Hospital services for stroke care. A European Perspective. European Study of Stroke Care

Association of outdoor air pollution with the medical expense of ischemic stroke: The case study of an industrial city in western China

Ischemic stroke, the most frequent cause of severe disability, imposes a significant mental and economic burden on patients and their families. There is increasing evidence to indicate that air pollution contributes to the risk of ischemic stroke. This study aimed to examine the correlation between air pollution and the expense imposed by an ischemic stroke. Data were obtained from hospitals and environmental monitoring stations in an industry city, Longspring, in western China. We used a generalized additive model to estimate the associations between the two factors, measured during 2015-2017. Counter-intuitively, the medical expenses arising from ischemia were negatively associated with the level of air pollution. The corresponding ER for per interquartile range increase of PM2.5, PM10, SO₂ , and NO₂ in lag10 was -0.17% (95% confidence interval (95% CI -0.31%, -0.03%), -0.11% (95% CI -0.2%, -0.02%), -1.04% (95% CI -1.92%, -0.17%) and -0.44% (95% CI -0.66%, -0.22%), respectively (p < 0.05). Subgroups based on gender, age, and season were considered in the analysis. The results indicated that pollutants had significant effects on ischaemia's medical expenses, which were stronger for older people, patients who survived, and warm seasons. This study is the first step in optimizing medical resources, which are essential for policymaking and service planning.

Dose-Response Effect of Daily Rehabilitation Time on Functional Gain in Stroke Patients

OBJECTIVE

To demonstrate the effect of daily treatment time on recovery of functional outcomes and how each type of rehabilitation treatment influences the improvement of subgroups of functional outcomes in stroke patients.

METHODS

We conducted a retrospective study in 168 patients who were admitted to the Department of Rehabilitation Medicine between 2015 and 2016. Patients who experienced their first-ever stroke and unilateral lesions were included. All patients underwent conventional rehabilitation treatment, and each treatment was administered one to two times a day depending on individual and treatment room schedules. Based on the mean daily treatment time, patients were divided into two groups: a high-amount group (n=54) and low-amount group (n=114). Outcomes were measured through the Korean version of Modified Barthel Index (MBI), FuglMeyer Assessment of the upper extremity, Trunk Impairment Scale (TIS), and Berg Balance Scale (BBS) scores on admission and at discharge.

RESULTS

The functional change and scores at discharge of MBI, TIS, and BBS were greater in the high-amount group than in the low-amount group. Among various types of rehabilitation treatments, occupational therapy training showed significant correlation with MBI, TIS, and BBS gain from admission to discharge.

CONCLUSION

The amount of daily mean treatment in post-stroke patients plays an important role in recovery. Mean daily rehabilitation treatment time seems to correlate with improved balance and basic activities of daily living after stroke.

Can augmented physiotherapy input enhance recovery of mobility after stroke? A randomized controlled trial

Objective: To discover if the provision of additional inpatient physiotherapy after stroke speeds the recovery of mobility.

Design: A multisite single-blind randomized controlled trial (RCT) comparing the effects of augmented physiotherapy input with normal input on the recovery of mobility after stroke.

Setting: Three rehabilitation hospitals in North Glasgow, Scotland.

Subjects: Patients admitted to hospital with a clinical diagnosis of stroke, who were able to tolerate and benefit from mobility rehabilitation.

Intervention: We aimed to provide double the amount of physiotherapy to the augmented group.

Main measures: Primary outcomes were mobility milestones (ability to stand, step and walk), Rivermead Mobility Index (RMI) and walking speed.

Results: Seventy patients were recruited. The augmented therapy group received more direct contact with a physiotherapist (62 versus 35 minutes per weekday) and were more active (8.0% versus 4.8% time standing or walking) than normal therapy controls. The augmented group tended to achieve independent walking earlier (hazard ratio 1.48, 95% confidence interval 0.90–2.43; p=0.12) and had higher Rivermead Mobility Index scores at three months (mean difference 1.6; 0.1 to 3.3; p=0.068) but these differences did not reach statistical significance. There was no significant difference in any other outcome.

Conclusions: A modest augmented physiotherapy programme resulted in patients having more direct physiotherapy time and being more active. The inability to show statistically significant changes in outcome measures could indicate either that this intervention is ineffective or that our study could not detect modest changes.

Stroke Rehabilitation 2007: What Should it Be?

Background

There are an estimated 62 million stroke survivors worldwide. The majority will have long-term disability. Despite this reality, there have been few large, high-quality randomized controlled trials of stroke rehabilitation interventions.

Summary of review

There is excellent evidence for the effectiveness of a number of stroke rehabilitation interventions, notably care of stroke patients in inpatient stroke units and stroke rehabilitation units providing organized, goal-focused care via a multidisciplinary team. Stroke units (in comparison with care on general medical wards) effectively reduce death and disability with the number needed to treat to prevent one person from failing to regain independence being 20. Unfortunately, only a minority of stroke patients have access to stroke unit care. The key principles of effective stroke rehabilitation have been identified. These include ( 1 ) a functional approach targeted at specific activities e.g. walking, activities of daily living, ( 2 ) frequent and intense practice, and ( 3 ) commencement in the first days or weeks after stroke.

Conclusion

The most effective approaches to restoration of brain function after stroke remain unknown and there is an urgent need for more high-quality research. In the meantime, simple, broadly applicable stroke rehabilitation interventions with proven efficacy, particularly stroke unit care, must be applied more widely.

International Comparison of Poststroke Resource Use: A Longitudinal Analysis in Europe

BACKGROUND

Long-term costs often represent a large proportion of the total costs induced by stroke, but data on long-term poststroke resource use are sparse, especially regarding the trajectory of costs by severity. We used a multinational longitudinal survey to estimate patterns of poststroke resource use by degree of functional disability and to compare resource use between regions.

METHODS

The Survey of Health, Ageing and Retirement in Europe (SHARE) is a multinational database of adults 50 years and older, which includes demographic information about respondents, age when stroke first occurred, current activity of daily living (ADL) limitations, and health care resource use in the year before interview. We modeled resource use with a 2-part regression for number of hospital days, home nursing hours, and paid and unpaid home caregiving hours.

RESULTS

After accounting for time since stroke, number of strokes and comorbidities, age, gender, and European regions, we found that poststroke resource use was strongly associated with ADL limitations. The duration since the stroke event was significantly associated only with inpatient care, and informal help showed significant regional heterogeneity across all ADL limitation levels.

CONCLUSIONS

Poststroke physical deficits appear to be a strong driver of long-term resource utilization; treatments that decrease such deficits offer substantial potential for downline cost savings. Analyzing internationally comparable panel data, such as SHARE, provide valuable insight into long-term cost of stroke. More comprehensive international comparisons will require registries with follow-up, particularly for informal and formal home-based care.

Modelling, evaluating and implementing cost-effective services to reduce the impact of stroke

Background

Stroke is a leading cause of death and disability but there is little information on the longer-term needs of patients and those of different ethnic groups.

Objectives

To estimate risk of stroke, longer-term needs and outcomes, risk of recurrence, trends and predictors of effective care, to model cost-effective configurations of care, to understand stakeholders’ perspectives of services and to develop proposals to underpin policy.

Design

Population-based stroke register, univariate and multivariate analyses, Markov and discrete event simulation, and qualitative methods for stakeholder perspectives of care and outcome.

Setting

South London, UK, with modelling for estimates of cost-effectiveness.

Participants

Inner-city population of 271,817 with first stroke in lifetime between 1995 and 2012.

Outcome measures

Stroke incidence rates and trends, recurrence, survival, activities of daily living, anxiety, depression, quality of life, appropriateness and cost-effectiveness of care, and qualitative narratives of perspectives.

Data sources

South London Stroke Register (SLSR), qualitative data, group discussions.

Results

Stroke incidence has decreased since 1995, particularly in the white population, but with a higher stroke risk in black groups. There are variations in risk factors and types of stroke between ethnic groups and a large number of strokes occurred in people with untreated risk factors with no improvement in detection observed over time. A total of 30% of survivors have a poor range of outcomes up to 10 years after stroke with differences in outcomes by sociodemographic group. Depression affects over half of all stroke patients and the prevalence of cognitive impairment remains 22%. Survival has improved significantly, particularly in the older black groups, and the cumulative risk of recurrence at 10 years is 24.5%. The proportion of patients receiving effective acute stroke care has significantly improved, yet inequalities of provision remain. Using register data, the National Audit Office (NAO) compared the levels of stroke care in the UK in 2010 with previous provision levels and demonstrated that improvements have been cost-effective. The treatment of, and productivity loss arising from, stroke results in total societal costs of £8.9B a year and 5% of UK NHS costs. Stroke unit care followed by early supported discharge is a cost-effective strategy, with the main gain being years of life saved. Half of stroke survivors report unmet long-term needs. Needs change over time, but may not be stroke specific. Analysis of patient journeys suggests that provision of care is also influenced by structural, social and personal characteristics.

Conclusions/recommendations

The SLSR has been a platform for a range of health services research activities of international relevance. The programme has produced data to inform policy and practice with estimates of need for stroke prevention and care services, identification of persistent sociodemographic inequalities in risk and care despite a reduction in stroke risk, quantification of the effectiveness and cost-effectiveness of care and development of models to simulate configurations of care. Stroke is a long-term condition with significant social impact and the data on need and economic modelling have been utilised by the Department of Health, the NAO and Healthcare for London to assess need and model cost-effective options for stroke care. Novel approaches are now required to ensure that such information is used effectively to improve population and patient outcomes.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme and the Department of Health via the National Institute for Health Research Biomedical Research Centre award to Guy’s and St Thomas’ NHS Foundation Trust in partnership with King’s College London.

Inequalities in stroke patients' management in English public hospitals: a survey on 200,000 patients

Background

According to clinical guidelines, every patient affected by stroke should be given a brain-imaging scan (BIS) - Computerized Tomography or Magnetic Resonance Imaging - immediately after being admitted to hospital.

Aim of the study

To describe the variation in use of BIS among English public hospitals and identify any patient groups being excluded from appropriate care.

Methods

We collected hospital administrative data for all patients admitted to any English public hospital with a principal diagnosis of stroke from 2006 to 2009. We calculated the proportion of patients treated with BIS in the whole sample and after stratification by hospital. We compared hospitals' performance using funnel plots. We performed a multiple logistic regression analysis using BIS as outcome and age, gender, socio-economic deprivation, and comorbidity as covariates.

Results

In English public hospitals there are about 70,000 emergency admissions for stroke per year. Nationally, only 35% receive a BIS immediately, and only 84% receive it within the admission. There is large variation in the use of BIS for stroke patients among English public hospitals, with some of them approaching the recommended 100% and some having very low rates. Young (P<0.001), male (P = 0.012), and least socio-economically deprived patients (P = 0.001), as well as patients with fewer comorbidities (P<0.001) appear to have more chance of being selected for a brain scan.

Conclusion

Some English public hospitals appear to be falling well below the clinical guideline standards for scanning stroke patients and inappropriate patient selection criteria may be being applied, leading to health inequalities.

Provision of acute stroke care and associated factors in a multiethnic population: prospective study with the South London Stroke Register

OBJECTIVES

To investigate time trends in receipt of effective acute stroke care and to determine the factors associated with provision of care.

DESIGN

Population based stroke register.

SETTING

South London.

PARTICIPANTS

3800 patients with first ever ischaemic stroke or primary intracerebral haemorrhage registered between January 1995 and December 2009.

MAIN OUTCOME MEASURES

Acute care interventions, admission to hospital, care on a stroke unit, acute drugs, and inequalities in access to care.

RESULTS

Between 2007 and 2009, 5% (33/620) of patients were still not admitted to a hospital after an acute stroke, particularly those with milder strokes, and 21% (124/584) of patients admitted to hospital were not admitted to a stroke unit. Rates of admission to stroke units and brain imaging, between 1995 and 2009, and for thrombolysis, between 2005 and 2009, increased significantly (P<0.001). Black patients compared with white patients had a significantly increased odds of admission to a stroke unit (odds ratio 1.76, 95% confidence interval 1.35 to 2.29, P<0.001) and of receipt of occupational therapy or physiotherapy (1.90, 1.21 to 2.97, P=0.01), independent of age or stroke severity. Patients with motor or swallowing deficits were also more likely to be admitted to a stroke unit (1.52, 1.12 to 2.06, P=0.001 and 1.32, 1.02 to 1.72, P<0.001, respectively). Length of stay in hospital decreased significantly between 1995 and 2009 (P<0.001). The odds of brain imaging were lowest in patients aged 75 or more years (P=0.004) and those of lower socioeconomic status (P<0.001). The likelihood of those with a functional deficit receiving rehabilitation increased significantly over time (P<0.001). Patients aged 75 or more were more likely to receive occupational therapy or physiotherapy (P=0.002).

CONCLUSION

Although the receipt of effective acute stroke care improved between 1995 and 2009, inequalities in its provision were significant, and implementation of evidence based care was not optimal.

The Debrecen Stroke Database: demographic characteristics, risk factors, stroke severity and outcome in 8088 consecutive hospitalised patients with acute cerebrovascular disease

BACKGROUND

High stroke mortality in central-eastern European countries might be due to higher stroke incidence, more severe strokes or less effective acute care than in countries with lower mortality rate. Hospital databases usually yield more detailed information on risk factors, stroke severity and short-term outcome than population-based registries.

PATIENTS AND METHODS

The Debrecen Stroke Database, data of 8088 consecutively hospitalised patients with acute cerebrovascular disease in a single stroke centre in East Hungary between October 1994 and December 2006, is analysed. Risk factors were recorded and stroke severity on admission was scored by the Mathew stroke scale. The modified Glasgow outcome scale was used to describe patient condition at discharge.

RESULTS

Mean age was 68+/-13 years, 11.4% had haemorrhagic stroke. The rate of hypertension on admission was 79% in men, and 84% in women, 40.3% of men and 19.8% of women were smokers, and 34% of all patients had a previous cerebrovascular disease in their history. Case fatality was 14.9%, and 43% had some disability at discharge. Outcome at discharge was worse with higher age, higher glucose, higher blood pressure, higher white cell count and erythrocyte sedimentation rate and more severe clinical signs on admission. In multivariate analysis admission blood pressure lost its significance in predicting outcome.

CONCLUSIONS

In this large Hungarian stroke unit database hypertension on admission, smoking and previous cerebrovascular disease were more frequent than in most western databases. These findings indicate major opportunities for more efficient stroke prevention in this and probably other eastern European countries.

Predictors of resuming therapy within four weeks after discharge from inpatient rehabilitation

PURPOSE

To identify the percentage of persons with stroke resuming therapy within 4 weeks of inpatient rehabilitation discharge, to compare the characteristics of those who did and did not resume therapy, and to determine the predictors of resuming physical (PT), occupational (OT), and speech (ST) therapy.

METHOD

Sociodemographic, stroke-related, and therapy data for persons with stroke (N = 131) were abstracted from inpatient rehabilitation charts. FIM, Stroke Impact Scale, Geriatric Depression Scale, and data on therapy received after discharge were also collected.

RESULTS

Logistic regression models demonstrated that minorities were less likely to resume PT (odds ratio [OR] = 0.30) and OT (OR = 0.25). Survivors with neglect/visual-field cut/spatial-perceptual loss were 2-3 times more likely to resume PT, OT, and ST. Survivors with higher scores on the SIS Physical domain subscale were less likely to resume PT (OR = 0.98) and OT (OR = 0.97). Men were 3.3 times more likely to have OT than women. Those with comprehensive health insurance were 11.2 times more likely to receive ST.

CONCLUSIONS

The benefits of outpatient therapy are not universally available to all persons with stroke. Further research needs to explore the factors that hinder the prompt resumption of therapy for minority and female persons with stroke and to test appropriate interventions.

Stroke in the young: access to care and outcome; a Western versus eastern European perspective

BACKGROUND

To develop effective strategies to address the needs of young patients with stroke, it is important to recognize what components of stroke care they receive. The aims of this study were to describe the provision of stroke care and the factors associated with 3-month mortality and disability (Barthel Index 0-14) in patients younger than 55 years across Western and Eastern Europe.

METHODS

Data from hospital-based stroke registers in Western Europe (7 centers, 6 countries) and Eastern Europe (4 centers, 3 countries) were analyzed.

RESULTS

Of 1735 patients admitted to hospital, 201 (11.5%) patients were younger than 55 years (Western European centers 51%, and Eastern European centers 49%). Stroke department care was higher in Western centers (67%) than in Eastern centers (24%) (P < .001). Doctor (P < .001), therapy (P = .01), and nursing (P < .001) time were higher in Western centers. At 3 months, case fatalities between Western and Eastern centers were 8% versus 23% (P = .003). Patients in Eastern European centers were more likely to have disability at 3 months (odds ratio = 24.3, confidence interval = 1.2-494, P = .04).

CONCLUSION

Young patients with stroke in Western Europe are more likely to gain access to a number of components of stroke care compared with those in Eastern Europe. The future challenge is to ensure that recommendations are adopted to ensure all young patients receive evidence-based stroke care across Europe.

In-hospital direct cost of acute ischemic and hemorrhagic stroke in Greece

OBJECTIVES

The geographic inequity and the wide variation in the patterns of care of stroke found across Europe together with the lack of health economics evaluation in Greece led to this prospective study, aiming to provide data on in-hospital direct cost of patients with an acute stroke in Greece, and to identify independent prognostic factors.

METHODS

Demographic and clinical data were recorded on 429 consecutive patients with an acute ischemic or hemorrhagic stroke admitted to a tertiary care hospital in Greece during a period of 18 months. The costs incurred were estimated using the official financial charts listing in euro (euro), the real expenditure of all hospital departments.

RESULTS

The direct in-hospital cost for all stroke cases was 1,551,445euro for a total of 4674 days (331.9euro per day in-hospital). The mean in-hospital cost per stroke patient was 3624.9euro (+/-2695.4). Hemorrhagic strokes were significantly more expensive than the ischemic strokes [mean 5305.4 (+/-4204.8)euro and 3214.5 (+/-1976.2)euro, respectively) and lacunar strokes the least expensive among ischemic stroke subtypes. The length of stay was highly correlated with in-hospital total cost. Multivariate linear regression analysis showed that admission ward, stroke severity on admission, stroke type and status discharge were independent predictors of cost.

CONCLUSIONS

Purchasers in our health services should differentiate in their cost estimates and pricing schemes between types of cerebrovascular events. Future studies should focus on modifiable factors related, not only with stroke characteristics, but also with operational policies of hospitals, that may influence length of stay.

Selective risk factors profiles and outcomes among patients with stroke and history of prior myocardial infarction. The European Community Stroke Project

BACKGROUND AND OBJECTIVE

Previous myocardial infarction (MI) has been linked with poorer stroke outcome. Whether this depends on a greater stroke severity is still uncertain. The aim of the study was to assess the effect of previous MI on characteristics and outcome of stroke in a large hospital cohort of patients.

METHODS

In a European Union Concerted Action, patients hospitalized for first-in-a-lifetime stroke were assessed for demographics, risk factors, clinical presentation, and 3-month survival and handicap.

RESULTS

Out of 4190 study patients, 460 (11%) reported a history of MI. Compared with patients without previous MI, those with MI were significantly older, more often males, smokers, alcohol consumers, and with a more severe pre-stroke level of handicap. They had more frequently atrial fibrillation and a history of transient ischemic attack. The acute neurological state and the 28-day mortality did not differ between the two groups. At 3 months, death or severe handicap were more frequent in the MI group (28.3% vs. 21.7%, P=0.001; 74.8% vs. 65.8%, P=0.008). Controlling by logistic regression analysis for age, sex, vascular risk factors, comorbidities, prior to stroke therapy, pre-stroke level of handicap, and clinical acute phase variables, prior MI remained an independent predictor of 3-month death (OR 1.30; 95% CI, 1.02-1.66) and 3-month handicap (OR 1.46; 95% CI, 1.01-2.11).

CONCLUSIONS

Previous MI has no impact on clinical severity of acute stroke, but significantly affects 3-month outcome in terms of handicap and mortality.

The hospital costs of care for stroke in nine European countries

Stroke is a major cause of mortality and morbidity, but the reasons for differences in costs of care within and between countries are not well understood. The HealthBASKET project used a vignette methodology to compare the mean costs and prices of hospital care across providers in nine European Union countries. Data on resource use, unit costs and prices of care for female stroke patients without co-morbidity were collected from a sample of 50 hospitals. Mean costs for each provider were analysed using multiple regression. Sensitivity analysis explored the effects on cost of using official exchange rates, purchasing power parity (PPP) and proportion of national income per capita. The mean cost of a hospital episode per patient for stroke at PPP was 3813 euros (standard error 227) with an additional day in hospital typically associated with 6.9% (95% CI: 4-9%) higher costs and thrombolysis associated with 41% higher costs (10-73%). After adjusting for explanatory factors, about 76% of the variation in cost could be attributed to between-country differences, and the extent of this variation was sensitive to the method of currency conversion. There was considerable variation in the care pathways within and between countries, including differences in the availability of stroke units and access to rehabilitative services, but only the length of stay and use of thrombolytic therapy were significantly associated with higher cost. The vignette methodology appears feasible, but further research needs to consider access to healthcare over a longer follow up and to include both costs and outcomes.

Risk factors and outcome of subtypes of ischemic stroke. Data from a multicenter multinational hospital-based registry. The European Community Stroke Project

BACKGROUND

Information on determinants and prognosis of ischemic stroke subtypes is scarce. We aimed at evaluating risk factors, pathogenesis, treatment and outcome of different ischemic stroke subtypes.

METHODS

In a European Concerted Action involving seven countries, ischemic stroke subtypes defined according to the Oxfordshire Community Stroke Project (OCSP) were evaluated for demographics, baseline risk factors, resource use, 3-month survival, disability (Barthel Index) and handicap (Rankin Scale).

RESULTS

During the 12-month study period, cerebral infarction was diagnosed in 2740 patients with first-in-a-lifetime stroke (mean age 70.5+/-12.4 years, 53.4% males). OCSP classification was achieved in 2472 (90.2%). Of these, 26.7% were total anterior circulation infarctions (TACI), 29.9% partial anterior circulation infarctions (PACI), 16.7% posterior circulation infarctions (POCI) and 26.7% lacunar infarctions (LACI). In multivariate analysis, atrial fibrillation was predictive of TACI (odds ratio [OR], 1.61; 95% CI, 1.28-2.03), hypertension (OR, 1.38; 95% CI, 1.16-1.65) and myocardial infarction (OR, 1.42; 95% CI, 1.08-1.86) predictive of PACI, hypertension (OR, 1.25; 95% CI, 1.04-1.50) predictive of LACI. A negative association was observed between TACI and hypertension (OR, 0.51; 95% CI, 0.42-0.61). Discharge home was 50% less probable in TACI and PACI than in LACI patients. As compared to LACI, TACI significantly increased the risk of 3-month death (OR, 5.73; 95% CI, 3.91-8.41), disability (OR, 3.27; 95% CI, 2.30-4.66) and handicap (OR, 2.71; 95% CI, 1.91-3.85).

CONCLUSIONS

Ischemic stroke subtypes have different risk factors profile, with consequences on pathogenesis and prognosis. Information on determinants of the clinical syndromes may impact on prevention and acute-phase interventions.

Socioeconomic status and stroke

This paper reviews the current evidence for the association between socioeconomic status and stroke incidence, survival, mortality, and other outcomes. The evidence is strongest for mortality and incidence of stroke, with high rates of stroke in low socioeconomic groups being a consistent finding. Low socioeconomic groups also have lower survival and greater stroke severity than high socioeconomic groups, although there is less evidence for this association. The mechanisms through which socioeconomic status affects stroke risk and outcomes are unclear but some studies report that differences in risk-factor prevalence could account for some of the variation. We discuss the implications of these findings and make recommendations for future research. Studies using prospective population-based methods with improved control for confounding factors are needed to confirm or refute these associations. Understanding the causal associations between socioeconomic status and stroke will allow interventions to be appropriately targeted and assessed.

TOAST classification of subtypes of ischaemic stroke: diagnostic and therapeutic procedures in stroke. A four-year observation

BACKGROUND

The purpose of this study was to classify ischaemic strokes according to TOAST in patients treated in the internal disease and neurological wards of a hospital in Lower Silesia, evaluate diagnostic and therapeutic methods, and compare their treatment effectiveness according to the Rankin scale.

METHODS

Two hundred and seventy-nine patients below 80 and 77 patients over 80 years of age suffering from ischaemic stroke were covered by the retrospective study.

RESULTS

Patients with large-artery atherosclerosis according to the TOAST classification and over 80 years old (p = 0.001) were more frequently hospitalised in the internal disease ward (p = 0.005). Strokes caused by small-vessel occlusion were more frequent in the neurological ward (p = 0.017).

CONCLUSIONS

The authors suggest the general use of the TOAST classification and an active information campaign among doctors of various specialisations about standard procedures in stroke according to AHA and EUSI guidelines.

[Epidemiology and management of stroke patients in emergency departments of the Centre region of France]

INTRODUCTION

Stroke is a leading cause of death and disability. Patients with suspected stroke are usually managed in emergency departments (ED). Stroke units must be created in our country, but only few French epidemiological data are available to define needs in stroke care.

OBJECTIVE

A prospective study was planned to evaluate epidemiology and stroke care for patients with suspected stroke admitted in the 22 ED of our region in the center of France during a two-month period.

METHODS

Patients with suspected stroke seen at the 22 ED were prospectively followed until discharge or one month after admission. Data on demographic characteristics, mode of transport, delay of arrival and imaging, clinical findings at arrival, department of admission, diagnosis, Rankin scale at day 7, in-hospital mortality, and outcome at a month were collected. A global statistical analysis and a comparison between rural and urban ED were performed.

RESULTS

Five hundred and ninety-eight patients were included. Mean age was 75 years. Median admission delay was 4 hours and 52 minutes. Predominant mode of transport was a private ambulance. A CT scan was obtained in 91 p.cent of cases with a median delay of 2 hours and 30 minutes. Only a third of the patients were admitted in departments of Neurology. Final diagnosis was: ischemic stroke (61 p.cent), transient ischemic attack (16 p.cent), hemorrhagic stroke (10 p.cent), other vascular disease (3 p.cent), non vascular disease (10 p.cent). In-hospital mortality was 20 p.cent, factors significantly associated with death rate were elevated age and a Glasgow coma scale<10 at admission. Mean length of stay was 12 days for stroke patients. At one month, 63 percent of patients were discharged to their home, 28 percent were transferred to an institution or in a rehabilitation unit, and 15 percent were still hospitalized. Significant differences in stroke care were found between rural and urban ED.

CONCLUSION

This prospective study provides epidemiological data for our region. Creation of stroke units and definition of acute stroke networks are necessary to improve stroke care.

Cognitive Impairment after Stroke – Impact on Activities of Daily Living and Costs of Care for Elderly People

BACKGROUND AND PURPOSE

The economic burden of stroke is substantial and is likely to increase with an increasing number of elderly individuals in the population. There is thus a need for information on the use of health care resources and costs among these elderly stroke patients. We examined the impact of the cognitive impairments on the ability to perform activities of daily living (ADL) and utilization and costs of health care in a cohort of elderly stroke patients.

METHODS

One hundred and forty-nine patients aged >/=70 years with acute stroke were included. The patients were assessed regarding their ability to carry out ADL and health resource utilization and cost during the first year after stroke. Cognitive impairments were assessed 18 months after the index stroke.

RESULTS

Stroke severity in acute stroke and cognitive impairment at 18 months after stroke onset was associated with impairment in ADL and increased costs for utilisation of care during the first year. Patients with cognitive impairment were more dependent on personal assistance in ADL. Costs per patient during the study were three times higher for patients with cognitive impairment. Hospital care, institutional living and different kinds of support from society accounted for the highest costs.

CONCLUSIONS

Costs of care utilisation during the first year after stroke were associated with cognitive impairments, stroke severity and dependence in ADL. The results should be interpreted cautiously as the assessment of cognitive function was made 18 months after stroke onset and costs were estimated for the first year after stroke.

Regional differences in the use of out-patient services by stroke patients after hospitalisation

BACKGROUND

To improve the quality of life in stroke patients, outreach care programmes are developed and assessed for effectiveness. The generalisability of the trials' results is uncertain since information on the comparability of the conventional out-patient services is lacking. This study intended to assess the use of 11 types of conventional out-patient services by stroke patients in the United States and a predefined set of Western European countries.

METHODS

Review of the literature from 1990 to 2001.

RESULTS

We found 11 studies, which contained data on 1,875 patients of 6 countries. Large differences in the use of out-patient services within and between countries prohibited pooling of the data.

CONCLUSIONS

The paucity of data on the use of conventional out-patient services by stroke patients and the regional differences found do not substantiate generalisability of the results from studies on outreach care for stroke patients.

[Evaluation of care given by nurses during the acute stage of stroke]

INTRODUCTION

We report the results of a one-day survey of nursing care load in University Hospitals (UH), General Hospitals (GH) and Stroke Units (SU) regarding the acute stage of stroke.

METHODS

The type of care and the time devoted to care were compared by type of stroke (transient ischemic attack, ischemic stroke, hemorrhagic stroke, cerebral thrombophlebitis, sub-arachnoid hemorrhage), and degree of handicap (Barthel score).

RESULTS

Twenty-two hospitals (13 UH and 9 GH) participated in the study and provided care for 328 stroke victims (30 transient ischemic attacks, 247 ischemic strokes, 36 hemorrhagic strokes, 3 cerebral thrombophlebitis events and 11 strokes of unknown mechanism). Care was given in UHs for 63 percent of the patients and in GHs for 37 percent; in SUs for 40 percent (132 patients) and general neurology units for 60 percent (196 patients). Care involved physiotherapy for 70 percent, speech therapy for 42 percent, and care for cognitive decline for 36 percent. Mean time spent by nurses and nursing assistants peaked in the morning with a significant time not devoted to care. More than 3 hours of nurse care per day of care was significantly more frequent in SUs (p<0.001) and in GHs (p=0.02) for patients with Barthel score<40 or hemorrhagic stroke, irrespective of age. Patients older than 80 years, with a Barthel score<40, with hemorrhagic stroke, and who were admitted more than 15 days before the survey required more than two hours per day of nursing assistant care significantly more often. The probability of more than three hours per day of nurse care for stroke increased 2.8-fold for hemorrhagic stroke, 6.0-fold for Barthel Score<40, and 2.0-fold for care in a GH. The probability of more than two hours per day of nurse assistant care for stroke increased 3.0-fold for hemorrhagic stroke, 6.1-fold for Barthel score<40, 2.0-fold for patients older than 70 years, and 1.5-fold for stroke onset more than 14 days before the survey.

CONCLUSION

This survey enabled calculating the number of care givers required for 10 patients: 6 nurses and 5 nursing assistants, a level in line with recommended practices. These results emphasize the important role of nursing care for stroke victims, and points out that the type of hospital, the type of stroke, and the patient's age and degree of handicap have an effect on nursing load. This one-day survey enabled calculation of the number of nurses and nursing assistants needed for a 10-patient unit.

Variations in care and outcome in the first year after stroke: a Western and Central European perspective

BACKGROUND

There are significant variations in the short term patterns of care and outcome after a first stroke in Europe.

OBJECTIVE

To estimate the variation in stroke care and outcome up to 1 year after a stroke in selected European centres.

METHODS

Hospital based stroke registers were established in 11 hospitals in seven western and central European countries to collect demographic, clinical, and resource use data at the time of first ever stroke during 1993-4. At 3 and 12 months, details of survival, activities of daily living score, and use of services were recorded. Univariate comparisons between centres were made using the chi2 test and stepwise regression was used to identify associations between centre, case mix, therapy provision, and outcomes.

RESULTS

Of the 4048 patients registered, 23% were lost to follow up and 38% had died at 1 year. The proportions of survivors who felt they needed assistance at 12 months ranged from 35% in Italy to 77% in UK2. There were comparatively high amounts of therapy provided up to 1 year in UK3, France and Germany 1, mainly at home. At 1 year, social services were still providing support in UK1, UK5 and France, with some support in Germany 1 and family support was provided in France. In multivariate analysis, after adjustment for case mix and receipt of rehabilitation, non-UK centres had improved activities of daily living (p<0.001). Older age was indicative of more need for assistance, but less likelihood of assistance from the family. Those in France were more likely to get assistance from their family than any other centre. Mainland European patients were more likely to get help from their family than those in the UK. Patients in all areas except UK2 and UK3 were more likely to be dead or dependent at 1 year than patients in UK1.

CONCLUSIONS

There were significant variations in the pathways of care for stroke across European centres in the mid 1990s, which were associated with variation in outcome, and remain unexplained. Family support is more prevalent in southern Europe and service support more prevalent in the UK.

An evaluation of a multidisciplinary team for intermediate care at home

Background

The implementation of the National Health Service Plan for the UK will see an expansion of services for intermediate care. Such services are usually targeted at older people and aim to: prevent ‘avoidable’ admissions to acute inpatient care; facilitate the timely discharge of patients from acute inpatient care; promote patient rehabilitation. A range of services might fall under the banner of intermediate care. They are usually delivered in patients' homes or in non-acute institutions. This paper describes an evaluation of a multidisciplinary Rapid Response Team (RRT). This service aimed to provide a home based alternative to care previously provided in an acute hospital bed which was acceptable to patients and carers and which maintained clinical care standards. The service was provided for the population of Hereford, a rural town in the middle of England.

Methods

A mixed-method descriptive design using quantitative and qualitative techniques was used to monitor: the characteristics of service users, the types and amounts of care received, any ‘adverse’ events arising from that care, and the acceptability of the service to patients and carers. A collaborative approach involving key stakeholders allowed appropriate data to be gathered from patient case notes, RRT staff, local health and social care providers, and patients and their carers. A suite of self-completed questionnaires was, therefore, designed to capture study data on patients and activities of care, and workshops and semi-structured interview schedules used to obtain feedback from users and stakeholders.

Results

Service users (231) were elderly (mean age 75.9), from three main diagnostic categories (respiratory conditions 19.0%, heart/stroke 16.2%, falls 13.4%), with the majority (57.0%) having both medical and social care needs. All patients received care at home (mean duration 5.6 days) with only 5.7% of patients having to be re-admitted to acute care. Overall, patients and carers had positive attitudes to the new service but some expressed concerns about their ability to influence the choice of care option (24.1% and 25.0% of patients and carers, respectively), whilst 22.7% of carers were concerned about the quality of information about care.

Conclusions

Both the nature of schemes for intermediate care, and the policy context in which they are introduced, mean that pragmatic methodologies are often required to evaluate their impacts. Unfortunately, this need for pragmatism can then mean that it is difficult to reach definitive conclusions about the merits of schemes. However, the findings of this evaluation suggest that the Rapid Response Team provided an ‘acceptable’ alternative to an extended period of care in an acute setting. Such schemes may have relevance beyond the NHS of the UK as a means of providing a more appropriate and cost efficient match between patients' needs for care, the types of care provided, and the place in which care is provided.

Beneficios clínicos de la implantación de un sistema de atención especializada y urgente del ictus

BACKGROUND AND OBJECTIVE

Several strategies as stroke teams, stroke code teams, or stroke units development have demonstrated to improve stroke care quality. The potential benefit of implementing them as a whole has not been studied. We aimed to test the clinical efficacy of a specialized and urgent stroke assistance system in a University Hospital, as well as the specific impact of each part of the system on several clinical indicators.

PATIENTS AND METHOD

The implementation of the system followed three consecutive steps: stroke team and stroke code development, stroke unit creation and finally on-call stroke neurologists incorporation. Several clinical indicators to evaluate results have been selected. We compared data available before system onset (1992-1997) with data obtained during the system implementation (1998-2002). Modification in the results indicators following each of the individual steps of the system was also evaluated.

RESULTS

During the five years of the system implementation, 5843 stroke patients have been prospectively studied. Admission and readmission necessities were reduced up to 34.2% and 81.8% respectively. Length of stay progressively decreased from 18 (pre-1998) to 7 days (2002). In-hospital mortality and institutionalization necessities were reduced to 50.1% and 50.5% respectively. The third step, in which on-call stroke neurologist were incorporated to the system, has demonstrated to be the most efficient in decreasing the length of stay, hospital mortality and institutionalization necessities.

CONCLUSIONS

The creation of a specialized urgent stroke care system, protocol based and developed in stroke units, improves the medical assistance quality for stroke patients. Stroke neurologists on-call have a relevant role in the system working.

Variation in the management of acute physiological parameters after ischaemic stroke: a European perspective

Studies have shown significant variation in stroke case fatality across Europe. These variations suggest the need to explore whether differences in physiological support in acute stroke exist across Europe. Data were collected in four European centres over 6 months. These included clinical status and management of acute physiology (hydration, oxygenation, nutrition, hypertension, hyperglycaemia and temperature in the first week of ischaemic stroke) and survival at 3 months. Differences in acute supportive care between centres were adjusted for case mix. Patients admitted to centres in London (n = 106), Dijon (n = 95), Erlangen (n = 91) and Warsaw (n = 72) were studied. There were significant differences in incontinence, dysphasia, dysphagia, conscious level, pyrexia, hyperglycaemia and comorbidity between centres. After adjusting for case mix, there were significant differences in intravenous fluid use (P = 0.04), enteral feeding (P = 0.003), initiation of new antihypertensive therapy (P = 0.0006) and insulin therapy (P = 0.004) between centres, with the London centre having the lowest uptake of interventions. Three-month case fatality rates varied from 10 to 28%. This pilot study shows significant variation in acute physiological support in acute stroke across four European centres, which remains unexplained by case mix. Further research is required to link variation in acute care with stroke outcome, to identify which interventions appear to be the most effective.

A new classification tool for clinical differentiation between haemorrhagic and ischaemic stroke

PURPOSE

To develop a simple and reliable diagnostic tool for differentiation of cerebral infarction (CIF) from intracerebral haemorrhage (ICH) in order to aid clinicians to decide about starting antiplatelet therapy in settings where rapid access to computed tomography (CT) is lacking.

METHODS

Thirty variables regarding each patient admitted with acute stroke were recorded and considered in a logistic regression analysis using ICH as end-point (internal study). CT was used as the golden standard. The score derived was validated with data from the next consecutive stroke patients and was compared with the three preexisting scores (external validation study).

RESULTS

Amongst 235 patients (119 males, mean age 70.6 +/- 11.2 years) of the internal study, 43 (18.3%) had ICH. Four independent correlates of ICH were identified and used for the derivation of the following integer-based scoring system: number of points=6 * (neurological deterioration within 3 h from admission) + 4 * (vomiting) + 4 * (WBC > 12 000) + 3 * (decreased level of consciousness). In the external study [168 patients, 85 males, mean age 70.2 +/- 10.8 years, 31 (18.5%) with ICH], when the cut-offs < or =3 points for CIF and > or =11 points for ICH were used, sensitivity, specificity, and positive and negative predictive values of the score for detection of stroke type were 97, 99, 97 and 99%, respectively; exceeding noticeably the three previously proposed systems.

CONCLUSIONS

The proposed model provides an easy to use tool for sufficiently accurate differentiation between haemorrhagic and nonhaemorrhagic stroke on the basis of information available to all physicians early after admission.

Hospital-based stroke care in Ireland: results from one regional register

BACKGROUND

Most patients with acute stroke are admitted to hospital. If stroke services in this country are to be improved, we need accurate and reliable information about the types of stroke patients being admitted, their present management and outcome.

AIMS

To examine the demography, severity, level of investigation, length of stay, mortality and discharge location of prospectively identified consecutive stroke admissions to three general hospitals in South East Dublin.

RESULTS

Three hundred and twenty nine consecutive stroke admissions to three general hospitals in South East Dublin were registered using the European Stroke Database over 50 weeks. The mean age was 73.3 years, whilst 20.1% patients were under 65 years. Prior to admission, 90% of patients were community dwelling with 14.9% of patients being dependent in activities of daily living. 22.4% of patients had some depression in level of consciousness on admission. The overall mortality rate was 26.1% whilst 136 (41.3%) were discharged home, 50 (15.2%) went to institutional care and 45 (13.7%) went to non general hospitals secondary rehabilitation units. The mean length of stay was 31.3 days. The combined poor outcome measure (mortality plus percentage of patients discharged to institutional care), was lower in one hospital compared to the other two hospitals (29.3% versus 44.65%, p > or = 0.05) probably reflecting case mix. Stroke accounted for 4.2% of all bed days in the major general hospital in this area. The overall CT scan rate was 84.5%, with 18.2% of CT scans showing a haemorrhagic component and two patients (0.8%) having brain tumours. Carotid doppler examinations were carried out in 37% of patients.

CONCLUSION

The results demonstrate the high mortality and prolonged hospital stay for stroke patients in this area and emphasise the need for co-ordinated stroke care and regular audit to ensure most effective use of hospital resources.

Acute neurological stroke care in Europe: results of the European Stroke Care Inventory

Following the 1997 Recommendations of the EFNS Task Force on Acute Neurological Stroke Care (European Journal of Neurology, 1997: 4:435-441) a European Inventory was undertaken to assess the development of acute stroke care in the EFNS member countries and to give an estimate of the needs based on 1997 data. All 30 members of the EFNS Stroke Scientist Panel were asked to complete a questionnaire on acute stroke epidemiology as well as acute stroke care in their country. Data were based either on national surveys, hospital statistics, or estimates given on the basis of extrapolation of regional studies, or other defined sources. Specialist estimates were also taken into account where no other data source was available. Data from 22 countries were received and referred to almost one million strokes occurring per year in a population of over 500 million. Most epidemiological data confirmed an east-west gap known from previous studies. These included rates that, in eastern countries, were higher for incidence, stroke as a leading cause of death, and 30-day case-fatality, and rates that were lower for overall hospitalization or availability of CT scanning. East-west differences were not seen for the total number of acute stroke units or the number of acute stroke units set up within neurological hospital departments, nor for most other quality indicators of acute stroke care with the exception of technological standards in some countries. The higher rates for 30-day case-fatality in eastern Europe (mostly above 20%) compared with western Europe (mostly below 20%) are probably caused by a case mix with more severe ischemic strokes and a higher percentage of cerebral haemorrhages admitted for acute care in eastern Europe. This is probably due to the higher prevalence of the most common risk factors for stroke in these countries which tend to result in more severe strokes. This, therefore, underlines the need for stroke prevention programmes especially in eastern Europe. This epidemiological east-west gap is not reflected by most quality indicators for acute stroke care, e.g. total number of acute stroke units available within each country. Most eastern European countries have a well-developed neurological care system for acute stroke but still have urgent technological and socioeconomical needs. The leading role of clinical neurology in acute stroke care is visible in most but not all European countries.

Evaluation of the American Heart Association Stroke Outcome Classification

BACKGROUND AND PURPOSE

The purpose of this study was to evaluate the concurrent validity of the American Heart Association Stroke Outcome Classification (AHA.SOC) and compare performance of its function classification with that of the Modified Rankin Scale.

METHODS

The individuals in this study included the last 105 consecutive subjects who were part of a cohort of 459 stroke patients in the Kansas City Stroke Study. The patients were evaluated with a variety of standardized assessments at enrollment (within 14 days of stroke onset) and followed at 1, 3, and 6 months after stroke. Specifically, we examined validity of AHA.SOC by comparing its 3 domains (ie, Domain, Severe, and Function) with stroke severity. We correlated AHA.SOC-Function with scores of the Barthel Index, Lawton Instrumental Activities of Daily Living (IADL) Scale, and Medical Outcome Study 36-Item Short-Form Health Survey (SF-36) measures of physical function and mental health. Finally, we compared the discriminant ability of AHA.SOC-Function and the Modified Rankin Scale in assessing disability and handicap. These data were analyzed with the use of Spearman rank correlations and Kruskal-Wallis tests.

RESULTS

All 3 domains of the AHA.SOC were significantly associated with stroke severity and scores of Barthel Index, Lawton IADL, and SF-36 physical function (all P<0.001). Both AHA.SOC-Function and the Modified Rankin Scale discriminated well the disabilities and handicap measured by Barthel Index, Lawton IADL, and SF-36 physical function (all P<0.001).

CONCLUSIONS

The AHA.SOC was able to capture impairments, disabilities, and handicap after stroke. The AHA. SOC-Function performed equally as well as the Modified Rankin Scale in assessing disabilities related to basic activities of daily living but differentiated slightly better than the Modified Rankin Scale in assessing disabilities/handicap related to instrumental activities of daily living. Neither the AHA.SOC-Function nor the Modified Rankin Scale captured differences in mental health after stroke.

Direct costs during the first year after intracerebral hemorrhage

OBJECTIVES

Knowledge of resource use and associated costs of treatment, care and rehabilitation at hospitals and in the health care and social service sectors is limited. This study presents data on the total resource use during the first year after spontaneous intracerebral hemorrhage.

METHODS

All patients hospitalized because of stroke at a university hospital in Copenhagen, Denmark, during a 1-year period 1994-1995 were included in a database. The patients were followed until 1 year after the stroke, and data on resource use during and after the hospital stay were collected prospectively. This study investigates a subgroup comprising 90 patients with intracerebral hemorrhage. Resource use is described and costs are calculated.

RESULTS

The cost of the hospital stay including acute care and rehabilitation had a mean of 90200 DKK (US$16100). The total cost of health care and social services during the first year had a mean of 123200 DKK (US$22000). Costs decreased significantly with age, but when differences of 30 days case fatality between age groups were considered, the association between costs and age disappeared.

CONCLUSIONS

The mean cost of treatment, care and rehabilitation during the first year after intracerebral hemorrhage was 123200 DKK, of which the primary hospital stay constituted 73%.

Basic characteristics of hospital stroke services in Eastern Hungary

Stroke mortality is extremely high in Central-Eastern European countries. We report basic characteristics of a stroke unit in Eastern Hungary, including age and sex distribution; the proportion of transient ischemic attacks (TIA), ischemic and hemorrhagic strokes; case fatality; application of diagnostic methods; and length of stay for all patients treated with acute cerebrovascular disease over a 12-month period. Records of all patients with acute cerebrovascular disease (n = 522) discharged in 1995 from a stroke unit with a well defined catchment area of 220,000 inhabitants in Eastern Hungary were retrospectively analyzed. Case fatality was 18.6% for all patients and 21.1% after excluding cases with TIA. Computer tomography, duplex carotid ultrasound, cerebrospinal fluid examination and electroencephalography were performed in 79%, 77%, 7% and 2% of the patients, respectively. The database of the university hospital with the same catchment area was electronically searched for patients who were discharged with the diagnosis of stroke from the three departments of internal medicine. Stroke mortality data of the catchment area based on death certificates was obtained from the Central Statistical Bureau. Two hundred twenty-eight stroke deaths were reported in the catchment area in 1995. In the same period 97 stroke deaths occurred at the stroke unit and 76 at the departments of internal medicine. If we aim to treat all patients with acute stroke at the stroke unit, with the present stroke incidence and duration of hospital stay the current capacity of the stroke unit (1 bed per 10.000 inhabitants) should be doubled.

Genetics of stroke--a review

Evidence from twin and family shows that genetic factors contribute to the risk of stroke and that their role may be at least as important in stroke as in coronary heart disease. Additional support for the significance of genetic factors comes from other findings such as epidemiological data showing phenotypic heterogeneity of stroke, genetic influence on many of the risk factors for stroke, and racial and geographic differences in morbidity and mortality in stroke victims. Yet, apart from the reported associations of a small number of cases with Mendelian cerebrovascular diseases, only a few studies have directly investigated gene markers or molecular genetics of stroke. This review presents the existing evidence on the genetic background of stroke and discusses results from the genetic studies of stroke published to date.

The uptake and costs of guidelines for stroke in a district of southern England

STUDY OBJECTIVE

To assess the impact of guidelines for stroke management on the utilisation of services by patients and the cost consequences of implementation.

DESIGN

Prospective audit.

SETTING

District health authority in southern England.

PATIENTS

A total of 468 live non-comatose stroke patients registered between November 1991 and May 1993.

MAIN OUTCOME MEASURES

A comparison between the three, six month periods for investigations performed and rehabilitation received and their associated costs.

RESULTS

The appropriateness of the use of investigations improved over time to between 88 and 92% except for computed tomography (CT) (24%). Younger, more severely impaired patients in a medical bed were more likely to have CT. Overall levels of rehabilitation were low. There was no change in use of physiotherapy (61% to 63%), a significant increase in occupational therapy (26% to 39%) and a non significant change in speech therapy (34% to 25%) over time. Guideline introduction caused a modest 23 Pounds increase in costs per patient in the 2nd six months and 41 Pounds in the 3rd six months but this sum could rise to 430 Pounds per patient if full implementation of the guidelines occurred which is still only around 13% of the costs of nursing care while in hospital.

CONCLUSIONS

This 18 month aduit shows only modest changes in practice compared with guidelines, and overall levels of rehabilitation were low. The costs of full implementation seem considerable, but in fact constitute only a small proportion of nursing care costs.