroke units with a primary diagnosis of stroke between 1 January and 31 December 2014, and nurse staffing data for all eight London hyperacute stroke units for the same period.
Results
We found no variation in quality of care by day and time of admission across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor in 3-day mortality nor disability at hospital discharge. Other quality-of-care measures significantly varied by day and time of admission. Quality of care was better if the nurse in charge was at a higher band and/or there were more nurses on duty. Staff deliver ‘front-door’ interventions consistently by taking on additional responsibilities out of hours, creating continuities between day and night, building trusting relationships and prioritising ‘front-door’ interventions.
Limitations
We were unable to measure long-term outcomes as our request to the Sentinel Stroke National Audit Programme, the Healthcare Quality Improvement Partnership and NHS Digital for Sentinel Stroke National Audit Programme data linked with patient mortality status was not fulfilled.
Conclusions
Organisational factors influence 24 hours a day, 7 days a week (24/7), provision of stroke care, creating temporal patterns of provision reflected in patient outcomes, including mortality, length of stay and functional independence.
Future work
Further research would help to explore 24/7 stroke systems in other contexts. We need a clearer understanding of variations by looking at absolute time intervals, rather than achievement of targets. Research is needed with longer-term mortality and modified Rankin Scale data, and a more meaningful range of outcomes.
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. 8, No. 34. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Robert Simister
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Georgia B Black
- Department of Applied Health Research, University College London, London, UK
| | - Mariya Melnychuk
- Department of Applied Health Research, University College London, London, UK
| | - Angus IG Ramsay
- Department of Applied Health Research, University College London, London, UK
| | - Abigail Baim-Lance
- Center for Innovation in Mental Health, City University of New York, New York, NY, USA
| | - David L Cohen
- Stroke Service, Haldane and Herrick Wards, Northwick Park Hospital, London, UK
| | - Jeannie Eng
- Cancer Division, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Martin M Brown
- Queen Square Institute of Neurology, University College London, London, UK
| | - Anthony G Rudd
- King’s College London and Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Steve Morris
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, London, UK
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Morciano M, Checkland K, Billings J, Coleman A, Stokes J, Tallack C, Sutton M. New integrated care models in England associated with small reduction in hospital admissions in longer-term: A difference-in-differences analysis. Health Policy 2020; 124:826-833. [PMID: 32595094 PMCID: PMC7386936 DOI: 10.1016/j.healthpol.2020.06.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 05/28/2020] [Accepted: 06/03/2020] [Indexed: 12/30/2022]
Abstract
Closer integration of health and social care services has become a cornerstone policy in many developed countries, but there is still debate over what population and service level is best to target. In England, the 2019 Long Term Plan for the National Health Service included a commitment to spread the integration prototypes piloted under the Vanguard `New Care Models' programme. The programme, running from 2015 to 2018, was one of the largest pilots in English history, covering around 9 % of the population. It was largely intended to design prototypes aimed at reducing hospital utilisation by moving specialist care out of hospital into the community and by fostering coordination of health, care and rehabilitation services for (i) the whole population ('population-based sites'), or (ii) care home residents ('care home sites'). We evaluate and compare the efficacy of the population-based and care home site integrated care models in reducing hospital utilisation. We use area-level monthly counts of emergency admissions and bed-days obtained from administrative data using a quasi-experimental difference-in-differences design. We found that Vanguard sites had higher hospital utilisation than non-participants in the pre-intervention period. In the post-intervention period, there is clear evidence of a substantial increase in emergency admissions among non-Vanguard sites. The Vanguard integrated care programme slowed the rise in emergency admissions, especially in care home sites and in the third and final year. There was no significant reduction in bed-days. In conclusion, integrated care policies should not be relied upon to make large reductions in hospital activity in the short-run, especially for population-based models.
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Affiliation(s)
- Marcello Morciano
- Health Organisation, Policy and Economics (HOPE) Research Group, University of Manchester, Manchester, M13 9PL, United Kingdom.
| | - Katherine Checkland
- Health Organisation, Policy and Economics (HOPE) Research Group, University of Manchester, Manchester, M13 9PL, United Kingdom
| | - Jenny Billings
- Centre for Health Service Studies, University of Kent, Canterbury, CT2 7NF, United Kingdom
| | - Anna Coleman
- Health Organisation, Policy and Economics (HOPE) Research Group, University of Manchester, Manchester, M13 9PL, United Kingdom
| | - Jonathan Stokes
- Health Organisation, Policy and Economics (HOPE) Research Group, University of Manchester, Manchester, M13 9PL, United Kingdom
| | - Charles Tallack
- Research and Economic Analysis for the Long Term (REAL) Centre, The Health Foundation, London, EC4Y 8AP, United Kingdom
| | - Matt Sutton
- Health Organisation, Policy and Economics (HOPE) Research Group, University of Manchester, Manchester, M13 9PL, United Kingdom
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Jones F, Gombert-Waldron K, Honey S, Cloud G, Harris R, Macdonald A, McKevitt C, Robert G, Clarke D. Using co-production to increase activity in acute stroke units: the CREATE mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08350] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Stroke is the most common neurological disability in the UK. Any activity contributes to recovery, but stroke patients can be inactive for > 60% of their waking hours. This problem remains, despite organisational changes and targeted interventions. A new approach to addressing post-stroke inactivity is needed. Experience-based co-design has successfully initiated improvements for patients and staff in other acute settings. Experience-based co-design uses observational fieldwork and filmed narratives with patients to trigger different conversations and interactions between patients and staff to improve health-care services.
Objectives
To complete a rapid evidence synthesis of the efficacy and effectiveness of co-production as an approach to quality improvement in acute health-care settings; to evaluate the feasibility and impact of patients, carers and staff co-producing and implementing interventions to increase supervised and independent therapeutic patient activity in acute stroke units; and to understand the experience of participating in experience-based co-design and whether or not interventions developed and implemented in two units could transfer to two additional units using an accelerated experience-based co-design cycle.
Design
A mixed-methods case comparison using interviews, observations, behavioural mapping and self-report surveys (patient-reported outcome measure/patient-reported experience measure) pre and post implementation of experience-based co-design cycles, and a process evaluation informed by normalisation process theory.
Setting
The setting was two stroke units (acute and rehabilitation) in London and two in Yorkshire.
Participants
In total, 130 staff, 76 stroke patients and 47 carers took part.
Findings
The rapid evidence synthesis showed a lack of rigorous evaluation of co-produced interventions in acute health care, and the need for a robust critique of co-production approaches. Interviews and observations (365 hours) identified that it was feasible to co-produce and implement interventions to increase activity in priority areas including ‘space’ (environment), ‘activity’ and, to a lesser extent, ‘communication’. Patients and families reported benefits from participating in co-design and perceived that they were equal and valued members. Staff perceived that experience-based co-design provided a positive experience, was a valuable improvement approach and led to increased activity opportunities. Observations and interviews confirmed the use of new social spaces and increased activity opportunities. However, staff interactions remained largely task focused, with limited focus on enabling patient activity. Behavioural mapping indicated a mixed pattern of activity pre and post implementation of co-designed changes. Patient-reported outcome measure/patient-reported experience measure response rates were low, at 12–38%; pre- and post-experience-based co-design cohorts reported dependency, emotional and social limitations consistent with national statistics. Post-experience-based co-design patient-reported experience measure data indicated that more respondents reported that they had ‘enough things to do in their free time’. The use of experience-based co-design – full and accelerated – legitimised and supported co-production activity. Staff, patients and families played a pivotal role in intervention co-design. All participants recognised that increased activity should be embedded in everyday routines and in work on stroke units.
Limitations
Communication by staff that enabled patient activity was challenging to initiate and sustain.
Conclusions
It was feasible to implement experience-based co-design in stroke units. This resulted in some positive changes in unit environments and increased activity opportunities for patients. There was no discernible difference in experiences or outcomes between full and accelerated experience-based co-design. Future work should consider multiple ways to embed increased patient activity into everyday routines in stroke units.
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. 8, No. 35. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Fiona Jones
- Centre for Health and Social Care Research, Faculty of Health, Social Care and Education, Kingston University and St George’s, University of London, London, UK
| | - Karolina Gombert-Waldron
- Centre for Health and Social Care Research, Faculty of Health, Social Care and Education, Kingston University and St George’s, University of London, London, UK
| | - Stephanie Honey
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Ruth Harris
- Department of Adult Nursing, King’s College London, London, UK
| | | | - Chris McKevitt
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Glenn Robert
- Department of Adult Nursing, King’s College London, London, UK
| | - David Clarke
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Abstract
Introduction The COVID-19 epidemic has led to the need for unprecedented decisions to be made to maintain the provision of neurological care. This article addresses operational decision-making during the epidemic. Development We report the measures taken, including the preparation of a functional reorganisation plan, strategies for hospitalisation and emergency management, the use of telephone consultations to maintain neurological care, provision of care at a unit outside the hospital for priority patients, decisions about complementary testing and periodic in-hospital treatments, and the use of a specific telephone service to prioritise patients with epileptic seizures. Conclusion Despite the situation of confinement, neurology departments must continue to provide patient care through different means of operation. Like all elements of management, these must be evaluated.
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Matías-Guiu J, Porta-Etessam J, Lopez-Valdes E, Garcia-Morales I, Guerrero-Solá A, Matias-Guiu JA. Management of neurological care during the COVID-19 pandemic. Neurologia 2020; 35:233-237. [PMID: 32336528 PMCID: PMC7151454 DOI: 10.1016/j.nrl.2020.04.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/06/2020] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The COVID-19 epidemic has led to the need for unprecedented decisions to be made to maintain the provision of neurological care. This article addresses operational decision-making during the epidemic. DEVELOPMENT We report the measures taken, including the preparation of a functional reorganisation plan, strategies for hospitalisation and emergency management, the use of telephone consultations to maintain neurological care, provision of care at a unit outside the hospital for priority patients, decisions about complementary testing and periodic in-hospital treatments, and the use of a specific telephone service to prioritise patients with epileptic seizures. CONCLUSION Despite the situation of confinement, neurology departments must continue to provide patient care through different means of operation. Like all elements of management, these must be evaluated.
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Affiliation(s)
- J Matías-Guiu
- Servicio de Neurología, Instituto de Neurociencias Hospital Clínico San Carlos, San Carlos, IdISSC, Madrid, España.
| | - J Porta-Etessam
- Servicio de Neurología, Instituto de Neurociencias Hospital Clínico San Carlos, San Carlos, IdISSC, Madrid, España
| | - E Lopez-Valdes
- Servicio de Neurología, Instituto de Neurociencias Hospital Clínico San Carlos, San Carlos, IdISSC, Madrid, España
| | - I Garcia-Morales
- Servicio de Neurología, Instituto de Neurociencias Hospital Clínico San Carlos, San Carlos, IdISSC, Madrid, España
| | - A Guerrero-Solá
- Servicio de Neurología, Instituto de Neurociencias Hospital Clínico San Carlos, San Carlos, IdISSC, Madrid, España
| | - J A Matias-Guiu
- Servicio de Neurología, Instituto de Neurociencias Hospital Clínico San Carlos, San Carlos, IdISSC, Madrid, España
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Zhao J, Rudd A, Liu R. Challenges and Potential Solutions of Stroke Care During the Coronavirus Disease 2019 (COVID-19) Outbreak. Stroke 2020; 51:1356-1357. [PMID: 32228369 PMCID: PMC7219852 DOI: 10.1161/strokeaha.120.029701] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Jing Zhao
- From the Department of Neurology, Minhang Hospital, Fudan University, Shanghai, China (J.Z.)
| | - Anthony Rudd
- Stroke Medicine, Kings College London, United Kingdom (A.R.)
| | - Renyu Liu
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (R.L.)
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Arumalla N, Coakley G. Septic arthritis: time to rethink service delivery? THE LANCET INFECTIOUS DISEASES 2020; 20:266-267. [DOI: 10.1016/s1473-3099(19)30563-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 09/11/2019] [Indexed: 11/29/2022]
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Wafa HA, Wolfe CDA, Bhalla A, Wang Y. Long-term trends in death and dependence after ischaemic strokes: A retrospective cohort study using the South London Stroke Register (SLSR). PLoS Med 2020; 17:e1003048. [PMID: 32163411 PMCID: PMC7067375 DOI: 10.1371/journal.pmed.1003048] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 02/10/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND There have been reductions in stroke mortality over recent decades, but estimates by aetiological subtypes are limited. This study estimates time trends in mortality and functional dependence by ischaemic stroke (IS) aetiological subtype over a 16-year period. METHODS AND FINDINGS The study population was 357,308 in 2011; 50.4% were males, 56% were white, and 25% were of black ethnic backgrounds. Population-based case ascertainment of stroke was conducted, and all participants who had their first-ever IS between 2000 and 2015 were identified. Further classification was concluded according to the underlying mechanism into large-artery atherosclerosis (LAA), cardio-embolism (CE), small-vessel occlusion (SVO), other determined aetiologies (OTH), and undetermined aetiologies (UND). Temporal trends in survival rates were examined using proportional-hazards survival modelling, adjusted for demography, prestroke risk factors, case mix variables, and processes of care. We carried out additional regression analyses to explore patterns in case-fatality rates (CFRs) at 30 days and 1 year and to explore whether these trends occurred at the expense of greater functional dependence (Barthel Index [BI] < 15) among survivors. A total of 3,128 patients with first-ever ISs were registered. The median age was 70.7 years; 50.9% were males; and 66.2% were white, 25.5% were black, and 8.3% were of other ethnic groups. Between 2000-2003 and 2012-2015, the adjusted overall mortality decreased by 24% (hazard ratio [HR] per year 0.976; 95% confidence interval [CI] 0.959-0.993). Mortality reductions were equally noted in both sexes and in the white and black populations but were only significant in CE strokes (HR per year 0.972; 95% CI 0.945‒0.998) and in patients aged ≥55 years (HR per year 0.975; 95% CI 0.959‒0.992). CFRs within 30 days and 1 year after an IS declined by 38% (rate ratio [RR] per year 0.962; 95% CI 0.941‒0.984) and 37% (RR per year 0.963; 95% CI 0.949‒0.976), respectively. Recent IS was independently associated with a 23% reduced risk of functional dependence at 3 months after onset (RR per year 0.983; 95% CI 0.968-0.998; p = 0.002 for trend). The study is limited by small number of events in certain subgroups (e.g., LAA), which could have led to insufficient power to detect significant trends. CONCLUSIONS Both mortality and 3-month functional dependence after IS decreased by an annual average of around 2.4% and 1.7%, respectively, during 2000‒2015. Such reductions were particularly evident in strokes of CE origins and in those aged ≥55 years.
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Affiliation(s)
- Hatem A. Wafa
- School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
- National Institute for Health Research (NIHR) Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, United Kingdom
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, London, United Kingdom
- * E-mail:
| | - Charles D. A. Wolfe
- School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
- National Institute for Health Research (NIHR) Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, United Kingdom
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, London, United Kingdom
| | - Ajay Bhalla
- School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Yanzhong Wang
- School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
- National Institute for Health Research (NIHR) Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, United Kingdom
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, London, United Kingdom
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41
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Arnold J, Sims D, Gill P, Cockwell P, Ferro C. Acute kidney injury calculated using admission serum creatinine underestimates 30-day and 1-year mortality after acute stroke. Clin Kidney J 2020; 13:46-54. [PMID: 32082552 PMCID: PMC7025354 DOI: 10.1093/ckj/sfz049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 03/29/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) diagnosis requires ascertainment of change from a known baseline. Although pre-admission serum creatinine (SCr) is recommended, to date, all studies of AKI in acute stroke have used the first SCr on admission. METHODS All patients admitted with an acute stroke to an emergency hospital were recruited. We compared use of pre-admission SCr with admission SCr to diagnose AKI. Regression analyses were used to identify risk factors for 30-day and 1-year mortality, respectively. RESULTS A total of 1354 patients were recruited from December 2012 to September 2015. Incidence of AKI was 18.7 and 19.9% using pre-admission SCr and admission SCr, respectively. Diagnosis of AKI was associated with significantly increased 30-day and 1-year mortality. Diagnosis of AKI using pre-admission SCr had a stronger relationship with both 30-day and 1-year mortality. In 443 patients with a pre-admission SCr and at least two SCr during admission, AKI diagnosed using pre-admission SCr had a stronger relationship than AKI diagnosed using admission SCr with 30-day mortality [odds ratio (OR) = 2.64; 95% confidence interval (CI) 1.36-5.12; P = 0.004 versus OR = 2.10; 95% CI 1.09-4.03; P = 0.026] and 1-year mortality [hazard ratio (HR) = 1.90, 95% CI 1.32-2.76; P = 0.001 versus HR = 1.47; 95% CI 1.01-2.15; P = 0.046] in fully adjusted models. CONCLUSIONS AKI after stroke is common and is associated with increased 30-day and 1-year mortality. Using first SCr on admission gives a comparable AKI incidence to pre-admission SCr, but underestimates 30-day and 1-year mortality risk.
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Affiliation(s)
- Julia Arnold
- Department of Nephrology, University Hospitals Birmingham, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Don Sims
- Department of Stroke, University Hospitals Birmingham, Birmingham, UK
| | - Paramjit Gill
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Paul Cockwell
- Department of Nephrology, University Hospitals Birmingham, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Charles Ferro
- Department of Nephrology, University Hospitals Birmingham, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Rocks S, Fazel M, Tsiachristas A. Impact of transforming mental health services for young people in England on patient access, resource use and health: a quasi-experimental study. BMJ Open 2020; 10:e034067. [PMID: 31948991 PMCID: PMC7044818 DOI: 10.1136/bmjopen-2019-034067] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/21/2019] [Accepted: 12/17/2019] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE To evaluate the impact of child and adolescent mental health services (CAMHS) transformation in South East England on patient access, resource utilisation and health outcomes. DESIGN In an observational study, we use difference-in-differences analysis with propensity score matching to analyse routinely collected patient level data. SETTING Three CAMHS services in South East England. PARTICIPANTS All patients attending CAMHS between April 2012 and December 2018, with more than 57 000 spells of care included. MAIN OUTCOME MEASURES The rate and volume of people accessing CAMHS; waiting times to the first contact and waiting times between the first and second contact; and health outcomes, including the Strengths and Difficulties Questionnaire (SDQ) and the Revised Child Anxiety and Depression Scale (RCADS). RESULTS The intervention led to 20% (incidence rate ratio: 1.20; 95% CI: 1.15 to 1.24) more new patients starting per month. There was mixed evidence on waiting times for the first contact. The intervention led to 10% (incidence rate ratio: 1.10; 95% CI: 1.02 to 1.18) higher waiting time for the second contact. The number of contacts per spell (OR: 1.08; 95% CI: 0.94 to 1.25) and the rereferral rate (OR: 1.06; 95% CI: 0.96 to 1.17) were not significantly different. During the post intervention period, patients in the intervention group scored on average 3.3 (95% CI: -5.0 to -1.6) points lower on the RCADS and 1.0 (95% CI: -1.8 to -0.3) points lower on the SDQ compared with the control group after adjusting for the baseline score. CONCLUSIONS Overall, there are signs that transformation can help CAMHS achieve the objectives of greater access and improved health outcomes, but trade-offs exist among different performance metrics, particularly between access and waiting times. Commissioners and providers should be conscious of any trade-offs when undertaking service redesign and transformation.
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Affiliation(s)
- Stephen Rocks
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Mina Fazel
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Apostolos Tsiachristas
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Price C, McCarthy S, Bate A, McMeekin P. Impact of emergency care centralisation on mortality and efficiency: a retrospective service evaluation. Emerg Med J 2020; 37:180-186. [PMID: 31911414 PMCID: PMC7146926 DOI: 10.1136/emermed-2019-208539] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 10/09/2019] [Accepted: 10/30/2019] [Indexed: 12/02/2022]
Abstract
Objective Evidence favours centralisation of emergency care for specific conditions, but it remains unclear whether broader implementation improves outcomes and efficiency. Routine healthcare data examined consolidation of three district general hospitals with mixed medical admission units (MAU) into a single high-volume site directing patients from the ED to specialty wards with consultant presence from 08:00 to 20:00. Methods Consecutive unscheduled adult index admissions from matching postcode areas were identified retrospectively in Hospital Episode Statistics over a 3-year period: precentralisation baseline (from 16 June 2014 to 15 June 2015; n=18 586), year 1 postcentralisation (from 16 June 2015 to 15 June 2016; n=16 126) and year 2 postcentralisation (from 16 June 2016 to 15 June 2017; n=17 727). Logistic regression including key demographic covariates compared baseline with year 1 and year 2 probabilities of mortality and daily discharge until day 60 after admission and readmission within 60 days of discharge. Results Relative to baseline, admission postcentralisation was associated with favourable OR (95% CI) for day 60 mortality (year 1: 0.95 (0.88 to 1.02), p=0.18; year 2: 0.94 (0.91 to 0.97), p<0.01), mainly among patients aged 80+ years (year 1: 0.88 (0.79 to 0.97); year 2: 0.91 (0.87 to 0.96)). The probability of being discharged alive on any day since admission increased (year 1: 1.07 (1.04 to 1.10), p<0.01; year 2: 1.04 (1.02 to 1.05), p<0.01) and the risk of readmission decreased (year 1: 0.90 (0.87 to 0.94), p<0.01; year 2: 0.92 (0.90 to 0.94), p<0.01). Conclusion A centralised site providing early specialist care was associated with improved short-term outcomes and efficiency relative to lower volume ED admitting to MAU, particularly for older patients.
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Affiliation(s)
- Christopher Price
- Population Health Sciences Institute, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Stephen McCarthy
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Angela Bate
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
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Morgan AS, Khoshnood B, Diguisto C, Foix L'Helias L, Marchand-Martin L, Kaminski M, Zeitlin J, Bréart G, Goffinet F, Ancel PY. Intensity of perinatal care for extremely preterm babies and outcomes at a higher gestational age: evidence from the EPIPAGE-2 cohort study. BMC Pediatr 2020; 20:8. [PMID: 31910799 PMCID: PMC6945524 DOI: 10.1186/s12887-019-1856-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/25/2019] [Indexed: 11/10/2022] Open
Abstract
Background Perinatal decision-making affects outcomes for extremely preterm babies (22–26 weeks’ gestational age (GA)): more active units have improved survival without increased morbidity. We hypothesised such units may gain skills and expertise meaning babies at higher gestational ages have better outcomes than if they were born elsewhere. We examined mortality and morbidity outcomes at age two for babies born at 27–28 weeks’ GA in relation to the intensity of perinatal care provided to extremely preterm babies. Methods Fetuses from the 2011 French national prospective EPIPAGE-2 cohort, alive at maternal admission to a level 3 hospital and delivered at 27–28 weeks’ GA, were included. Morbidity-free survival (survival without sensorimotor (blindness, deafness or cerebral palsy) disability) and overall survival at age two were examined. Sensorimotor disability and Ages and Stages Questionnaire (ASQ) result below threshold among survivors were secondary outcomes. Perinatal care intensity level was based on birth hospital, grouped using the ratio of 24–25 weeks’ GA babies admitted to neonatal intensive care to fetuses of the same gestation alive at maternal admission. Sensitivity analyses used ratios based upon antenatal steroids, Caesarean section, and newborn resuscitation. Multiple imputation was used for missing data; hierarchical logistic regression accounted for births nested within centres. Results 633 of 747 fetuses (84.7%) born at 27–28 weeks’ GA survived to age two. There were no differences in survival or morbidity-free survival: respectively, fully adjusted odds ratios were 0.96 (95% CI: 0.54 to 1.71) and 1.09 (95% CI: 0.59 to 2.01) in medium and 1.12 (95% CI: 0.63 to 2.00) and 1.16 (95% CI: 0.62 to 2.16) in high compared to low-intensity hospitals. Among survivors, there were no differences in sensorimotor disability or ASQ below threshold. Sensitivity analyses were consistent with the main results. Conclusions No difference was seen in survival or morbidity-free survival at two years of age among fetuses alive at maternal hospital admission born at 27–28 weeks’ GA, or in sensorimotor disability or presence of an ASQ below threshold among survivors. There is no evidence for an impact of intensity of perinatal care for extremely preterm babies on births at a higher gestational age.
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Affiliation(s)
- Andrei Scott Morgan
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France. .,UCL Elizabeth Garrett Anderson Institute for Women's Health, 74 Huntley Street, London, WC1E 6AU, UK. .,SAMU 93 - SMUR Pédiatrique, CHI André Gregoire, Groupe Hospitalier Universitaire Paris Seine-Saint-Denis, Assistance Publique des Hôpitaux de Paris, Montreuil, France.
| | - Babak Khoshnood
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France
| | - Caroline Diguisto
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France.,Maternité Olympe de Gouges, Centre Hospitalier Regional Universitaire Tours, Tours, France.,Université François Rabelais, Tours, France
| | - Laurence Foix L'Helias
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France.,UPMC Université Paris 6, Sorbonne Universités, Paris, France.,Service de Néonatologie, Hopital Armand Trousseau, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Laetitia Marchand-Martin
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France
| | - Monique Kaminski
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France
| | - Jennifer Zeitlin
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France
| | - Gérard Bréart
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France
| | - François Goffinet
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France.,Maternité Port-Royal, University Paris-Descartes, Hôpitaux Universitaires Paris Centre, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Pierre-Yves Ancel
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France.,URC CIC P1419, DHU Risk in Pregnancy, Cochin Hotel Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France
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Amatangelo MP, Thomas SB. Priority Nursing Interventions Caring for the Stroke Patient. Crit Care Nurs Clin North Am 2019; 32:67-84. [PMID: 32014162 DOI: 10.1016/j.cnc.2019.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Nearly 20% of all patients with ischemic stroke will require care in an intensive care unit (ICU), particularly those who have received intravenous alteplase or endovascular therapy. Prioritizing nursing intervention and intensive care monitoring can improve patient outcomes and reduce disability. A collaborative interdisciplinary team approach best facilitates the ICU care of an acute stroke patient.
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Affiliation(s)
- Mary P Amatangelo
- Neurology, Stroke, Neurocritical Care, Brigham and Women's Hospital, 15 Francis Street, BB 335, Boston, MA 02115, USA.
| | - Sarah Beth Thomas
- Neuroscience/Critical Care, Brigham Health/Brigham and Women's Hospital, 75 Francis Street, Tower 10-65, Boston, MA 02115, USA
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Variation in Dysphagia Assessment and Management in Acute Stroke: An Interview Study. Geriatrics (Basel) 2019; 4:geriatrics4040060. [PMID: 31731452 PMCID: PMC6960646 DOI: 10.3390/geriatrics4040060] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/20/2019] [Accepted: 10/23/2019] [Indexed: 11/17/2022] Open
Abstract
(1) Background: Patients with dysphagia are at increased risk of stroke-associated pneumonia. There is wide variation in the way patients are screened and assessed. The aim of this study is to explore staff opinions about current practice of dysphagia screening, assessment and clinical management in acute phase stroke. (2) Methods: Fifteen interviews were conducted in five English National Health Service hospitals. Hospitals were selected based on size and performance against national targets for dysphagia screening and assessment, and prevalence of stroke-associated pneumonia. Participants were purposefully recruited to reflect a range of healthcare professions. Data were analysed using a six-stage thematic process. (3) Results: Three meta themes were identified: delays in care, lack of standardisation and variability in resources. Patient, staff, and service factors that contribute to delays in dysphagia screening, assessment by a speech and language therapist, and delays in nasogastric tube feeding were identified. These included admission route, perceived lack of ownership for screening patients, prioritisation of assessments and staff resources. There was a lack of standardisation of dysphagia screening protocols and oral care. There was variability in staff competences and resources to assess patients, types of medical interventions, and care processes. (4) Conclusion: There is a lack of standardisation in the way patients are assessed for dysphagia and variation in practice relating to staff competences, resources and care processes between hospitals. A range of patient, staff and service factors have the potential to impact on stroke patients being assessed within the recommended national guidelines.
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Cisse FA, Damien C, Bah AK, Touré ML, Barry M, Djibo Hamani AB, Haba M, Soumah FM, Naeije G. Minimal Setting Stroke Unit in a Sub-Saharan African Public Hospital. Front Neurol 2019; 10:856. [PMID: 31447769 PMCID: PMC6692431 DOI: 10.3389/fneur.2019.00856] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/24/2019] [Indexed: 12/17/2022] Open
Abstract
Introduction: Sub-Saharan Africa (SSA) has the highest stroke prevalence along with a case fatality that amounts to 40%. We aimed to assess the effect of a minimal setting stroke unit in SSA Public hospital on stroke mortality and main medical complications. Materials and Methods: The study was set in Conakry, Guinea, Ignace Deen public referral hospital. Clinical characteristics, hospital mortality and main medical stroke complications rates (pneumonia, urinary tract infections, sores and venous thromboembolism) of admitted stroke patients after the installation of a minimal stroke unit equipped with heart rate, blood pressure and blood oxygen saturation monitoring and portable oxygen concentrator (POST) were compared to a similar number of stroke patients admitted before the stroke unit creation (PRE). Results: PRE (n = 318) and POST (n = 361) stroke, patients were comparable in term of age (61 ± 14 vs. 60 ± 14.8 years, p = 0.24), sex (56 vs. 50% males, p = 0.09), High blood pressure rate (76.7 vs. 79%, p = 0.44), stroke subtype (ischemic in 72 vs. 78% of cases, p = 0.05) and NIHSS (11 ± 4 vs. 11 ± 4, p = 0.85). Diabetes was more frequent in the PRE group (19 vs. 9%, p < 0.001). Mortality was significantly lower in the POST group (7.2 vs. 22.3%, p < 0.0001) as well as medical complications (4.1 vs. 27.7%, p < 0.001) and lower pneumonia rate (3.3 vs. 14.5%, p < 0.001). Conclusions: Minimally equipped stroke units significantly reduce stroke mortality and main medical complications in SSA.
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Affiliation(s)
- Fode A Cisse
- Department of Neurology, CHU Ignace Deen, Université Gamal Abdel Nasser Conakry (UGANC), Conakry, Guinea
| | - Charlotte Damien
- Department of Neurology, CUB Hôpital Erasme, Université libre de Bruxelles (ULB), Brussels, Belgium
| | - Aissatou K Bah
- Department of Neurology, CHU Ignace Deen, Université Gamal Abdel Nasser Conakry (UGANC), Conakry, Guinea
| | - M L Touré
- Department of Neurology, CHU Ignace Deen, Université Gamal Abdel Nasser Conakry (UGANC), Conakry, Guinea
| | - M Barry
- Department of Neurology, CHU Ignace Deen, Université Gamal Abdel Nasser Conakry (UGANC), Conakry, Guinea
| | - A B Djibo Hamani
- Department of Neurology, CHU Ignace Deen, Université Gamal Abdel Nasser Conakry (UGANC), Conakry, Guinea
| | - Michel Haba
- Department of Neurology, CHU Ignace Deen, Université Gamal Abdel Nasser Conakry (UGANC), Conakry, Guinea
| | - Fode M Soumah
- Department of Neurology, CHU Ignace Deen, Université Gamal Abdel Nasser Conakry (UGANC), Conakry, Guinea
| | - Gilles Naeije
- Department of Neurology, CUB Hôpital Erasme, Université libre de Bruxelles (ULB), Brussels, Belgium
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Phan TG, Beare R, Srikanth V, Ma H. Googling Location for Operating Base of Mobile Stroke Unit in Metropolitan Sydney. Front Neurol 2019; 10:810. [PMID: 31447755 PMCID: PMC6691052 DOI: 10.3389/fneur.2019.00810] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 07/15/2019] [Indexed: 11/13/2022] Open
Abstract
Background and purpose: The recent advances in stroke therapy have placed focus on delivering care within the first hour after stroke onset (golden hour), principally through the use of Mobile Stroke Unit (MSU) to bring the hospital to the patient. The aim of this project is to search the location of MSU hub in Sydney, Australia, optimizing for catchment, transport to nearest thrombolysis and endovascular clot retrieval (ECR)/thrombectomy capable hospital and population at risk. Methods: Traveling time was performed using ggmap package in R to interface with Google Maps application program interface (API). This analysis estimates the travel time from the centroids of each suburbs to five potential MSU hubs (Royal Prince Alfred, Prince of Wales, Royal North Shore, Liverpool, and Westmead hospitals) and eight thrombolysis capable hospitals. It is proposed that the MSU should be deployed at ECR hub to cover the suburbs, not well-covered by thrombolysis and ECR capable hospitals. This step was performed by assigning membership to hospitals within 30 min traveling time to the ECR hub. The base hub of the MSU was proposed as the closest hub (providing ECR) to the least well-served suburbs. The population serviceable by MSU was estimated using stroke incidence studies in Melbourne and Adelaide. Results: The largest population, serviceable by MSU within 30 min (4,606 cases), 45 min radius (8,918 cases), and 60 min (10,084 cases), was Royal North Shore followed by Royal Prince Alfred, Liverpool, Westmead, and Prince of Wales hospitals. Prince of Wales hospital has the smallest catchment within 30 min (3,078 cases), 45 min (7,721 cases), and 60 min (9,984 cases). Suburbs at the edge of metropolitan Sydney such as the Northern Suburbs are less well-served by thrombolysis and ECR capable hospitals. There are 10 suburbs within 30 min travel of one hospital. The remainders are within 30 min of two or more hospitals. Conclusions: Any of the five endovascular clot retrieval capable hospitals are capable of serving as a hub for MSU. We provide a method to identify the hub based on location of suburbs less well-served by other hospital.
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Affiliation(s)
- Thanh G Phan
- Stroke Unit, Monash Health, Melbourne, VIC, Australia.,Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Richard Beare
- Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,Department of Medicine, Frankston Hospital, Peninsula Health, Melbourne, VIC, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia.,Developmental Imaging, Murdoch Children Research Institute, Melbourne, VIC, Australia
| | - Velandai Srikanth
- Stroke Unit, Monash Health, Melbourne, VIC, Australia.,Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,Department of Medicine, Frankston Hospital, Peninsula Health, Melbourne, VIC, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Henry Ma
- Stroke Unit, Monash Health, Melbourne, VIC, Australia.,Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
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Fulop NJ, Ramsay AIG. Authors' reply to Crawford. BMJ 2019; 365:l4415. [PMID: 31253665 DOI: 10.1136/bmj.l4415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Naomi J Fulop
- UCL Department of Applied Health Research, London, UK
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