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Gao L, Moodie M, Freedman B, Lam C, Tu H, Swift C, Ma SH, Mok VCT, Sui Y, Sharpe D, Ghia D, Jannes J, Davis S, Liu X, Yan B. Cost-Effectiveness of Monitoring Patients Post-Stroke With Mobile ECG During the Hospital Stay. J Am Heart Assoc 2022; 11:e022735. [PMID: 35411782 PMCID: PMC9238470 DOI: 10.1161/jaha.121.022735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The effectiveness of a nurse‐led in‐hospital monitoring protocol with mobile ECG (iECG) was investigated for detecting atrial fibrillation in patients post‐ischemic stroke or post‐transient ischemic attack. The study aimed to assess the cost‐effectiveness of using iECG during the initial hospital stay compared with standard 24‐hour Holter monitoring. Methods and Results A Markov microsimulation model was constructed to simulate the lifetime health outcomes and costs. The rate of atrial fibrillation detection in iECG and Holter monitoring during the in‐hospital phase and characteristics of modeled population (ie, age, sex, CHA2DS2‐VASc) were informed by patient‐level data. Costs related to recurrent stroke, stroke management, medications (new oral anticoagulants), and rehabilitation were included. The cost‐effectiveness analysis outcome was calculated as an incremental cost per quality‐adjusted life‐year gained. As results, monitoring patients with iECG post‐stroke during the index hospitalization was associated with marginally higher costs (A$31 196) and greater benefits (6.70 quality‐adjusted life‐years) compared with 24‐hour Holter surveillance (A$31 095 and 6.66 quality‐adjusted life‐years) over a 20‐year time horizon, with an incremental cost‐effectiveness ratio of $3013/ quality‐adjusted life‐years. Monitoring patients with iECG also contributed to lower recurrence of stroke and stroke‐related deaths (140 recurrent strokes and 20 deaths avoided per 10 000 patients). The probabilistic sensitivity analyses suggested iECG is highly likely to be a cost‐effective intervention (100% probability). Conclusions A nurse‐led iECG monitoring protocol during the acute hospital stay was found to improve the rate of atrial fibrillation detection and contributed to slightly increased costs and improved health outcomes. Using iECG to monitor patients post‐stroke during initial hospitalization is recommended to complement routine care.
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Affiliation(s)
- Lan Gao
- Faculty of Health Deakin Health Economics Institute for Health TransformationDeakin University Melbourne Australia
| | - Marj Moodie
- Faculty of Health Deakin Health Economics Institute for Health TransformationDeakin University Melbourne Australia
| | - Ben Freedman
- Heart Research Institute Charles Perkins Centre, and Concord Hospital CardiologyUniversity of Sydney Sydney Australia
| | - Christina Lam
- The Melbourne Brain Centre at the Royal Melbourne Hospital and the University of Melbourne Parkville Australia
| | - Hans Tu
- Department of Neurology and Medicine Western HealthThe University of Melbourne Footscray Australia
| | - Corey Swift
- The Melbourne Brain Centre at the Royal Melbourne Hospital and the University of Melbourne Parkville Australia
| | - Sze-Ho Ma
- Division of Neurology Department of Medicine and Therapeutics Gerald Choa Neuroscience Centre Lui Che Woo Institute of Innovative Medicine Faculty of Medicine Prince of Wales HospitalThe Chinese University of Hong Kong Hong Kong China
| | - Vincent C T Mok
- Division of Neurology Department of Medicine and Therapeutics Gerald Choa Neuroscience Centre Lui Che Woo Institute of Innovative Medicine Faculty of Medicine Prince of Wales HospitalThe Chinese University of Hong Kong Hong Kong China
| | - Yi Sui
- Department of Neurology Shenyang First People's Hospital Shenyang China
| | - David Sharpe
- Neurology Department Concord General Hospital Sydney Australia
| | - Darshan Ghia
- Fiona Stanley Hospital and University of Western Australia Perth Australia
| | - Jim Jannes
- Department of Neurology Royal Adelaide Hospital Adelaide Australia
| | - Stephen Davis
- The Melbourne Brain Centre at the Royal Melbourne Hospital and the University of Melbourne Parkville Australia
| | - Xinfeng Liu
- Department of Neurology Jinling HospitalMedical School of Nanjing University Nanjing China
| | - Bernard Yan
- The Melbourne Brain Centre at the Royal Melbourne Hospital and the University of Melbourne Parkville Australia
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2
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Walton NT, Mohr NM. Concept review of regionalized systems of acute care: Is regionalization the next frontier in sepsis care? J Am Coll Emerg Physicians Open 2022; 3:e12631. [PMID: 35024689 PMCID: PMC8733842 DOI: 10.1002/emp2.12631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/21/2021] [Accepted: 11/23/2021] [Indexed: 11/10/2022] Open
Abstract
Regionalization has become a buzzword in US health care policy. Regionalization, however, has varied meanings, and definitions have lacked contextual information important to understanding its role in improving care. This concept review is a comprehensive primer and summation of 8 common core components of the national models of regionalization informed by text-based analysis of the writing of involved organizations (professional, regulatory, and research) guided by semistructured interviews with organizational leaders. Further, this generalized model of regionalized care is applied to sepsis care, a novel discussion, drawing on existing small-scale applications. This discussion highlights the fit of regionalization principles to the sepsis care model and the actualized and perceived potential benefits. The principal aim of this concept review is to outline regionalization in the United States and provide a roadmap and novel discussion of regionalized care integration for sepsis care.
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Affiliation(s)
| | - Nicholas M. Mohr
- Departments of Emergency Medicine, Anesthesia‐Critical Care Medicine, and EpidemiologyUniversity of Iowa–Carver College of MedicineIowa CityIowaUSA
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3
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Anand SK, Benjamin WJ, Adapa AR, Park JV, Wilkinson DA, Daou BJ, Burke JF, Pandey AS. Trends in acute ischemic stroke treatments and mortality in the United States from 2012 to 2018. Neurosurg Focus 2021; 51:E2. [PMID: 34198248 DOI: 10.3171/2021.4.focus21117] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/07/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The establishment of mechanical thrombectomy (MT) as a first-line treatment for select patients with acute ischemic stroke (AIS) and the expansion of stroke systems of care have been major advancements in the care of patients with AIS. In this study, the authors aimed to identify temporal trends in the usage of tissue-type plasminogen activator (tPA) and MT within the AIS population from 2012 to 2018, and the relationship to mortality. METHODS Using a nationwide private health insurance database, 117,834 patients who presented with a primary AIS between 2012 and 2018 in the United States were identified. The authors evaluated temporal trends in tPA and MT usage and clinical outcomes stratified by treatment and age using descriptive statistics. RESULTS Among patients presenting with AIS in this population, the mean age was 69.1 years (SD ± 12.3 years), and 51.7% were female. Between 2012 and 2018, the use of tPA and MT increased significantly (tPA, 6.3% to 11.8%, p < 0.0001; MT, 1.6% to 5.7%, p < 0.0001). Mortality at 90 days decreased significantly in the overall AIS population (8.7% to 6.7%, p < 0.0001). The largest reduction in 90-day mortality was seen in patients treated with MT (21.4% to 14.1%, p = 0.0414) versus tPA (11.8% to 7.0%, p < 0.0001) versus no treatment (8.3% to 6.3%, p < 0.0001). Age-standardized mortality at 90 days decreased significantly only in patients aged 71-80 years (11.4% to 7.8%, p < 0.0001) and > 81 years (17.8% to 11.6%, p < 0.0001). Mortality at 90 days stagnated in patients aged 18 to 50 years (3.0% to 2.2%, p = 0.4919), 51 to 60 years (3.8% to 3.9%, p = 0.7632), and 61 to 70 years (5.5% to 5.2%, p = 0.2448). CONCLUSIONS From 2012 to 2018, use of tPA and MT increased significantly, irrespective of age, while mortality decreased in the entire AIS population. The most dramatic decrease in mortality was seen in the MT-treated population. Age-standardized mortality improved only in patients older than 70 years, with no change in younger patients.
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Affiliation(s)
| | | | | | | | - D Andrew Wilkinson
- 1Department of Neurosurgery.,3Department of Neurosurgery, Penn State Health, Hershey, Pennsylvania
| | | | - James F Burke
- 4Department of Neurology, University of Michigan, Ann Arbor, Michigan; and
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Haas K, Rücker V, Hermanek P, Misselwitz B, Berger K, Seidel G, Janssen A, Rode S, Burmeister C, Matthis C, Koennecke HC, Heuschmann PU. Association Between Adherence to Quality Indicators and 7-Day In-Hospital Mortality After Acute Ischemic Stroke. Stroke 2020; 51:3664-3672. [DOI: 10.1161/strokeaha.120.029968] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Background and Purpose:
Quality indicators (QI) are an accepted tool to measure performance of hospitals in routine care. We investigated the association between quality of acute stroke care defined by overall adherence to evidence-based QI and early outcome in German acute care hospitals.
Methods:
Patients with ischemic stroke admitted to one of the hospitals cooperating within the ADSR (German Stroke Register Study Group) were analyzed. The ADSR is a voluntary network of 9 regional stroke registers monitoring quality of acute stroke care across 736 hospitals in Germany. Quality of stroke care was defined by adherence to 11 evidence-based indicators of early processes of stroke care. The correlation between overall adherence to QI with outcome was investigated by assessing the association between 7-day in-hospital mortality with the proportion of QI fulfilled from the total number of QI the individual patient was eligible for. Generalized linear mixed model analysis was performed adjusted for the variables age, sex, National Institutes of Health Stroke Scale and living will and as random effect for the variable hospital.
Results:
Between 2015 and 2016, 388 012 patients with ischemic stroke were reported (median age 76 years, 52.4% male). Adherence to distinct QI ranged between 41.0% (thrombolysis in eligible patients) and 95.2% (early physiotherapy). Seven-day in-hospital mortality was 3.4%. The overall proportion of QI fulfilled was median 90% (interquartile range, 75%–100%). In multivariable analysis, a linear association between overall adherence to QI and 7-day in-hospital-mortality was observed (odds ratio adherence <50% versus 100%, 12.7 [95% CI, 11.8–13.7];
P
<0.001).
Conclusions:
Higher quality of care measured by adherence to a set of evidence-based process QI for the early phase of stroke treatment was associated with lower in-hospital mortality.
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Affiliation(s)
- Kirsten Haas
- Institute of Clinical Epidemiology and Biometry, University of Würzburg (K.H., V.R., P.U.H.)
| | - Viktoria Rücker
- Institute of Clinical Epidemiology and Biometry, University of Würzburg (K.H., V.R., P.U.H.)
| | - Peter Hermanek
- Bavarian Permanent Working Party for Quality Assurance (BAQ), Munich (P.H.)
| | | | - Klaus Berger
- Quality Assurance Project ”Stroke Register Northwest Germany”, Institute of Epidemiology and Social Medicine, University of Münster (K.B.)
| | - Günter Seidel
- Department of Neurology, Asklepios Klinik Nord, Hamburg (G.S.)
| | - Alfred Janssen
- Quality Assurance in Stroke Management in North Rhine–Westphalia, Medical Association North Rhine (A.J.)
| | - Susanne Rode
- Office for Quality Assurance in Health Care Baden-Württemberg GmbH (QiG BW GmbH), Stuttgart (S.R.)
| | | | - Christine Matthis
- Quality Association for Acute Stroke Treatment Schleswig-Holstein (QugSS), Institute of Social Medicine and Epidemiology, University of Lübeck (C.M.)
| | | | - Peter U. Heuschmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg (K.H., V.R., P.U.H.)
- Clinical Trial Center, University Hospital Würzburg (P.U.H.)
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5
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Joundi RA, Saposnik G, Martino R, Fang J, Kapral MK. Development and Validation of a Prognostic Tool for Direct Enteral Tube Insertion After Acute Stroke. Stroke 2020; 51:1720-1726. [PMID: 32397928 DOI: 10.1161/strokeaha.120.028949] [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: 11/16/2022]
Abstract
Background and Purpose- We aimed to create a novel prognostic risk score to estimate outcomes after direct enteral tube placement in acute stroke. Methods- We used the Ontario Stroke Registry and linked databases to obtain clinical information on all patients with direct enteral tube insertion after ischemic stroke or intracerebral hemorrhage from July 1, 2003 to June 30, 2010 (derivation cohort) and July 1, 2010 to March 31, 2013 (validation cohort). We used multivariable regression to assign scores to predictor variables for 3 outcomes after tube placement: favorable outcome (discharge modified Rankin Scale score 0-3 and alive at 90 days), poor outcome (discharge modified Rankin Scale score 5 or death at 90 days), and 30-day mortality. Results- Variables associated with a favorable outcome were younger age, preadmission independence, ischemic stroke rather than intracerebral hemorrhage, lower stroke severity, and a shorter time between stroke and tube placement. Variables associated with a poor outcome were older age, preadmission dependence, atrial fibrillation, greater stroke severity, and tracheostomy. Age, preadmission dependence, atrial fibrillation, cancer, chronic obstructive pulmonary disease, and shorter time to tube placement were associated with increased 30-day mortality. Using these variables, we created an online calculator to facilitate estimation of individual patient risk of favorable and poor outcomes. C-statistic in the validation cohort was 0.82 for favorable outcome, 0.65 for poor outcome, and 0.62 for 30-day mortality, and calibration was adequate. Conclusions- We developed risk scores to estimate outcomes after direct enteral tube insertion for acute dysphagic stroke. This information may be useful in discussions with patients and families when there is prognostic uncertainty surrounding outcomes with direct enteral tube placement after stroke.
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Affiliation(s)
- Raed A Joundi
- From the Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary (R.A.J.).,ICES, Toronto, Canada (R.A.J., G.S., J.F., M.K.K.)
| | - Gustavo Saposnik
- ICES, Toronto, Canada (R.A.J., G.S., J.F., M.K.K.).,Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine, St. Michael's Hospital (G.S.), University of Toronto, Canada.,Institute of Health Policy, Management and Evaluation (G.S.), University of Toronto, Canada
| | - Rosemary Martino
- Department of Speech-Language Pathology (R.M.), University of Toronto, Canada.,Graduate Department of Rehabilitation Science (R.M.), University of Toronto, Canada.,Health Care and Outcomes Research, Krembil Research Institute, University Health Network, Canada (R.M.)
| | - Jiming Fang
- ICES, Toronto, Canada (R.A.J., G.S., J.F., M.K.K.)
| | - Moira K Kapral
- ICES, Toronto, Canada (R.A.J., G.S., J.F., M.K.K.).,Division of General Internal Medicine, Department of Medicine (M.K.), University of Toronto, Canada.,Institute of Health Policy, Management, and Evaluation (M.K.), University of Toronto, Canada
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6
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Mohammed M, Zainal H, Tangiisuran B, Harun SN, Ghadzi SM, Looi I, Sidek NN, Yee KL, Aziz ZA. Impact of adherence to key performance indicators on mortality among patients managed for ischemic stroke. Pharm Pract (Granada) 2020; 18:1760. [PMID: 32256900 PMCID: PMC7092711 DOI: 10.18549/pharmpract.2020.1.1760] [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] [Received: 11/27/2019] [Accepted: 02/09/2020] [Indexed: 01/01/2023] Open
Abstract
Background: Stroke is a leading cause of death worldwide. The cases of acute ischemic stroke are on the increase in the Asia Pacific, particularly in Malaysia. Various health organizations have recommended guidelines for managing ischemic stroke, but adherence to key performance indicators (KPI) from the guidelines and impact on patient outcomes, particularly mortality, are rarely explored. Objective: This study aims to evaluate the impact of adherence to key performance indicators on mortality among patients managed for ischemic stroke. Methods: We included all first-ever ischemic stroke patients enrolled in the multiethnic Malaysian National Neurology Registry (NNeuR) - a prospective cohort study and followed-up for six months. Patients’ baseline clinical characteristics, risk factors, neurological findings, treatments, KPI and mortality outcome were evaluated. The KPI nonadherence (NAR) and relationship with mortality were evaluated. NAR>25% threshold was considered suboptimal. Results: A total of 579 first-ever ischemic stroke patients were included in the final analysis. The overall mortality was recorded as 23 (4.0%) in six months, with a median (interquartile) age of 65 (20) years. Majority of the patients (dead or alive) had partial anterior circulation infarct, PACI (43.5%; 34.0%) and total anterior circulation infarct, TACI (26.1%; 8.8%). In addition, DVT prophylaxis (82.8%), anticoagulant for atrial fibrillation (AF) patients (48.8%) and rehabilitation (26.2%) were considered suboptimal. NAR < 2 was significantly associated with a decrease in mortality (odds ratio 0.16; 0.02-0.12) compared to NAR>2. Survival analysis showed that death is more likely in patients with NAR>2 (p=0.05). Conclusions: KPI nonadherence was associated with mortality among ischemic stroke patients. The adherence to the KPI was sub-optimal, particularly in DVT prophylaxis, anticoagulant for AF patients and rehabilitation. These findings reflect the importance of continuous quality measurement and implementation of evidence recommendations in healthcare delivery to achieve optimal outcome among stroke patients.
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Affiliation(s)
- Mustapha Mohammed
- School of Pharmaceutical Sciences. University of Science Malaysia. Pulau Pinang (Malaysia).
| | - Hadzliana Zainal
- School of Pharmaceutical Sciences. University of Science Malaysia. Pulau Pinang (Malaysia).
| | | | - Sabariah N Harun
- School of Pharmaceutical Sciences. University of Science Malaysia. Pulau Pinang (Malaysia).
| | - Siti M Ghadzi
- School of Pharmaceutical Sciences. University of Science Malaysia. Pulau Pinang (Malaysia).
| | - Irene Looi
- Clinical Research Centre, Hospital Seberang Jaya, Pulau Pinang (Malaysia).
| | - Norsima N Sidek
- Clinical Research Centre, Hospital Sultanah Nur Zahirah. Terengganu (Malaysia).
| | - Keng L Yee
- National Institute of Health, Ministry of Health. Selangor (Malaysia).
| | - Zariah A Aziz
- Clinical Research Centre, Hospital Sultanah Nur Zahirah. Terengganu (Malaysia).
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Edwards SJ, Wakefield V, Jhita T, Kew K, Cain P, Marceniuk G. Implantable cardiac monitors to detect atrial fibrillation after cryptogenic stroke: a systematic review and economic evaluation. Health Technol Assess 2020; 24:1-184. [PMID: 31944175 PMCID: PMC6983910 DOI: 10.3310/hta24050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Cryptogenic stroke is a stroke for which no cause is identified after standard diagnostic tests. Long-term implantable cardiac monitors may be better at diagnosing atrial fibrillation and provide an opportunity to reduce the risk of stroke recurrence with anticoagulants. OBJECTIVES The objectives were to assess the diagnostic test accuracy, clinical effectiveness and cost-effectiveness of three implantable monitors [BioMonitor 2-AF™ (Biotronik SE & Co. KG, Berlin, Germany), Confirm Rx™ (Abbott Laboratories, Lake Bluff, IL, USA) and Reveal LINQ™ (Medtronic plc, Minneapolis, MN, USA)] in patients who have had a cryptogenic stroke and for whom no atrial fibrillation is detected after 24 hours of external electrocardiographic monitoring. DATA SOURCES MEDLINE, EMBASE, The Cochrane Library, Database of Abstracts of Reviews of Effects and Health Technology Assessment databases were searched from inception until September 2018. REVIEW METHODS A systematic review was undertaken. Two reviewers agreed on studies for inclusion and performed quality assessment using the Cochrane Risk of Bias 2.0 tool. Results were discussed narratively because there were insufficient data for synthesis. A two-stage de novo economic model was developed: (1) a short-term patient flow model to identify cryptogenic stroke patients who have had atrial fibrillation detected and been prescribed anticoagulation treatment (rather than remaining on antiplatelet treatment) and (2) a long-term Markov model that captured the lifetime costs and benefits of patients on either anticoagulation or antiplatelet treatment. RESULTS One randomised controlled trial, Cryptogenic Stroke and underlying Atrial Fibrillation (CRYSTAL-AF) (Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014;370:2478-86), was identified, and no diagnostic test accuracy study was identified. The CRYSTAL-AF trial compared the Reveal™ XT (a Reveal LINQ predecessor) (Medtronic plc) monitor with standard of care monitoring. Twenty-six single-arm observational studies for the Reveal devices were also identified. The only data for BioMonitor 2-AF or Confirm Rx were from mixed population studies supplied by the companies. Atrial fibrillation detection in the CRYSTAL-AF trial was higher with the Reveal XT than with standard monitoring at all time points. By 36 months, atrial fibrillation was detected in 19% of patients with an implantable cardiac monitor and in 2.3% of patients receiving conventional follow-up. The 26 observational studies demonstrated that, even in a cryptogenic stroke population, atrial fibrillation detection rates are highly variable and most cases are asymptomatic; therefore, they probably would not have been picked up without an implantable cardiac monitor. Device-related adverse events, such as pain and infection, were low in all studies. The de novo economic model produced incremental cost effectiveness ratios comparing implantable cardiac monitors with standard of care monitoring to detect atrial fibrillation in cryptogenic stroke patients based on data for the Reveal XT device, which can be related to Reveal LINQ. The BioMonitor 2-AF and Confirm RX were included in the analysis by making a strong assumption of equivalence with Reveal LINQ. The results indicate that implantable cardiac monitors could be considered cost-effective at a £20,000-30,000 threshold. When each device is compared incrementally, BioMonitor 2-AF dominates Reveal LINQ and Confirm RX. LIMITATIONS The cost-effectiveness analysis for implantable cardiac monitors is based on a strong assumption of clinical equivalence and should be interpreted with caution. CONCLUSIONS All three implantable cardiac monitors could be considered cost-effective at a £20,000-30,000 threshold, compared with standard of care monitoring, for cryptogenic stroke patients with no atrial fibrillation detected after 24 hours of external electrocardiographic monitoring; however, further clinical studies are required to confirm their efficacy in cryptogenic stroke patients. STUDY REGISTRATION This study is registered as PROSPERO CRD42018109216. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Steven J Edwards
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | | | - Tracey Jhita
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | - Kayleigh Kew
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | - Peter Cain
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | - Gemma Marceniuk
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
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8
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Predictors of Direct Enteral Tube Placement After Acute Stroke. J Stroke Cerebrovasc Dis 2019; 28:191-197. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 09/10/2018] [Accepted: 09/19/2018] [Indexed: 01/22/2023] Open
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9
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Pross C, Strumann C, Geissler A, Herwartz H, Klein N. Quality and resource efficiency in hospital service provision: A geoadditive stochastic frontier analysis of stroke quality of care in Germany. PLoS One 2018; 13:e0203017. [PMID: 30188906 PMCID: PMC6126832 DOI: 10.1371/journal.pone.0203017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 08/14/2018] [Indexed: 02/07/2023] Open
Abstract
We specify a Bayesian, geoadditive Stochastic Frontier Analysis (SFA) model to assess hospital performance along the dimensions of resources and quality of stroke care in German hospitals. With 1,100 annual observations and data from 2006 to 2013 and risk-adjusted patient volume as output, we introduce a production function that captures quality, resource inputs, hospital inefficiency determinants and spatial patterns of inefficiencies. With high relevance for hospital management and health system regulators, we identify performance improvement mechanisms by considering marginal effects for the average hospital. Specialization and certification can substantially reduce mortality. Regional and hospital-level concentration can improve quality and resource efficiency. Finally, our results demonstrate a trade-off between quality improvement and resource reduction and substantial regional variation in efficiency.
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Affiliation(s)
- Christoph Pross
- Department of Healthcare Management, Berlin University of Technology, Straße des 17. Juni 135, 10623 Berlin, Germany
| | - Christoph Strumann
- Institute for Entrepreneurship and Business Development, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Alexander Geissler
- Department of Healthcare Management, Berlin University of Technology, Straße des 17. Juni 135, 10623 Berlin, Germany
| | - Helmut Herwartz
- Chair of Econometrics, Georg-August-University Göttingen, Humboldtallee 3, 37073 Göttingen, Germany
| | - Nadja Klein
- Melbourne Business School, University of Melbourne, 200 Leicester Street, Carlton VIC 3053, Australia
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10
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Dave A, Cagniart K, Holtkamp MD. A Case for Telestroke in Military Medicine: A Retrospective Analysis of Stroke Cost and Outcomes in U.S. Military Health-Care System. J Stroke Cerebrovasc Dis 2018; 27:2277-2284. [PMID: 29887364 DOI: 10.1016/j.jstrokecerebrovasdis.2018.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 02/11/2018] [Accepted: 04/12/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The development of primary stroke centers has improved outcomes for stroke patients. Telestroke networks have expanded the reach of stroke experts to underserved, geographically remote areas. This study illustrates the outcome and cost differences between neurology and primary care ischemic stroke admissions to demonstrate a need for telestroke networks within the Military Health System (MHS). MATERIALS AND METHODS All adult admissions with a primary diagnosis of ischemic stroke in the MHS Military Mart database from calendar years 2010 to 2015 were reviewed. Neurology, primary care, and intensive care unit (ICU) admissions were compared across primary outcomes of (1) disposition status and (2) intravenous tissue plasminogen activator administration and for secondary outcomes of (1) total cost of hospitalization and (2) length of stay (LOS). RESULTS A total of 3623 admissions met the study's parameters. The composition was neurology 462 (12.8%), primary care 2324 (64.1%), ICU 677 (18.7%), and other/unknown 160 (4.4%). Almost all neurology admissions (97%) were at the 3 neurology training programs, whereas a strong majority of primary care admissions (80%) were at hospitals without a neurology admitting service. Hospitals without a neurology admitting service had more discharges to rehabilitation facilities and higher rates of in-hospital mortality. LOS was also longer in primary care admissions. CONCLUSIONS Ischemic stroke admissions to neurology had better outcomes and decreased LOS when compared to primary care within the MHS. This demonstrates a possible gap in care. Implementation of a hub and spoke telestroke model is a potential solution.
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Affiliation(s)
- Ajal Dave
- Department of Neurology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Kendra Cagniart
- Department of Neurology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Matthew D Holtkamp
- Department of Medicine, Carl R. Darnall Army Medical Center, Fort Hood, Texas.
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12
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Joundi RA, Saposnik G, Martino R, Fang J, Porter J, Kapral MK. Outcomes among patients with direct enteral vs nasogastric tube placement after acute stroke. Neurology 2018; 90:e544-e552. [PMID: 29367443 DOI: 10.1212/wnl.0000000000004962] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 10/16/2017] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To compare complications, disability, and long-term mortality of patients who received direct enteral tube vs nasogastric tube feeding alone after acute stroke. METHODS We used the Ontario Stroke Registry to identify patients who received direct enteral tubes (DET; gastrostomy or jejunostomy) or temporary nasogastric tubes (NGT) alone during hospital stay after acute ischemic stroke or intracerebral hemorrhage from July 1, 2003, to March 31, 2013. We used propensity matching to compare groups from discharge and evaluated discharge disability, institutionalization, complications, and mortality, with follow-up over 2 years, and with cumulative incidence functions used to account for competing risks. RESULTS Among 1,448 patients with DET placement who survived until discharge, 1,421 were successfully matched to patients with NGT alone. Patients with DET had reduced risk of death within 30 days after discharge (9.7% vs 15.3%; hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.49-0.75), but this difference was eliminated after matching on length of stay and discharge disability (HR 0.90, 95% CI 0.70-1.17). Patients with DET had higher rates of severe disability at discharge (modified Rankin Scale score 4-5; 89.6% vs 78.4%), discharge to long-term care (38.0% vs 16.1%), aspiration pneumonia (14.4% vs 5.1%) and other complications, and mortality at 2 years (41.1% vs 35.9%). CONCLUSIONS Patients with DET placement after acute stroke have more severe disability at discharge compared to those with NGT placement alone, and associated higher rates of institutionalization, medical complications, and long-term mortality. These findings may inform goals of care discussions and decisions regarding long-term tube feeding after acute stroke.
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Affiliation(s)
- Raed A Joundi
- From the Division of Neurology (R.A.J.), Department of Medicine, Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine, St. Michael's Hospital (G.S.), Institute of Health Policy, Management and Evaluation (G.S., M.K.K.), Department of Speech-Language Pathology (R.M.), Graduate Department of Rehabilitation Science (R.M.), and Division of General Internal Medicine (M.K.K.), Department of Medicine, University of Toronto; Health Care and Outcomes Research, Krembil Research Institute (R.M.), University Health Network; and Institute for Clinical Evaluative Sciences (ICES) (J.F., J.P., M.K.K., G.S.), Toronto, Canada
| | - Gustavo Saposnik
- From the Division of Neurology (R.A.J.), Department of Medicine, Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine, St. Michael's Hospital (G.S.), Institute of Health Policy, Management and Evaluation (G.S., M.K.K.), Department of Speech-Language Pathology (R.M.), Graduate Department of Rehabilitation Science (R.M.), and Division of General Internal Medicine (M.K.K.), Department of Medicine, University of Toronto; Health Care and Outcomes Research, Krembil Research Institute (R.M.), University Health Network; and Institute for Clinical Evaluative Sciences (ICES) (J.F., J.P., M.K.K., G.S.), Toronto, Canada
| | - Rosemary Martino
- From the Division of Neurology (R.A.J.), Department of Medicine, Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine, St. Michael's Hospital (G.S.), Institute of Health Policy, Management and Evaluation (G.S., M.K.K.), Department of Speech-Language Pathology (R.M.), Graduate Department of Rehabilitation Science (R.M.), and Division of General Internal Medicine (M.K.K.), Department of Medicine, University of Toronto; Health Care and Outcomes Research, Krembil Research Institute (R.M.), University Health Network; and Institute for Clinical Evaluative Sciences (ICES) (J.F., J.P., M.K.K., G.S.), Toronto, Canada
| | - Jiming Fang
- From the Division of Neurology (R.A.J.), Department of Medicine, Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine, St. Michael's Hospital (G.S.), Institute of Health Policy, Management and Evaluation (G.S., M.K.K.), Department of Speech-Language Pathology (R.M.), Graduate Department of Rehabilitation Science (R.M.), and Division of General Internal Medicine (M.K.K.), Department of Medicine, University of Toronto; Health Care and Outcomes Research, Krembil Research Institute (R.M.), University Health Network; and Institute for Clinical Evaluative Sciences (ICES) (J.F., J.P., M.K.K., G.S.), Toronto, Canada
| | - Joan Porter
- From the Division of Neurology (R.A.J.), Department of Medicine, Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine, St. Michael's Hospital (G.S.), Institute of Health Policy, Management and Evaluation (G.S., M.K.K.), Department of Speech-Language Pathology (R.M.), Graduate Department of Rehabilitation Science (R.M.), and Division of General Internal Medicine (M.K.K.), Department of Medicine, University of Toronto; Health Care and Outcomes Research, Krembil Research Institute (R.M.), University Health Network; and Institute for Clinical Evaluative Sciences (ICES) (J.F., J.P., M.K.K., G.S.), Toronto, Canada
| | - Moira K Kapral
- From the Division of Neurology (R.A.J.), Department of Medicine, Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine, St. Michael's Hospital (G.S.), Institute of Health Policy, Management and Evaluation (G.S., M.K.K.), Department of Speech-Language Pathology (R.M.), Graduate Department of Rehabilitation Science (R.M.), and Division of General Internal Medicine (M.K.K.), Department of Medicine, University of Toronto; Health Care and Outcomes Research, Krembil Research Institute (R.M.), University Health Network; and Institute for Clinical Evaluative Sciences (ICES) (J.F., J.P., M.K.K., G.S.), Toronto, Canada.
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14
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Urimubenshi G, Langhorne P, Cadilhac DA, Kagwiza JN, Wu O. Association between patient outcomes and key performance indicators of stroke care quality: A systematic review and meta-analysis. Eur Stroke J 2017; 2:287-307. [PMID: 31008322 DOI: 10.1177/2396987317735426] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 09/09/2017] [Indexed: 01/09/2023] Open
Abstract
Purpose Translating research evidence into clinical practice often uses key performance indicators to monitor quality of care. We conducted a systematic review to identify the stroke key performance indicators used in large registries, and to estimate their association with patient outcomes. Method We sought publications of recent (January 2000-May 2017) national or regional stroke registers reporting the association of key performance indicators with patient outcome (adjusting for age and stroke severity). We searched Ovid Medline, EMBASE and PubMed and screened references from bibliographies. We used an inverse variance random effects meta-analysis to estimate associations (odds ratio; 95% confidence interval) with death or poor outcome (death or disability) at the end of follow-up. Findings We identified 30 eligible studies (324,409 patients). The commonest key performance indicators were swallowing/nutritional assessment, stroke unit admission, antiplatelet use for ischaemic stroke, brain imaging and anticoagulant use for ischaemic stroke with atrial fibrillation, lipid management, deep vein thrombosis prophylaxis and early physiotherapy/mobilisation. Lower case fatality was associated with stroke unit admission (odds ratio 0.79; 0.72-0.87), swallow/nutritional assessment (odds ratio 0.78; 0.66-0.92) and antiplatelet use for ischaemic stroke (odds ratio 0.61; 0.50-0.74) or anticoagulant use for ischaemic stroke with atrial fibrillation (odds ratio 0.51; 0.43-0.64), lipid management (odds ratio 0.52; 0.38-0.71) and early physiotherapy or mobilisation (odds ratio 0.78; 0.67-0.91). Reduced poor outcome was associated with adherence to swallowing/nutritional assessment (odds ratio 0.58; 0.43-0.78) and stroke unit admission (odds ratio 0.83; 0.77-0.89). Adherence with several key performance indicators appeared to have an additive benefit. Discussion Adherence with common key performance indicators was consistently associated with a lower risk of death or disability after stroke. Conclusion Policy makers and health care professionals should implement and monitor those key performance indicators supported by good evidence.
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Affiliation(s)
- Gerard Urimubenshi
- 1Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Peter Langhorne
- 1Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Dominique A Cadilhac
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia.,The Florey Institute Neuroscience and Mental Health, University of Melbourne, Victoria, Australia
| | - Jeanne N Kagwiza
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Olivia Wu
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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15
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McElwaine P, McCormack J, McCormick M, Rudd A, Brennan C, Coetzee H, Cotter PE, Doyle R, Hickey A, Horgan F, Loughnane C, Macey C, Marsden P, McCabe D, Mulcahy R, Noone I, Shelley E, Stapleton T, Williams D, Kelly P, Harbison J. A comparison of service organisation and guideline compliance between two adjacent European health services. Eur Stroke J 2017; 2:238-243. [PMID: 31008317 DOI: 10.1177/2396987317703209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 03/14/2017] [Indexed: 01/19/2023] Open
Abstract
Introduction Outcomes in stroke patients are improved by a co-ordinated organisation of stroke services and provision of evidence-based care. We studied the organisation of care and application of guidelines in two neighbouring health care systems with similar characteristics. Methods Organisational elements of the 2015 National Stroke Audit (NSA) from the Republic of Ireland (ROI) were compared with the Sentinel Stroke National Audit Programme (SSNAP) in Northern Ireland (NI) and the United Kingdom (UK). Compliance was compared with UK and European guidelines. Results Twenty-one of 28 ROI hospitals (78%) reported having a stroke unit (SU) compared with all 10 in NI. Average SU size was smaller in ROI (6 beds vs. 15 beds) and bed availability per head of population was lower (1:30,633 vs. 1:12,037 p < 0.0001 Chi Sq). Fifty-four percent of ROI patients were admitted to SU care compared with 96% of UK patients (p < 0.0001). Twenty-four-hour physiological monitoring was available in 54% of ROI SUs compared to 91% of UK units (p < 0.0001). There was no significant difference between ROI and NI in access to senior specialist physicians or nurses or in SU nurse staffing (3.9/10 beds weekday mornings) but there was a higher proportion of trained nurses in ROI units (2.9/10 beds vs. 2.3/10 beds (p = 0.02 Chi Sq). Conclusion Whilst the majority of hospitals in both jurisdictions met key criteria for organised stroke care the small size and underdevelopment of the ROI units meant a substantial proportion of patients were unable to access this specialised care.
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Affiliation(s)
- Paul McElwaine
- National Clinical Programme for Stroke, Health Service Executive, Ireland.,Trinity College, University of Dublin, Ireland
| | - Joan McCormack
- National Clinical Programme for Stroke, Health Service Executive, Ireland.,Trinity College, University of Dublin, Ireland.,Irish Heart Foundation, Ireland
| | | | - Anthony Rudd
- Sentinel Stroke National Audit Programme and Kings College London, UK
| | - Carmel Brennan
- National Clinical Programme for Stroke, Health Service Executive, Ireland.,Department of Public Health, Health Service Executive, Ireland
| | - Heather Coetzee
- Ireland East Hospitals Group and University College Dublin, Ireland
| | - Paul E Cotter
- Ireland East Hospitals Group and University College Dublin, Ireland
| | - Rachel Doyle
- Ireland East Hospitals Group and University College Dublin, Ireland
| | | | | | | | | | - Paul Marsden
- Department of Public Health, Health Service Executive, Ireland
| | - Dominick McCabe
- Trinity College, University of Dublin, Ireland.,Dublin Midlands Hospitals Group, Ireland
| | | | - Imelda Noone
- Ireland East Hospitals Group and University College Dublin, Ireland
| | - Emer Shelley
- Department of Public Health, Health Service Executive, Ireland
| | | | | | - Peter Kelly
- National Clinical Programme for Stroke, Health Service Executive, Ireland.,Ireland East Hospitals Group and University College Dublin, Ireland
| | - Joseph Harbison
- National Clinical Programme for Stroke, Health Service Executive, Ireland.,Trinity College, University of Dublin, Ireland.,Dublin Midlands Hospitals Group, Ireland
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Abstract
BACKGROUND Few studies have tracked stroke survivors through transitions across the health system and identified the most common trajectories and quality of care received. The objectives of our study were to examine the trajectories that incident stroke patients experience and to quantify the extent to which their care adhered to the best practices for stroke care. METHODS A population-based cohort of first-ever stroke/transient ischemic attack (TIA) patients from the 2012/13 Ontario Stroke Audit was linked to administrative databases using an encrypted health card number to identify dominant trajectories (N=12,362). All trajectories began in the emergency department (ED) and were defined by the transitions that followed immediately after the ED. Quality indicators were calculated to quantify best practice adherence within trajectories. RESULTS Six trajectories of stroke care were identified with significant variability in patient characteristics and quality of care received. Almost two-thirds (64.5%) required hospital admission. Trajectories that only involved the ED had the lowest rates of brain and carotid artery imaging (91.5 and 44.2%, respectively). Less than 20% of patients in trajectories involving hospital admissions received care on a stroke unit. The trajectory involving inpatient rehabilitation received suboptimal secondary prevention measures. CONCLUSIONS There are six main trajectories stroke patients follow, and adherence to best practices varies by trajectory. Trajectories resulting in patients being transitioned to home care following ED management only are least likely and those including inpatient rehabilitation are most likely to receive stroke best practices. Increased time in facility-based care results in greater access to best practices. Stroke patients receiving only ED care require closer follow-up by stroke specialists.
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17
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O'Brien EC, Wu J, Zhao X, Schulte PJ, Fonarow GC, Hernandez AF, Schwamm LH, Peterson ED, Bhatt DL, Smith EE. Healthcare Resource Availability, Quality of Care, and Acute Ischemic Stroke Outcomes. J Am Heart Assoc 2017; 6:JAHA.116.003813. [PMID: 28159820 PMCID: PMC5523738 DOI: 10.1161/jaha.116.003813] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Healthcare resources vary geographically, but associations between hospital‐based resources and acute stroke quality and outcomes remain unclear. Methods and Results Using Get With The Guidelines‐Stroke and Dartmouth Atlas of Health Care data, we examined associations between healthcare resource availability, stroke care, and outcomes. We categorized hospital referral regions with high‐, medium‐, or low‐resource levels based on the 2006 national per‐capita availability median of 6 relevant acute stroke care resources. Using multivariable logistic regression, we examined healthcare resource level and in‐hospital quality and outcomes. Of 1 480 308 admitted ischemic stroke patients (2006–2013), 28.8% were hospitalized in low‐, 44.4% in medium‐, and 26.9% in high‐resource hospital referral regions. Quality‐of‐care/timeliness metrics, adjusted length of stay, and in‐hospital mortality were similar across all resource levels. Conclusions Significant variation exists in regional availability of healthcare resources for acute ischemic stroke treatment, yet among Get With the Guidelines‐Stroke hospitals, quality of care and in‐hospital outcomes did not differ by regional resource availability.
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Affiliation(s)
| | - Jingjing Wu
- Duke Clinical Research Institute, Durham, NC
| | - Xin Zhao
- Duke Clinical Research Institute, Durham, NC
| | | | | | | | - Lee H Schwamm
- Stroke Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA
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18
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Reuter B, Gumbinger C, Sauer T, Wiethölter H, Bruder I, Diehm C, Ringleb PA, Hacke W, Hennerici MG, Kern R. Access, timing and frequency of very early stroke rehabilitation - insights from the Baden-Wuerttemberg stroke registry. BMC Neurol 2016; 16:222. [PMID: 27852229 PMCID: PMC5112693 DOI: 10.1186/s12883-016-0744-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 11/08/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND While the precise timing and intensity of very early rehabilitation (VER) after stroke onset is still under discussion, its beneficial effect on functional disability is generally accepted. The recently published randomized controlled AVERT trial indicated that patients with severe stroke might be more susceptible to harmful side effects of VER, which we hypothesized is contrary to current clinical practice. We analyzed the Baden-Wuerttemberg stroke registry to gain insight into the application of VER in acute ischemic stroke (IS) and intracerebral hemorrhage (ICH) in clinical practice. METHODS 99,753 IS patients and 8824 patients with ICH hospitalized from January 2008 to December 2012 were analyzed. Data on the access to physical therapy (PT), occupational therapy (OT), and speech therapy (ST), the time from admission to first contact with a therapist and the average number of therapy sessions during the first 7 days of admission are reported. Multiple logistic regression models adjusted for patient and treatment characteristics were carried out to investigate the influence of VER on clinical outcome. RESULTS PT was applied in 90/87% (IS/ICH), OT in 63/57%, and ST in 70/65% of the study population. Therapy was mostly initiated within 24 h (PT 87/82%) or 48 h after admission (OT 91/89% and ST 93/90%). Percentages of patients under therapy and also the average number of therapy sessions were highest in those with a discharge modified Rankin Scale score of 2 to 5 and lowest in patients with complete recovery or death during hospitalization. The outcome analyses were fundamentally hindered due to biases by individual decision making regarding the application and frequency of VER. CONCLUSIONS While most patients had access to PT we noticed an undersupply of OT and ST. Only little differences were observed between patients with IS and ICH. The staff decisions for treatment seem to reflect attempts to optimize resources. Patients with either excellent or very unfavorable prognosis were less frequently assigned to VER and, if treated, received a lower average number of therapy sessions. On the contrary, severely disabled patients received VER at high frequency, although potentially harmful according to recent indications from the randomized controlled AVERT trial.
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Affiliation(s)
- Björn Reuter
- Department of Neurology and Neurophysiology, University Hospital Freiburg, Breisacher Straße 64, 79106 Freiburg, Germany
| | - Christoph Gumbinger
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Tamara Sauer
- Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Horst Wiethölter
- formerly affiliated to Department of Neurology, Bürgerhospital, Stuttgart, Germany
| | - Ingo Bruder
- Office for Quality Assurance in Hospitals (GeQiK), Baden-Wuerttembergische Hospital Association, Stuttgart, Germany
| | - Curt Diehm
- Department of Internal/Vascular Medicine, Max-Grundig-Klinik, Bühl, Germany
| | - Peter A. Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Werner Hacke
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Michael G. Hennerici
- Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Rolf Kern
- Department of Neurology, Klinikum Kempten-Oberallgaeu, Kempten, Germany
| | - and Stroke Working Group of Baden-Wuerttemberg
- Department of Neurology and Neurophysiology, University Hospital Freiburg, Breisacher Straße 64, 79106 Freiburg, Germany
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
- formerly affiliated to Department of Neurology, Bürgerhospital, Stuttgart, Germany
- Office for Quality Assurance in Hospitals (GeQiK), Baden-Wuerttembergische Hospital Association, Stuttgart, Germany
- Department of Internal/Vascular Medicine, Max-Grundig-Klinik, Bühl, Germany
- Department of Neurology, Klinikum Kempten-Oberallgaeu, Kempten, Germany
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Muñoz Venturelli P, Robinson T, Lavados PM, Olavarría VV, Arima H, Billot L, Hackett ML, Lim JY, Middleton S, Pontes-Neto O, Peng B, Cui L, Song L, Mead G, Watkins C, Lin RT, Lee TH, Pandian J, de Silva HA, Anderson CS. Regional variation in acute stroke care organisation. J Neurol Sci 2016; 371:126-130. [PMID: 27871433 DOI: 10.1016/j.jns.2016.10.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 09/21/2016] [Accepted: 10/17/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Few studies have assessed regional variation in the organisation of stroke services, particularly health care resourcing, presence of protocols and discharge planning. Our aim was to compare stroke care organisation within middle- (MIC) and high-income country (HIC) hospitals participating in the Head Position in Stroke Trial (HeadPoST). METHODS HeadPoST is an on-going international multicenter crossover cluster-randomized trial of 'sitting-up' versus 'lying-flat' head positioning in acute stroke. As part of the start-up phase, one stroke care organisation questionnaire was completed at each hospital. The World Bank gross national income per capita criteria were used for classification. RESULTS 94 hospitals from 9 countries completed the questionnaire, 51 corresponding to MIC and 43 to HIC. Most participating hospitals had a dedicated stroke care unit/ward, with access to diagnostic services and expert stroke physicians, and offering intravenous thrombolysis. There was no difference for the presence of a dedicated multidisciplinary stroke team, although greater access to a broad spectrum of rehabilitation therapists in HIC compared to MIC hospitals was observed. Significantly more patients arrived within a 4-h window of symptoms onset in HIC hospitals (41 vs. 13%; P<0.001), and a significantly higher proportion of acute ischemic stroke patients received intravenous thrombolysis (10 vs. 5%; P=0.002) compared to MIC hospitals. CONCLUSIONS Although all hospitals provided advanced care for people with stroke, differences were found in stroke care organisation and treatment. Future multilevel analyses aims to determine the influence of specific organisational factors on patient outcomes.
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Affiliation(s)
- Paula Muñoz Venturelli
- The George Institute for Global Health, University of Sydney, Sydney, Australia; Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Medicina, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Thompson Robinson
- Department of Cardiovascular Sciences and NIHR Biomedical Research Unit for Cardiovascular Disease, University of Leicester, Leicester, UK
| | - Pablo M Lavados
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Medicina, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile; Departamento de Ciencias Neurológicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Verónica V Olavarría
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Medicina, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Laurent Billot
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Maree L Hackett
- The George Institute for Global Health, University of Sydney, Sydney, Australia; College of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Joyce Y Lim
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincents Health Australia (Sydney) and Australian Catholic University, Australia
| | - Octavio Pontes-Neto
- Stroke Service, Neurology Division, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, Brazil
| | - Bin Peng
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
| | - Liying Cui
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
| | - Lily Song
- Department of Neurology, Shanghai 85th Hospital of PLA, Shanghai, China
| | - Gillian Mead
- Department of Geriatric Medicine, Centre for Clinical Brain Sciences, University of Edinburgh, Scotland, UK
| | - Caroline Watkins
- College of Health and Wellbeing, University of Central Lancashire, Preston, UK; Nursing Research Institute, St Vincents Health Australia (Sydney) and Australian Catholic University, Australia
| | - Ruey-Tay Lin
- Department of Neurology, Kaohsiung Medical University Chung-Ho Memorial Hospital, Taiwan
| | - Tsong-Hai Lee
- Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - H Asita de Silva
- Clinical Trials Unit, Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Craig S Anderson
- The George Institute for Global Health, University of Sydney, Sydney, Australia; Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia; The George Institute, China, Peking University Health Sciences Center, Beijing, China.
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Pongmoragot J, Lee DS, Park TH, Fang J, Austin PC, Saposnik G. Stroke and Heart Failure: Clinical Features, Access to Care, and Outcomes. J Stroke Cerebrovasc Dis 2016; 25:1048-1056. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.01.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 11/17/2015] [Accepted: 01/02/2016] [Indexed: 01/10/2023] Open
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Almeida SRM, Bahia MM, Lima FO, Paschoal IA, Cardoso TAMO, Li LM. Predictors of pneumonia in acute stroke in patients in an emergency unit. ARQUIVOS DE NEURO-PSIQUIATRIA 2015; 73:415-9. [PMID: 26017207 DOI: 10.1590/0004-282x20150046] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Accepted: 01/16/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the risk factors and comorbid conditions associated with the development of pneumonia in patients with acute stroke. To determine the independent predictors of pneumonia. METHOD Retrospective study from July to December 2011. We reviewed all medical charts with diagnosis of stroke. RESULTS 159 patients (18-90 years) were admitted. Prevalence of pneumonia was 32%. Pneumonia was more frequent in patients with hemorrhagic stroke (OR: 4.36; 95%CI: 1.9-10.01, p < 0.001), higher National Institute of Health Stroke Scale (NIHSS) (p = 0.047) and, lower Glasgow Coma Score (GCS) (p < 0.0001). Patients with pneumonia had longer hospitalization (p < 0.0001). Multivariable logistic regression analysis identified NIHSS as an independent predictor of pneumonia (95%CI: 1.049-1.246, p = 0.002). CONCLUSION Pneumonia was associated with severity and type of stroke and length of hospital stay. The severity of the deficit as evaluated by the NIHSS was shown to be the only independent risk factor for pneumonia in acute stroke patients.
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Affiliation(s)
- Sara R M Almeida
- Departamento de Neurologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Mariana M Bahia
- Departamento de Neurologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Fabrício O Lima
- Departamento de Neurologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Ilma A Paschoal
- Departamento de Clínica Médica, Faculdade de Ciências Médicas, Universidade de Campinas, Campinas, SP, Brazil
| | - Tânia A M O Cardoso
- Departamento de Neurologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Li Min Li
- Departamento de Neurologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
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Krishnan P, Saposnik G, Ovbiagele B, Zhang L, Symons S, Aviv R. Contribution and additional impact of imaging to the SPAN-100 score. AJNR Am J Neuroradiol 2015; 36:646-52. [PMID: 25572947 DOI: 10.3174/ajnr.a4195] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Accepted: 10/16/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Stroke Prognostication by Using Age and NIHSS score (SPAN-100 index) facilitates stroke outcomes. We assessed imaging markers associated with the SPAN-100 index and their additional impact on outcome determination. MATERIALS AND METHODS Of 273 consecutive patients with acute ischemic stroke (<4.5 hours), 55 were characterized as SPAN-100-positive (age +NIHSS score ≥ 100). A comprehensive imaging review evaluated differences, using the presence of the hyperattenuated vessel sign, ASPECTS, clot burden score, collateral score, CBV, CBF, and MTT. The primary outcome assessed was favorable outcome (mRS ≤ 2). Secondary outcomes included recanalization, lack of neurologic improvement, and hemorrhagic transformation. Uni- and multivariate analyses assessed factors associated with favorable outcome. Area under the curve evaluated predictors of favorable clinical outcome. RESULTS Compared with the SPAN-100-negative group, the SPAN-100-positive group (55/273; 20%) demonstrated larger CBVs (<0.001), poorer collaterals (P < .001), and increased hemorrhagic transformation rates (56.0% versus 36%, P = .02) despite earlier time to rtPA (P = .03). Favorable outcome was less common among patients with SPAN-100-positive compared with SPAN-100-negative (10.9% versus 42.2%; P < .001). Multivariate regression revealed poorer outcome for SPAN-100-positive (OR = 0.17; 95% CI, 0.06-0.38; P = .001), clot burden score (OR = 1.14; 95% CI, 1.05-1.25; P < .001), and CBV (OR = 0.58; 95% CI, 0.46-0.72; P = .001). The addition of the clot burden score and CBV improved the predictive value of SPAN-100 alone for favorable outcome from 60% to 68% and 74%, respectively. CONCLUSIONS SPAN-100-positivity predicts a lower likelihood of favorable outcome and increased hemorrhagic transformation. CBV and clot burden score contribute to poorer outcomes among high-risk patients and improve stroke-outcome prediction.
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Affiliation(s)
- P Krishnan
- From the Division of Neuroradiology (P.K., S.S., R.A.), Department of Medical Imaging, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - G Saposnik
- Stroke Outcome Reach Center (G.S.), Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - B Ovbiagele
- Department of Neurosciences (B.O.), Medical University of South Carolina, Charleston, South Carolina
| | - L Zhang
- Biostatistician (L.Z.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - S Symons
- From the Division of Neuroradiology (P.K., S.S., R.A.), Department of Medical Imaging, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - R Aviv
- From the Division of Neuroradiology (P.K., S.S., R.A.), Department of Medical Imaging, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Cereda CW, George PM, Pelloni LS, Gandolfi-Decristophoris P, Mlynash M, Biancon Montaperto L, Limoni C, Stojanova V, Malacrida R, Städler C, Bassetti CL. Beneficial Effects of a Semi-Intensive Stroke Unit are Beyond the Monitor. Cerebrovasc Dis 2015; 39:102-9. [DOI: 10.1159/000369919] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 11/14/2014] [Indexed: 11/19/2022] Open
Abstract
Background and Purpose: Precise mechanisms underlying the effectiveness of the stroke unit (SU) are not fully established. Studies that compare monitored stroke units (semi-intensive type, SI-SU) versus an intensive care unit (ICU)-based mobile stroke team (MST-ICU) are lacking. Although inequalities in access to stroke unit care are globally improving, acute stroke patients may be admitted to Intensive Care Units for monitoring and followed by a mobile stroke team in hospital's lacking an SU with continuous cardiovascular monitoring. We aimed at comparing the stroke outcome between SI-SU and MST-ICU and hypothesized that the benefits of SI-SU are driven by additional elements other than cardiovascular monitoring, which is equally offered in both care systems. Methods: In a single-center setting, we compared the unfavorable outcomes (dependency and mortality) at 3 months in consecutive patients with ischemic stroke or spontaneous intracerebral hemorrhage admitted to a stroke unit with semi-intensive monitoring (SI-SU) to a cohort of stroke patients hospitalized in an ICU and followed by a mobile stroke team (MST-ICU) during an equal observation period of 27 months. Secondary objectives included comparing mortality and the proportion of patients with excellent outcomes (modified Rankin Score (mRS) 0-1). Equal cardiovascular monitoring was offered in patients admitted in both SI-SU and MST-ICU. Results: 458 patients were treated in the SI-SU and compared to the MST-ICU (n = 370) cohort. The proportion of death and dependency after 3 months was significantly improved for patients in the SI-SU compared to MST-ICU (p < 0.001; aOR = 0.45; 95% CI: 0.31-0.65). The shift analysis of the mRS distribution showed significant shift to the lower mRS in the SI-SU group, p < 0.001. The proportion of mortality in patients after 3 months also differed between the MST-ICU and the SI-SU (p < 0.05), but after adjusting for confounders this association was not significant (aOR = 0.59; 95% CI: 0.31-1.13). The proportion of patients with excellent outcome was higher in the SI-SU (59.4 vs. 44.9%, p < 0.001) but the relationship was no more significant after adjustment (aOR = 1.17; 95% CI: 0.87-1.5). Conclusions: Our study shows that moving from a stroke team in a monitored setting (ICU) to an organized stroke unit leads to a significant reduction in the 3 months unfavorable outcome in patients with an acute ischemic or hemorrhagic stroke. Cardiovascular monitoring is indispensable, but benefits of a semi-intensive Stroke Unit are driven by additional elements beyond intensive cardiovascular monitoring. This observation supports the ongoing development of Stroke Centers for efficient stroke care.
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Kara H, Degirmenci S, Bayir A, Ak A, Akinci M, Dogru A, Akyurek F, Kayis SA. Red cell distribution width and neurological scoring systems in acute stroke patients. Neuropsychiatr Dis Treat 2015; 11:733-9. [PMID: 25834448 PMCID: PMC4370912 DOI: 10.2147/ndt.s81525] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The purpose of the present study was to evaluate the association between the red blood cell distribution width (RDW) and the Glasgow Coma Scale (GCS), Canadian Neurological Scale (CNS), and National Institutes of Health Stroke Scale (NIHSS) scores in patients who had acute ischemic stroke. METHODS This prospective observational cohort study included 88 patients who have had acute ischemic stroke and a control group of 40 patients who were evaluated in the Emergency Department for disorders other than acute ischemic stroke. All subjects had RDW determined, and stroke patients had scoring with the GCS, CNS, and NIHSS scores. The GCS, CNS, and NIHSS scores of the patients were rated as mild, moderate, or severe and compared with RDW. RESULTS Stroke patients had significantly higher median RDW than control subjects. The median RDW values were significantly elevated in patients who had more severe rather than milder strokes rated with all three scoring systems (GCS, CNS, and NIHSS). The median RDW values were significantly elevated for patients who had moderate rather than mild strokes rated by GCS and CNS and for patients who had severe rather than mild strokes rated by NIHSS. The area under the receiver operating characteristic curve was 0.760 (95% confidence interval, 0.676-0.844). Separation of stroke patients and control groups was optimal with RDW 14% (sensitivity, 71.6%; specificity, 67.5%; accuracy, 70.3%). CONCLUSION In stroke patients who have symptoms <24 hours, the RDW may be useful in predicting the severity and functional outcomes of the stroke.
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Affiliation(s)
- Hasan Kara
- Department of Emergency Medicine, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Selim Degirmenci
- Department of Emergency Medicine, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Aysegul Bayir
- Department of Emergency Medicine, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Ahmet Ak
- Department of Emergency Medicine, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Murat Akinci
- Department of Emergency Medicine, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Ali Dogru
- Department of Emergency Medicine, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Fikret Akyurek
- Department of Biochemistry, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Seyit Ali Kayis
- Department of Biostatistics, Faculty of Medicine, Karabuk University, Karabuk, Turkey
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Galanth S, Tressieres B, Lannuzel A, Foucan P, Alecu C. Factors Influencing Prognosis and Functional Outcome One Year After a First-Time Stroke in a Caribbean Population. Arch Phys Med Rehabil 2014; 95:2134-9. [DOI: 10.1016/j.apmr.2014.07.394] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 07/07/2014] [Accepted: 07/12/2014] [Indexed: 11/29/2022]
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Tsai JP, Rochon PA, Raptis S, Bronskill SE, Bell CM, Saposnik G. A Prescription at Discharge Improves Long-term Adherence for Secondary Stroke Prevention. J Stroke Cerebrovasc Dis 2014; 23:2308-15. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.04.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 04/13/2014] [Indexed: 10/24/2022] Open
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Ji R, Shen H, Pan Y, Du W, Wang P, Liu G, Wang Y, Li H, Zhao X, Wang Y. Risk score to predict hospital-acquired pneumonia after spontaneous intracerebral hemorrhage. Stroke 2014; 45:2620-8. [PMID: 25028448 DOI: 10.1161/strokeaha.114.005023] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We aimed to develop a risk score (intracerebral hemorrhage-associated pneumonia score, ICH-APS) for predicting hospital-acquired stroke-associated pneumonia (SAP) after ICH. METHODS The ICH-APS was developed based on the China National Stroke Registry (CNSR), in which eligible patients were randomly divided into derivation (60%) and validation (40%) cohorts. Variables routinely collected at presentation were used for predicting SAP after ICH. For testing the added value of hematoma volume measure, we separately developed 2 models with (ICH-APS-B) and without (ICH-APS-A) hematoma volume included. Multivariable logistic regression was performed to identify independent predictors. The area under the receiver operating characteristic curve (AUROC), Hosmer-Lemeshow goodness-of-fit test, and integrated discrimination index were used to assess model discrimination, calibration, and reclassification, respectively. RESULTS The SAP was 16.4% and 17.7% in the overall derivation (n=2998) and validation (n=2000) cohorts, respectively. A 23-point ICH-APS-A was developed based on a set of predictors and showed good discrimination in the overall derivation (AUROC, 0.75; 95% confidence interval, 0.72-0.77) and validation (AUROC, 0.76; 95% confidence interval, 0.71-0.79) cohorts. The ICH-APS-A was more sensitive for patients with length of stay >48 hours (AUROC, 0.78; 95% confidence interval, 0.75-0.81) than those with length of stay <48 hours (AUROC, 0.64; 95% confidence interval, 0.55-0.73). The ICH-APS-A was well calibrated (Hosmer-Lemeshow test) in the derivation (P=0.20) and validation (P=0.66) cohorts. Similarly, a 26-point ICH-APS-B was established. The ICH-APS-A and ICH-APS-B were not significantly different in discrimination and reclassification for SAP after ICH. CONCLUSION The ICH-APSs are valid risk scores for predicting SAP after ICH, especially for patients with length of stay >48 hours.
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Affiliation(s)
- Ruijun Ji
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.)
| | - Haipeng Shen
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.)
| | - Yuesong Pan
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.)
| | - Wanliang Du
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.)
| | - Penglian Wang
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.)
| | - Gaifen Liu
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.)
| | - Yilong Wang
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.)
| | - Hao Li
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.)
| | - Xingquan Zhao
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.)
| | - Yongjun Wang
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.).
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Robinson A, Lord-Vince H, Williams R. The Need for a 7-day Therapy Service on an Emergency Assessment Unit. Br J Occup Ther 2014. [DOI: 10.4276/030802214x13887685335508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This practice analysis acknowledges the changing nature of healthcare, recognizing the need for a 7-day therapy service on an Emergency Assessment Unit within the acute sector. A critical reflection on practice is offered to share the experiences of trialling a 7-day therapy service as a solution to managing today's political, economic, and demographic challenges. A 12-month pilot of 4-hour therapy shifts at the weekend demonstrated therapists could discharge 40% of patients assessed on the Emergency Assessment Unit; thus evidencing the need for a permanently funded 7-day service to sustain these results long term. Improved access to therapy on a Saturday and Sunday enhances equality of service provision, patient outcomes and weekend discharge rates. The findings are relevant to all occupational therapists and physiotherapists working in the acute sector.
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Affiliation(s)
- Anna Robinson
- Senior Occupational Therapist, Ipswich Hospital NHS Trust, Suffolk
| | - Hannah Lord-Vince
- Advanced Occupational Therapist, Ipswich Hospital NHS Trust, Suffolk
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29
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Gorelick PB. Primary and comprehensive stroke centers: history, value and certification criteria. J Stroke 2013; 15:78-89. [PMID: 24324943 PMCID: PMC3779669 DOI: 10.5853/jos.2013.15.2.78] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Revised: 01/24/2013] [Accepted: 01/24/2013] [Indexed: 01/28/2023] Open
Abstract
In the United States (US) stroke care has undergone a remarkable transformation in the past decades at several levels. At the clinical level, randomized trials have paved the way for many new stroke preventives, and recently, several new mechanical clot retrieval devices for acute stroke treatment have been cleared for use in practice by the US Federal Drug Administration. Furthermore, in the mid 1990s we witnessed regulatory approval of intravenous recombinant tissue plasminogen activator for administration in acute ischemic stroke. In the domain of organization of medical care and delivery of health services, stroke has transitioned from a disease dominated by neurologic consultation services only to one managed by vascular neurologists in geographical stroke units, stroke teams and care pathways, primary stroke center certification according to The Joint Commission, and most recently comprehensive stroke center designation under the aegis of The Joint Commission. Many organizations in the US have been involved to enhance stroke care. To name a few, the American Heart Association/American Stroke Association, Brain Attack Coalition, and National Stroke Association have been on the forefront of this movement. Additionally, governmental initiatives by the US Centers for Disease Control and Prevention and legislative initiatives such as the Paul Coverdell National Acute Stroke Registry program have paved the way to focus on stroke prevention, acute treatment and quality improvement. In this invited review, we discuss a brief history of organized stroke care in the United States, evidence to support the value of primary and comprehensive stroke centers, and the certification criteria and process to become a primary or comprehensive stroke center.
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Affiliation(s)
- Philip B Gorelick
- Translational Science and Molecular Medicine, Michigan State College of Human Medicine, Michigan, USA. ; Hauenstein Neuroscience Center, Saint Mary's Health Care, Michigan, USA
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Bray BD, Ayis S, Campbell J, Hoffman A, Roughton M, Tyrrell PJ, Wolfe CDA, Rudd AG. Associations between the organisation of stroke services, process of care, and mortality in England: prospective cohort study. BMJ 2013; 346:f2827. [PMID: 23667071 PMCID: PMC3650920 DOI: 10.1136/bmj.f2827] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To estimate the relations between the organisation of stroke services, process measures of care quality, and 30 day mortality in patients admitted with acute ischaemic stroke. DESIGN Prospective cohort study. SETTING Hospitals (n=106) admitting patients with acute stroke in England and participating in the Stroke Improvement National Audit Programme and 2010 Sentinel Stroke Audit. PARTICIPANTS 36,197 adults admitted with acute ischaemic stroke to a participating hospital from 1 April 2010 to 30 November 2011. MAIN OUTCOME MEASURE Associations between process of care (the assessments, interventions, and treatments that patients receive) and 30 day all cause mortality, adjusting for patient level characteristics. Process of care was measured using six individual measures of stroke care and summarised into an overall quality score. RESULTS Of 36,197 patients admitted with acute ischaemic stroke, 25,904 (71.6%) were eligible to receive all six care processes. Patients admitted to stroke services with high organisational scores were more likely to receive most (5 or 6) of the six care processes. Three of the individual processes were associated with reduced mortality, including two care bundles: review by a stroke consultant within 24 hours of admission (adjusted odds ratio 0.86, 95%confidence interval 0.78 to 0.96), nutrition screening and formal swallow assessment within 72 hours (0.83, 0.72 to 0.96), and antiplatelet therapy and adequate fluid and nutrition for first the 72 hours (0.55, 0.49 to 0.61). Receipt of five or six care processes was associated with lower mortality compared with receipt of 0-4 in both multilevel (0.74, 0.66 to 0.83) and instrumental variable analyses (0.62, 0.46 to 0.83). CONCLUSIONS Patients admitted to stroke services with higher levels of organisation are more likely to receive high quality care as measured by audited process measures of acute stroke care. Those patients receiving high quality care have a reduced risk of death in the 30 days after stroke, adjusting for patient characteristics and controlling for selection bias.
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Affiliation(s)
- Benjamin D Bray
- King's College London, Division of Health and Social Care Research, London SE13QD, UK.
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Ji R, Shen H, Pan Y, Wang P, Liu G, Wang Y, Li H, Wang Y. Novel Risk Score to Predict Pneumonia After Acute Ischemic Stroke. Stroke 2013; 44:1303-9. [DOI: 10.1161/strokeaha.111.000598] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ruijun Ji
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., P.W., G.L., Y.W., H.L., Y.W.); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill, NC (H.S.)
| | - Haipeng Shen
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., P.W., G.L., Y.W., H.L., Y.W.); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill, NC (H.S.)
| | - Yuesong Pan
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., P.W., G.L., Y.W., H.L., Y.W.); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill, NC (H.S.)
| | - Panglian Wang
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., P.W., G.L., Y.W., H.L., Y.W.); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill, NC (H.S.)
| | - Gaifen Liu
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., P.W., G.L., Y.W., H.L., Y.W.); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill, NC (H.S.)
| | - Yilong Wang
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., P.W., G.L., Y.W., H.L., Y.W.); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill, NC (H.S.)
| | - Hao Li
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., P.W., G.L., Y.W., H.L., Y.W.); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill, NC (H.S.)
| | - Yongjun Wang
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., P.W., G.L., Y.W., H.L., Y.W.); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill, NC (H.S.)
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Abstract
Neurological disorders place a considerable burden upon individuals, their families, and society. Some like stroke are common, while others like amyotrophic lateral sclerosis are much rarer. Some conditions such as multiple sclerosis are reported to vary by latitude, while others such as traumatic brain injury can vary considerably by locality. Depending upon the nature of the lesion, and factors such as time since onset, the consequences to the individual may also vary considerably, not just among different disorders, but within a given disorder. Consequently the patterns of disease incidence, its prevalence, and its consequences are complex and may vary not just because of the condition itself, but also because, for example, case ascertainment may vary from study to study. The cumulative annual incidence of disabling neurological disorders is likely to exceed 1000 per 100000, or 1% of the population. The incidence is characterized by significant variation, which is mediated by genetic, geographical, demographic, and environmental factors. While useful comparisons can be made through standardization techniques, planning for local services should be based upon local epidemiology, whenever available.
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Kim DH, Cha JK, Bae HJ, Park HS, Choi JH, Kang MJ, Kim BG, Huh JT, Kim SB. Organized Comprehensive Stroke Center is Associated with Reduced Mortality: Analysis of Consecutive Patients in a Single Hospital. J Stroke 2013; 15:57-63. [PMID: 24324940 PMCID: PMC3779674 DOI: 10.5853/jos.2013.15.1.57] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 01/16/2013] [Accepted: 01/24/2013] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND AND PURPOSE Organized inpatient stroke care is one of the most effective therapies for improving patient outcomes. Many stroke centers have been established to meet this need, however, there are limited data on the effectiveness of these organized comprehensive stroke center (CSC) in the real-world setting. Our aim is to determine whether inpatient care following the establishment of CSC lowers mortality of patients with acute ischemic stroke (AIS). METHODS Based on a prospective stroke registry, we identified AIS patients hospitalized before and after the establishment of a CSC. We observed all-cause mortality within 30 days from time of admission. Logistic regression was used to determine whether the establishment of the CSC affects independently the 30-day all-cause mortality. RESULTS A total of 3,117 consecutive patients with AIS were admitted within seven days after the onset of the symptoms. Unadjusted 30-day mortality was lower for patients admitted to our hospital after the establishment of the CSC than before (5.9% vs. 8.2%, P=0.012). Advanced age, female gender, previous coronary artery disease, non-smoking, stroke subtype, admission on a holiday, referral from other hospitals, high NIHSS on admission, and admission before the establishment of CSC were associated with increased 30-day stroke case fatality. After adjustment for these factors, stroke inpatient care subsequent to the establishment of the CSC was independently associated with lower 30-day mortality (OR, 0.57; 95% CI, 0.412-0.795). CONCLUSIONS Patients treated after the establishment of a CSC had lower 30-mortality rates than ever before, even adjusting for the differences in the baseline characteristics. The present study reveals that organized stroke care in a CSC might improve the outcome after AIS.
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Affiliation(s)
- Dae-Hyun Kim
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
- Busan-Ulsan Regional Cardiocerebrovascular Center, Busan, Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
- Busan-Ulsan Regional Cardiocerebrovascular Center, Busan, Korea
| | - Hyo-Jin Bae
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
- Busan-Ulsan Regional Cardiocerebrovascular Center, Busan, Korea
| | - Hyun-Seok Park
- Busan-Ulsan Regional Cardiocerebrovascular Center, Busan, Korea
| | - Jae-Hyung Choi
- Busan-Ulsan Regional Cardiocerebrovascular Center, Busan, Korea
| | - Myung-Jin Kang
- Busan-Ulsan Regional Cardiocerebrovascular Center, Busan, Korea
| | - Byoung-Gwon Kim
- Busan-Ulsan Regional Cardiocerebrovascular Center, Busan, Korea
| | - Jae-Taeck Huh
- Busan-Ulsan Regional Cardiocerebrovascular Center, Busan, Korea
| | - Sang-Beom Kim
- Busan-Ulsan Regional Cardiocerebrovascular Center, Busan, Korea
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Chumbler NR, Jia H, Phipps MS, Li X, Ordin D, Vogel WB, Castro JG, Myers J, Williams LS, Bravata DM. Does Inpatient Quality of Care Differ by Age Among US Veterans with Ischemic Stroke? J Stroke Cerebrovasc Dis 2012; 21:844-51. [DOI: 10.1016/j.jstrokecerebrovasdis.2011.04.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Revised: 04/22/2011] [Accepted: 04/24/2011] [Indexed: 01/21/2023] Open
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Aboa-Eboulé C, Mengue D, Benzenine E, Hommel M, Giroud M, Béjot Y, Quantin C. How accurate is the reporting of stroke in hospital discharge data? A pilot validation study using a population-based stroke registry as control. J Neurol 2012; 260:605-13. [PMID: 23076827 PMCID: PMC3566387 DOI: 10.1007/s00415-012-6686-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 09/21/2012] [Accepted: 09/22/2012] [Indexed: 11/26/2022]
Abstract
Population-based stroke registries can provide valid stroke incidence because they ensure exhaustiveness of case ascertainment. However, their results are difficult to extrapolate because they cover a small population. The French Hospital Discharge Database (FHDDB), which routinely collects administrative data, could be a useful tool for providing data on the nationwide burden of stroke. The aim of our pilot study was to assess the validity of stroke diagnosis reported in the FHDDB. All records of patients with a diagnosis of stroke between 2004 and 2008 were retrieved from the FHDDB of Dijon Teaching Hospital. The Dijon Stroke Registry was considered as the gold standard. The sensitivity, positive predictive value (PPV), and weighted kappa were calculated. The Dijon Stroke Registry identified 811 patients with a stroke, among whom 186 were missed by the FHDDB and thus considered false-negatives. The FHDDB identified 903 patients discharged following a stroke including 625 true-positives confirmed by the registry and 278 false-positives. The overall sensitivity and PPV of the FHDDB for the diagnosis of stroke were, respectively, 77.1 % (95 % CI 74.2–80) and 69.2 % (95 % CI 66.1–72.2). For cardioembolic and lacunar strokes, the FHDDB yielded higher PPVs (respectively 86.7 and 84.6 %; p < 0.0001) than those of other stroke subtypes. The PPV but not sensitivity significantly increased over the years (p < 0.0001). Agreement with the stroke registry was moderate (kappa 52.8; 95 % CI 46.8–58.9). The FHDDB-based stroke diagnosis showed moderate validity compared with the Dijon Stroke Registry as the gold standard. However, its accuracy (PPV) increased with time and was higher for some stroke subtypes.
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Affiliation(s)
- Corine Aboa-Eboulé
- Stroke Registry of Dijon, EA 4184, University Hospital and Faculty of Medicine of Dijon, STIC-Santé, University of Burgundy, Dijon, France
| | - Dominique Mengue
- Stroke Registry of Dijon, EA 4184, University Hospital and Faculty of Medicine of Dijon, STIC-Santé, University of Burgundy, Dijon, France
| | - Eric Benzenine
- Département d’Informatique Médicale, University Hospital of Dijon, Dijon, France
| | | | - Maurice Giroud
- Stroke Registry of Dijon, EA 4184, University Hospital and Faculty of Medicine of Dijon, STIC-Santé, University of Burgundy, Dijon, France
- Service de Neurologie, CHU Dijon, BP 77908, 21079 Dijon CEDEX, France
| | - Yannick Béjot
- Stroke Registry of Dijon, EA 4184, University Hospital and Faculty of Medicine of Dijon, STIC-Santé, University of Burgundy, Dijon, France
| | - Catherine Quantin
- Département d’Informatique Médicale, University Hospital of Dijon, Dijon, France
- INSERM U666, University of Burgundy, Dijon, France
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Panella M, Marchisio S, Brambilla R, Vanhaecht K, Di Stanislao F. A cluster randomized trial to assess the effect of clinical pathways for patients with stroke: results of the clinical pathways for effective and appropriate care study. BMC Med 2012; 10:71. [PMID: 22781160 PMCID: PMC3403956 DOI: 10.1186/1741-7015-10-71] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Accepted: 07/10/2012] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Clinical pathways (CPs) are used to improve the outcomes of acute stroke, but their use in stroke care is questionable, because the evidence on their effectiveness is still inconclusive. The objective of this study was to evaluate whether CPs improve the outcomes and the quality of care provided to patients after acute ischemic stroke. METHODS This was a multicentre cluster-randomized trial, in which 14 hospitals were randomized to the CP arm or to the non intervention/usual care (UC) arm. Healthcare workers in the CP arm received 3 days of training in quality improvement of CPs and in use of a standardized package including information on evidence-based key interventions and indicators. Healthcare workers in the usual-care arm followed their standard procedures. The teams in the CP arm developed their CPs over a 6-month period. The primary end point was mortality. Secondary end points were: use of diagnostic and therapeutic procedures, implementation of organized care, length of stay, re-admission and institutionalization rates after discharge, dependency levels, and complication rates. RESULTS Compared with the patients in the UC arm, the patients in the CP arm had a significantly lower risk of mortality at 7 days (OR = 0.10; 95% CI 0.01 to 0.95) and significantly lower rates of adverse functional outcomes, expressed as the odds of not returning to pre-stroke functioning in their daily life (OR = 0.42; 95 CI 0.18 to 0.98). There was no significant effect on 30-day mortality. Compared with the UC arm, the hospital diagnostic and therapeutic procedures were performed more appropriately in the CP arm, and the evidence-based key interventions and organized care were more applied in the CP arm. CONCLUSIONS CPs can significantly improve the outcomes of patients with ischemic patients with stroke, indicating better application of evidence-based key interventions and of diagnostic and therapeutic procedures. This study tested a new hypothesis and provided evidence on how CPs can work. TRIAL REGISTRATION ClinicalTrials.gov ID: [NCT00673491].
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Affiliation(s)
- Massimiliano Panella
- Department of Clinical and Experimental Medicine, University of Eastern Piedmont, Novara, Italy.
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Kazley AS, Wilkerson RC, Jauch E, Adams RJ. Access to Expert Stroke Care with Telemedicine: REACH MUSC. Front Neurol 2012; 3:44. [PMID: 22461780 PMCID: PMC3309563 DOI: 10.3389/fneur.2012.00044] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Accepted: 03/06/2012] [Indexed: 11/13/2022] Open
Abstract
Stroke is a leading cause of death and disability, and recombinant tissue plasminogen activator (rtPA) can significantly reduce the long-term impact of acute ischemic stroke (AIS) if given within 3 h of symptom onset. South Carolina is located in the "stroke belt" and has a high rate of stroke and stroke mortality. Many small rural SC hospitals do not maintain the expertise needed to treat AIS patients with rtPA. MUSC is an academic medical center using REACH MUSC telemedicine to deliver stroke care to 15 hospitals in the state, increasing the likelihood of timely treatment with rtPA. The purpose of this study is to determine the increase in access to rtPA through the use of telemedicine for AIS in the general population and in specific segments of the population based on age, gender, race, ethnicity, education, urban/rural residence, poverty, and stroke mortality. We used a retrospective cross-sectional design examining Census data from 2000 and geographic information systems analysis to identify South Carolina residents that live within 30 or 60 min of a primary stroke center (PSC) or a REACH MUSC site. We include all South Carolina citizens in our analysis and specifically examine the population's age, gender, race, ethnicity, education, urban/rural residence, poverty, and stroke mortality. Our sample includes 4,012,012 South Carolinians. The main measure is access to expert stroke care at a PSC or a REACH MUSC hospital within 30 or 60 min. We find that without REACH MUSC, only 38% of the population has potential access to expert stroke care in SC within 60 min given that most PSCs will maintain expert stroke coverage. REACH MUSC allows 76% of the population to be within 60 min of expert stroke care, and 43% of the population to be within 30 min drive time of expert stroke care. These increases in access are especially significant for groups that have faced disparities in care and high rates of AIS. The use of telemedicine can greatly increase access to care for residents throughout South Carolina.
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Affiliation(s)
- Abby Swanson Kazley
- Department of Health Care Leadership and Management, Medical University of South Carolina Charleston, SC, USA
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Abstract
BACKGROUND Population-based studies on physical therapy use in acute care are lacking. OBJECTIVES The purpose of this study was to examine population-based, hospital discharge data from North Carolina to describe the demographic and diagnostic characteristics of individuals who receive physical therapy and, for common diagnostic subgroups, to identify factors associated with the receipt of and intensity of physical therapy use. DESIGN This was a cross-sectional, descriptive study. METHODS Hospital discharge data for 2006-2007 from the 128 acute care hospitals in the state were examined to identify the most common diagnoses that receive physical therapy and to describe the characteristics of physical therapy users. For 2 of the most common diagnoses, logistic and linear regression analyses were conducted to identify factors associated with the receipt and intensity of physical therapy. RESULTS Of the more than 2 million people treated in acute care hospitals, 22.5% received physical therapy (mean age=66 years; 58% female). Individuals with osteoarthritis (admitted for joint replacement) and stroke were 2 of the most common patient types to receive physical therapy. Almost all individuals admitted for a joint replacement received physical therapy, with little between-hospital variation. Between-hospital variation in physical therapy use for stroke was greater. Demographic and hospital-related factors were associated with physical therapy use and physical therapy intensity for both diagnoses, after controlling for illness severity and comorbidities. LIMITATIONS Data from only one state were examined, and the studied variables were limited. CONCLUSIONS The use and intensity of physical therapy for stroke and joint replacement in acute care hospitals in North Carolina vary by clinical and nonclinical factors. Reasons behind the association of hospital characteristics and physical therapy use need further investigation.
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Saposnik G, Raptis S, Kapral MK, Liu Y, Tu JV, Mamdani M, Austin PC. The iScore Predicts Poor Functional Outcomes Early After Hospitalization for an Acute Ischemic Stroke. Stroke 2011; 42:3421-8. [DOI: 10.1161/strokeaha.111.623116] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The iScore is a prediction tool originally developed to estimate the risk of death after hospitalization for an acute ischemic stroke. Our objective was to determine whether the iScore could also predict poor functional outcomes.
Methods—
We applied the iScore to patients presenting with an acute ischemic stroke at multiple hospitals in Ontario, Canada, between 2003 and 2008, who had been identified from the Registry of the Canadian Stroke Network regional stroke center database (n=3818) and from an external data set, the Registry of the Canadian Stroke Network Ontario Stroke Audit (n=4635). Patients were excluded if they were included in the sample used to develop and validate the initial iScore. Poor functional outcomes were defined as: (1) death at 30 days or disability at discharge, in which disability was defined as having a modified Rankin Scale 3 to 5; and (2) death at 30 days or institutionalization at discharge.
Results—
The prevalence of poor functional outcomes in the Registry of the Canadian Stroke Network and the Ontario Stroke Audit, respectively, were 55.7% and 44.1% for death at 30 days or disability at discharge and 16.9% and 16.2%, respectively, for death at 30 days or institutionalization at discharge. The iScore stratified the risk of poor outcomes in low- and high-risk individuals. Observed versus predicted outcomes showed high correlations: 0.988 and 0.940 for mortality or disability and 0.985 and 0.993 for mortality or institutionalization in the Registry of the Canadian Stroke Network and Ontario Stroke Audit cohorts.
Conclusions—
The iScore can be used to estimate the risk of death or a poor functional outcome after an acute ischemic stroke.
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Affiliation(s)
- Gustavo Saposnik
- From the Division of Neurology (G.S.), Department of Medicine, St Michael's Hospital, Toronto, Canada, the Institute for Clinical Evaluative Sciences, Toronto, Canada, and the Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; the Applied Health Research Centre (S.R.), Keenan Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Canada; the Division of General Internal Medicine and Clinical Epidemiology (M.K.K.)
| | - Stavroula Raptis
- From the Division of Neurology (G.S.), Department of Medicine, St Michael's Hospital, Toronto, Canada, the Institute for Clinical Evaluative Sciences, Toronto, Canada, and the Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; the Applied Health Research Centre (S.R.), Keenan Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Canada; the Division of General Internal Medicine and Clinical Epidemiology (M.K.K.)
| | - Moira K. Kapral
- From the Division of Neurology (G.S.), Department of Medicine, St Michael's Hospital, Toronto, Canada, the Institute for Clinical Evaluative Sciences, Toronto, Canada, and the Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; the Applied Health Research Centre (S.R.), Keenan Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Canada; the Division of General Internal Medicine and Clinical Epidemiology (M.K.K.)
| | - Ying Liu
- From the Division of Neurology (G.S.), Department of Medicine, St Michael's Hospital, Toronto, Canada, the Institute for Clinical Evaluative Sciences, Toronto, Canada, and the Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; the Applied Health Research Centre (S.R.), Keenan Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Canada; the Division of General Internal Medicine and Clinical Epidemiology (M.K.K.)
| | - Jack V. Tu
- From the Division of Neurology (G.S.), Department of Medicine, St Michael's Hospital, Toronto, Canada, the Institute for Clinical Evaluative Sciences, Toronto, Canada, and the Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; the Applied Health Research Centre (S.R.), Keenan Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Canada; the Division of General Internal Medicine and Clinical Epidemiology (M.K.K.)
| | - Muhammad Mamdani
- From the Division of Neurology (G.S.), Department of Medicine, St Michael's Hospital, Toronto, Canada, the Institute for Clinical Evaluative Sciences, Toronto, Canada, and the Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; the Applied Health Research Centre (S.R.), Keenan Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Canada; the Division of General Internal Medicine and Clinical Epidemiology (M.K.K.)
| | - Peter C. Austin
- From the Division of Neurology (G.S.), Department of Medicine, St Michael's Hospital, Toronto, Canada, the Institute for Clinical Evaluative Sciences, Toronto, Canada, and the Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; the Applied Health Research Centre (S.R.), Keenan Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Canada; the Division of General Internal Medicine and Clinical Epidemiology (M.K.K.)
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Aaronson DS, Bardach NS, Lin GA, Chattopadhyay A, Goldman LE, Dudley RA. Prediction of hospital acute myocardial infarction and heart failure 30-day mortality rates using publicly reported performance measures. J Healthc Qual 2011; 35:15-23. [PMID: 22093186 DOI: 10.1111/j.1945-1474.2011.00173.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 09/28/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To identify an approach to summarizing publicly reported hospital performance data for acute myocardial infarction (AMI) or heart failure (HF) that best predicts current year hospital mortality rates. SETTING A total of 1,868 U.S. hospitals reporting process and outcome measures for AMI and HF to the Centers for Medicare and Medicaid Services (CMS) from July 2005 to June 2006 (Year 0) and July 2006 to June 2007 (Year 1). DESIGN Observational cohort study measuring the percentage variation in Year 1 hospital 30-day risk-adjusted mortality rate explained by denominator-based weighted composite scores summarizing hospital Year 0 performance. DATA COLLECTION Data were prospectively collected from hospitalcompare.gov. RESULTS Percentage variation in Year 1 mortality was best explained by mortality rate alone in Year 0 over other composites including process performance. If only Year 0 mortality rates were reported, and consumers using hospitals in the highest decile of mortality instead chose hospitals in the lowest decile of mortality rate, the number of deaths at 30 days that potentially could have been avoided was 1.31 per 100 patients for AMI and 2.12 for HF (p < .001). CONCLUSION Public reports focused on 30-day risk-adjusted mortality rate may more directly address policymakers' goals of facilitating consumer identification of hospitals with better outcomes.
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Rolim CLRC, Martins M. Qualidade do cuidado ao acidente vascular cerebral isquêmico no SUS. CAD SAUDE PUBLICA 2011; 27:2106-16. [DOI: 10.1590/s0102-311x2011001100004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Accepted: 08/19/2011] [Indexed: 11/22/2022] Open
Abstract
A taxa de mortalidade hospitalar é uma medida do resultado do cuidado, utilizada como indicador da qualidade do cuidado para o acidente vascular cerebral (AVC). A tomografia computadorizada é o principal método de imagem utilizado para o diagnóstico e condução terapêutica dessa patologia. O objetivo deste artigo é avaliar a qualidade do cuidado hospitalar ao AVC isquêmico (AVCi) agudo no SUS, considerando o perfil de gravidade dos casos e a realização de tomografia computadorizada. Análise multivariada foi empregada para ajustar a mortalidade por risco, avaliar o uso de tomografia e classificar o desempenho dos hospitais no período entre abril de 2006 e dezembro de 2007. 16.879 internações foram analisadas. A realização de, pelo menos, um exame de tomografia computadorizada equivaleu a 28,6% das internações. A taxa de mortalidade bruta foi 34,3%, e a taxa ajustada, 31,2%. A realização de exame de tomografia computadorizada apresentou um efeito protetor: OR ajustado de 0,27 para um exame e de 0,32 para a realização de dois exames. A subutilização da tomografia computadorizada é um dos fatores limitantes para a boa prática médica no tratamento do AVCi no SUS.
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Ahuja C, Mamdani M, Saposnik G. Influence of socioeconomic status on distance traveled and care after stroke. Stroke 2011; 43:233-5. [PMID: 21980198 DOI: 10.1161/strokeaha.111.635045] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Vital to maintaining an efficient delivery of services is an understanding of patient travel patterns during an acute ischemic stroke. Socioeconomic status may influence access to stroke care, including transportation and admission to different facility types. METHODS We analyzed all acute ischemic stroke admissions between 2003 and 2007 through the Discharge Abstract Database, a national database containing patient-level sociodemographic, diagnostic, procedural, and administrative information across Canada. Socioeconomic status was defined in neighborhood quintiles according to Statistics Canada. Distances between patients and facilities were derived from postal codes. A principal diagnosis of ischemic stroke was identified using the International Classification of Diseases (versions 9 and 10). Analysis of variance and regression analyses were performed with adjustment for demographic characteristics. RESULTS Admitted to acute care institutions were 243 410 patients with ischemic stroke. Mean patient age was 72.8 and 49.5% were male; 44.2% traveled beyond their closest center, amounting to an average 7.2 km additional distance traveled. Socioeconomic status quintile had minimal effect on travel patterns, with the lowest socioeconomic status accessing the closest center most frequently (odds ratio, 1.19; 95% confidence interval [CI], 1.13-1.16). Increased utilization of the closest hospital occurred with academic (odds ratio, 6.90; 95% CI, 6.69-7.11) or high-volume (odds ratio, 1.93; 95% CI, 1.88-1.98) facilities. Older patients (β=0.28; 95% CI, 0.27-0.28), expert destination facility (β=0.13; 95% CI, 0.12-0.14), and ambulance use increased travel beyond the closest center. CONCLUSIONS Patients tend to choose care facilities based on hospital expertise; investment promoting improved regional facilities may be of greatest benefit to patients. Socioeconomic status has little bearing on travel patterns associated with stroke in Canada. These findings may assist in allocating funding to centers and improving patient care.
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Freburger JK, Holmes GM, Ku LJE, Cutchin MP, Heatwole-Shank K, Edwards LJ. Disparities in postacute rehabilitation care for stroke: an analysis of the state inpatient databases. Arch Phys Med Rehabil 2011; 92:1220-9. [PMID: 21807141 PMCID: PMC4332528 DOI: 10.1016/j.apmr.2011.03.019] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 02/23/2011] [Accepted: 03/20/2011] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To determine the extent to which sociodemographic and geographic disparities exist in the use of postacute rehabilitation care (PARC) after stroke. DESIGN Cross-sectional analysis of data for 2 years (2005-2006) from the State Inpatient Databases. SETTING All short-term acute-care hospitals in 4 demographically and geographically diverse states. PARTICIPANTS Individuals (age, ≥45y; mean age, 72.6y) with a primary diagnosis of stroke who survived their inpatient stay (N=187,188). The sample was 52.4% women, 79.5% white, 11.4% black, and 9.1% Hispanic. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES (1) Discharge to an institution versus home. (2) For those discharged to home, receipt of home health (HH) versus no HH care. (3) For those discharged to an institution, receipt of inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF) care. Multilevel logistic regression analyses were conducted to identify sociodemographic and geographic disparities in PARC use, controlling for illness severity/comorbid conditions, hospital characteristics, and PARC supply. RESULTS Blacks, women, older individuals, and those with lower incomes were more likely to receive institutional care; Hispanics and the uninsured were less likely. Racial minorities, women, older individuals, and those with lower incomes were more likely to receive HH care; uninsured individuals were less likely. Blacks, women, older individuals, the uninsured, and those with lower incomes were more likely to receive SNF versus IRF care. PARC use varied significantly by hospital and geographic location. CONCLUSIONS Several sociodemographic and geographic disparities in PARC use were identified.
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Affiliation(s)
- Janet K Freburger
- Cecil G. Sheps Center for HealthServices Research, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd., Chapel Hill, NC 27599-7590, USA.
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Lichtman JH, Jones SB, Wang Y, Watanabe E, Leifheit-Limson E, Goldstein LB. Outcomes after ischemic stroke for hospitals with and without Joint Commission-certified primary stroke centers. Neurology 2011; 76:1976-82. [PMID: 21543736 PMCID: PMC3109877 DOI: 10.1212/wnl.0b013e31821e54f3] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Accepted: 12/27/2010] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The Joint Commission (JC) began certifying primary stroke centers (PSCs) in the United States in 2003. We assessed whether 30-day risk-standardized mortality (RSMR) and readmission (RSRR) rates differed between hospitals with and without JC-certified PSCs in 2006. METHODS The study cohort included all fee-for-service Medicare beneficiaries ≥65 years old discharged with a primary diagnosis of ischemic stroke (International Classification of Diseases, ninth revision, Clinical Modification 433, 434, 436) in 2006. Hierarchical linear regression models calculated hospital-level RSMRs and RSRRs, adjusting for patient demographics, comorbid conditions, and hospital referral region. Hospitals were categorized as being higher than, no different from, or lower than the national average. RESULTS There were 310,381 ischemic stroke discharges from 315 JC-certified PSC and 4,231 noncertified hospitals. Mean overall 30-day RSMR and RSRR were 10.9% ± 1.7% and 12.5% ± 1.4%, respectively. The RSMRs of hospitals with JC-certified PSCs were lower than in noncertified hospitals (10.7% ± 1.7% vs 11.0% ± 1.7%), but the RSRRs were comparable (12.5% ± 1.3% vs 12.4% ± 1.7%). Almost half of JC-certified PSC hospitals had RSMRs lower than the national average compared with 19% of noncertified hospitals, but 13% of JC-certified PSC hospitals had lower RSRRs vs 15% of noncertified hospitals. CONCLUSIONS Hospitals with JC-certified PSCs had lower RSMRs compared with noncertified hospitals in 2006; however, differences were small. Readmission rates were similar between the 2 groups. PSC certification generally identified better-performing hospitals for mortality outcomes, but some hospitals with certified PSCs may have high RSMRs and RSRRs whereas some hospitals without PSCs have low rates. Unmeasured factors may contribute to this heterogeneity.
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Affiliation(s)
- J H Lichtman
- Yale University School of Medicine, PO Box 208034, New Haven, CT 06520, USA.
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Saposnik G, Hassan KA, Selchen D, Fang J, Kapral MK, Smith EE. Stroke unit care: does ischemic stroke subtype matter? Int J Stroke 2011; 6:244-50. [PMID: 21557812 DOI: 10.1111/j.1747-4949.2011.00604.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Stroke unit care improves outcomes following ischemic stroke. However, it is not known whether all ischemic stroke subtypes benefit equally from stroke unit admission. OBJECTIVE To determine whether the benefit of stroke unit admission is similar among all ischemic stroke subtypes. Design, setting and patients Prospective cohort study including patients admitted with an acute ischemic stroke between July 2003 and September 2007 to stroke centers participating institutions in the Registry of the Canadian Stroke Network. Ischemic stroke subtype information was determined according to the modified Trial of Org 10 172 in Acute Stroke Treatment criteria and categorized as small vessel disease (lacunar), large artery atherosclerotic disease, cardioembolic, or other (including both other determined and undetermined causes). Main outcome measures The primary outcome measure was all-cause mortality at 30 days after stroke. Secondary outcomes were seven-day mortality and death or institutionalization at discharge. RESULTS Among 6223 eligible patients with ischemic stroke admitted to regional stroke centers in Ontario, the mean age was 72 years and 52·4% were male. Overall 30-day mortality was 12·2%. The 30-day risk-adjusted mortality was lower for stroke unit care across all stroke subtypes (for lacunar stroke 3·0% vs. 5·3%; for large artery disease 7·5% vs. 14·5%; for cardioembolic 15·3% vs. 23·3%; and for other causes 8·9% vs. 15·9%). In multivariable analysis, after controlling for age, gender, medical comorbidities, and stroke severity, there was a significant reduction in stroke mortality associated with stroke unit admission in all stroke subtypes (odds ratio (95% confidence interval) for lacunar stroke 0·48 (0·27-0·88), for large artery atherosclerotic disease 0·39 (0·27-0·56), for cardioembolic 0·46 (0·36-0·59), and for other causes 0·45 (0·29-0·70)). The results remained similar after a sensitivity analysis excluding patients receiving palliative care, and a secondary analysis including 3215 patients with missing Trial of Org 10 172 in Acute Stroke Treatment classification. CONCLUSION This study provides 'real-world' evidence that all ischemic stroke subtypes do benefit from a stroke unit admission regardless of the etiology. There is no justification for withholding access to stroke unit care based on stroke subtype.
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Affiliation(s)
- Gustavo Saposnik
- Stroke Outcomes Research Unit, Stroke Research Unit, Department of Medicine, Division of Neurology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
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Abstract
Background—
A predictive model of stroke mortality may be useful for clinicians to improve communication with and care of hospitalized patients. Our aim was to identify predictors of mortality and to develop and validate a risk score model using information available at hospital presentation.
Methods and Results—
This retrospective study included 12 262 community-based patients presenting with an acute ischemic stroke at multiple hospitals in Ontario, Canada, between 2003 and 2008 who had been identified from the Registry of the Canadian Stroke Network (8223 patients in the derivation cohort, 4039 in the internal validation cohort) and the Ontario Stroke Audit (3720 for the external validation cohort). The mortality rates for the derivation and internal validation cohorts were 12.2% and 12.6%, respectively, at 30 days and 22.5% and 22.9% at 1 year. Multivariable predictors of 30-day and 1-year mortality included older age, male sex, severe stroke, nonlacunar stroke subtype, glucose ≥7.5 mmol/L (135 mg/dL), history of atrial fibrillation, coronary artery disease, congestive heart failure, cancer, dementia, kidney disease on dialysis, and dependency before the stroke. A risk score index stratified the risk of death and identified low- and high- risk individuals. The c statistic was 0.850 for 30-day mortality and 0.823 for 1-year mortality for the derivation cohort, 0.851 for the 30-day model and 0.840 for the 1-year mortality model in the internal validation set, and 0.790 for the 30-day model and 0.782 for the 1-year model in the external validation set.
Conclusion—
Among patients with ischemic stroke, factors identifiable within hours of hospital presentation predicted mortality risk at 30 days and 1 year. The predictive score may assist clinicians in estimating stroke mortality risk and policymakers in providing a quantitative tool to compare facilities.
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Saposnik G, Barinagarrementeria F, Brown RD, Bushnell CD, Cucchiara B, Cushman M, deVeber G, Ferro JM, Tsai FY. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011; 42:1158-92. [PMID: 21293023 DOI: 10.1161/str.0b013e31820a8364] [Citation(s) in RCA: 1139] [Impact Index Per Article: 87.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The purpose of this statement is to provide an overview of cerebral venous sinus thrombosis and to provide recommendations for its diagnosis, management, and treatment. The intended audience is physicians and other healthcare providers who are responsible for the diagnosis and management of patients with cerebral venous sinus thrombosis. METHODS AND RESULTS Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represent different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 1966 and used the American Heart Association levels-of-evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. CONCLUSIONS Evidence-based recommendations are provided for the diagnosis, management, and prevention of recurrence of cerebral venous thrombosis. Recommendations on the evaluation and management of cerebral venous thrombosis during pregnancy and in the pediatric population are provided. Considerations for the management of clinical complications (seizures, hydrocephalus, intracranial hypertension, and neurological deterioration) are also summarized. An algorithm for diagnosis and management of patients with cerebral venous sinus thrombosis is described.
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Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Fujimori K. Reconsidering the value of rehabilitation for patients with cerebrovascular disease in Japanese acute health care hospitals. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2011; 14:166-176. [PMID: 21211499 DOI: 10.1016/j.jval.2010.10.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVES The 21st century has an increasing elderly population at risk of cerebrovascular disease (CVD). Efficient care for recovering functional status is emphasized among policy makers. We investigated whether rehabilitation and its early initiation provided for CVD patients produced functional recovery in acute care hospitals. METHODS Using a Japanese administrative database during a 4-month interval from 2004 to 2008 in patients ages ≥ 15 years, we measured the demographics, consciousness level at admission, comorbidities, complications, procedures, ventilation administration, initiation day of rehabilitation, and hospital characteristics. Outcomes included total charges (TC) and functional status measured by the Barthel index (BI). Multivariate analysis measured the impact of rehabilitation and its early initiation on outcomes. To reduce the selection bias of rehabilitation and the ecological fallacy, we used propensity score matching and the linear mixed model. RESULTS Excluding 488 deceased patients, we analyzed 45,014 CVD patients. Rehabilitation at a generalized unit produced greater BI improvement than no rehabilitation or at intensive care units. A longer hospitalization, but not a 1-day delay of rehabilitation initiation, resulted in less BI improvement and more TC. A higher patient volume and academic hospitals were associated with more TC but not with BI improvement. CONCLUSIONS Rehabilitation, but not the timing of rehabilitation, might accompany functional recovery in acute care hospitals. Because the hospital mix or medical units can explain the variation in the quality of rehabilitation, policy makers, along with monitoring unnecessary long hospitalizations, should encourage a referral policy for rehabilitation-intensive facilities and develop effective rehabilitation using technology to optimize functional outcomes.
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Affiliation(s)
- Kazuaki Kuwabara
- Kyushu University, Graduate School of Medical Sciences, Department of Health Care Administration and Management, Fukuoka, Japan.
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Asplund K, Hulter Åsberg K, Appelros P, Bjarne D, Eriksson M, Johansson Å, Jonsson F, Norrving B, Stegmayr B, Terént A, Wallin S, Wester PO. The Riks-Stroke Story: Building a Sustainable National Register for Quality Assessment of Stroke Care. Int J Stroke 2010; 6:99-108. [DOI: 10.1111/j.1747-4949.2010.00557.x] [Citation(s) in RCA: 139] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Riks-Stroke, the Swedish Stroke Register, is the world's longest-running national stroke quality register (established in 1994) and includes all 76 hospitals in Sweden admitting acute stroke patients. The development and maintenance of this sustainable national register is described. Methods Riks-Stroke includes information on the quality of care during the acute phase, rehabilitation and secondary prevention of stroke, as well as data on community support. Riks-Stroke is unique among stroke quality registers in that patients are followed during the first year after stroke. The data collected describe processes, and medical and patient-reported outcome measurements. The register embraces most of the dimensions of health-care quality (evidence-based, safe, provided in time, distributed fairly and patient oriented). Result Annually, approximately 25 000 patients are included. In 2009, approximately 320 000 patients had been accumulated (mean age 76-years). The register is estimated to cover 82% of all stroke patients treated in Swedish hospitals. Among critical issues when building a national stroke quality register, the delicate balance between simplicity and comprehensiveness is emphasised. Future developments include direct transfer of data from digital medical records to Riks-Stroke and comprehensive strategies to use the information collected to rapidly implement new evidence-based techniques and to eliminate outdated methods in stroke care. Conclusions It is possible to establish a sustainable quality register for stroke at the national level covering all hospitals admitting acute stroke patients. Riks-Stroke is fulfilling its main goals to support continuous quality improvement of Swedish stroke services and serve as an instrument for following up national stroke guidelines.
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Affiliation(s)
- Kjell Asplund
- Riks-Stroke, Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | | | - Peter Appelros
- Department of Neurology, University Hospital, Örebro, Sweden
| | | | - Marie Eriksson
- Riks-Stroke, Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Åsa Johansson
- Riks-Stroke, Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Fredrik Jonsson
- Riks-Stroke, Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Bo Norrving
- Department of Neurology, University Hospital, Lund, Sweden
| | - Birgitta Stegmayr
- Epidemiologic Center, National Board of Health and Welfare, Stockholm, Sweden
| | - Andreas Terént
- Department of Medicine, Uppsala University Hospital, Uppsala, Sweden
| | - Sari Wallin
- Riks-Stroke, Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Per-Olov Wester
- Riks-Stroke, Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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