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Hsia RY, Sarkar N, Shen YC. Provision of Stroke Care Services by Community Disadvantage Status in the US, 2009-2022. JAMA Netw Open 2024; 7:e2421010. [PMID: 39052294 PMCID: PMC11273237 DOI: 10.1001/jamanetworkopen.2024.21010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 05/08/2024] [Indexed: 07/27/2024] Open
Abstract
Importance Stroke center certification is granted to facilities that demonstrate distinct capabilities for treating patients with stroke. A thorough understanding of structural discrimination in the provision of stroke centers is critical for identifying and implementing effective interventions to improve health inequities for socioeconomically disadvantaged populations. Objective To determine whether (1) hospitals in socioeconomically disadvantaged communities (defined using the Area Deprivation Index) are less likely to adopt any stroke certification and (2) adoption rates differ between entry-level (acute stroke-ready hospitals) and higher-level certifications (primary, thrombectomy capable, and comprehensive) by community disadvantage status. Design, Setting, and Participants This cohort study used newly collected stroke center data merged with data from the American Hospital Association, Healthcare Cost Report Information datasets, and the US Census. All general acute hospitals in the continental US between January 1, 2009, and December 31, 2022, were included. Data analysis was conducted from July 2023 to May 2024. Main Outcomes and Measures The primary outcome was the likelihood of hospitals adopting stroke care certification. Cox proportional hazard and competing risk models were used to estimate the likelihood of a hospital becoming stroke certified based on the socioeconomic disadvantage status of the community. Results Among the 5055 hospitals studied from 2009 to 2022, 2415 (47.8%) never achieved stroke certification, 602 (11.9%) were certified as acute stroke-ready hospitals, and 2038 (40.3%) were certified as primary stroke centers or higher. When compared with mixed-advantage communities, adoption of any stroke certification was most likely to occur near the most advantaged communities (hazard ratio [HR], 1.24; 95% CI, 1.07-1.44) and least likely near the most disadvantaged communities (HR, 0.43; 95% CI, 0.34-0.55). Adoption of acute stroke-ready certification was most likely in mixed-advantage communities, while adoption of higher-level certification was more likely in the most advantaged communities (HR,1.41; 95% CI, 1.22-1.62) and less likely for the most disadvantaged communities (HR, 0.31; 95% CI, 0.21-0.45). After adjusting for population size and hospital capacity, compared with mixed-advantage communities, stroke certification adoption hazard was still 20% lower for relatively disadvantaged communities (adjusted HR, 0.80; 95% CI, 0.73-0.87) and 42% lower for the most disadvantaged communities (adjusted HR, 0.58; 95% CI, 0.45-0.74). Conclusions and Relevance In this cohort study examining hospital adoption of stroke services, when compared with mixed-advantage communities, hospitals located in the most disadvantaged communities had a 42% lower hazard of adopting any stroke certification and relatively disadvantaged communities had a 20% lower hazard of adopting any stroke certification. These findings suggest that there is a need to support hospitals in disadvantaged communities to obtain stroke certification as a way to reduce stroke disparities.
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Affiliation(s)
- Renee Y. Hsia
- Department of Emergency Medicine, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Nandita Sarkar
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Yu-Chu Shen
- National Bureau of Economic Research, Cambridge, Massachusetts
- Department of Defense Management, Naval Postgraduate School, Monterey, California
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Chou A, Beach SR, Lutz BJ, Rodakowski J, Terhorst L, Freburger JK. Moderating Effects of Informal Care on the Relationship Between ADL Limitations and Adverse Outcomes in Stroke Survivors. Stroke 2024; 55:1554-1561. [PMID: 38660796 DOI: 10.1161/strokeaha.123.045427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 03/29/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Stroke survivors with limitations in activities of daily living (ADL) have a greater risk of experiencing falls, hospitalizations, or physical function decline. We examined how informal caregiving received in hours per week by stroke survivors moderated the relationship between ADL limitations and adverse outcomes. METHODS In this retrospective cohort, community-dwelling participants were extracted from the National Health and Aging Trends Study (2011-2020; n=277) and included if they had at least 1 formal or informal caregiver and reported an incident stroke in the prior year. Participants reported the amount of informal caregiving received in the month prior (low [<5.8], moderate [5.8-27.1], and high [27.2-350.4] hours per week) and their number of ADL limitations (ranging from 0 to 7). Participants were surveyed 1 year later to determine the number of adverse outcomes (ie, falls, hospitalizations, and physical function decline) experienced over the year. Poisson regression coefficients were converted to average marginal effects and estimated the moderating effects of informal caregiving hours per week on the relationship between ADL limitations and adverse outcomes. RESULTS Stroke survivors were 69.7% White, 54.5% female, with an average age of 80.5 (SD, 7.6) years and 1.2 adverse outcomes at 2 years after the incident stroke. The relationships between informal caregiving hours and adverse outcomes and between ADL limitations and adverse outcomes were positive. The interaction between informal caregiving hours per week and ADL limitations indicated that those who received the lowest amount of informal caregiving had a rate of 0.12 more adverse outcomes per ADL (average marginal effect, 0.12 [95% CI, 0.005-0.23]; P=0.041) than those who received the highest amounts. CONCLUSIONS Informal caregiving hours moderated the relationship between ADL limitations and adverse outcomes in this sample of community-based stroke survivors. Higher amounts relative to lower amounts of informal caregiving hours per week may be protective by decreasing the rate of adverse outcomes per ADL limitation.
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Affiliation(s)
- Aileen Chou
- Departments of Physical Therapy (A.C., J.K.F.), University of Pittsburgh, PA
| | | | - Barbara J Lutz
- School of Nursing, College of Health and Human Services, University of North Carolina-Wilmington, NC (B.J.L.)
| | | | - Lauren Terhorst
- Occupational Therapy (J.R., L.T.), University of Pittsburgh, PA
| | - Janet K Freburger
- Departments of Physical Therapy (A.C., J.K.F.), University of Pittsburgh, PA
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Acute Hospital Management of Pediatric Stroke. Semin Pediatr Neurol 2022; 43:100990. [PMID: 36344020 DOI: 10.1016/j.spen.2022.100990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 08/13/2022] [Accepted: 08/14/2022] [Indexed: 11/24/2022]
Abstract
The field of pediatric stroke has historically been hampered by limited evidence and small patient cohorts. However the landscape of childhood stroke is rapidly changing due in part to increasing awareness of the importance of pediatric stroke and the emergence of dedicated pediatric stroke centers, care pathways, and alert systems. Acute pediatric stroke management hinges on timely diagnosis confirmed by neuroimaging, appropriate consideration of recanalization therapies, implementation of neuroprotective measures, and attention to secondary prevention. Because pediatric stroke is highly heterogenous in etiology, management strategies must be individualized. Determining a child's underlying stroke etiology is essential to appropriately tailoring hyperacute stroke management and determining best approach to secondary prevention. Herein, we review the methods of recognition, diagnosis, management, current knowledge gaps and promising research for pediatric stroke.
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Abreu P, Magalhães R, Baptista D, Azevedo E, Correia M. Admission and Readmission/Death Patterns in Hospitalized and Non-hospitalized First-Ever-in-a-Lifetime Stroke Patients During the First Year: A Population-Based Incidence Study. Front Neurol 2021; 12:685821. [PMID: 34566836 PMCID: PMC8455946 DOI: 10.3389/fneur.2021.685821] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/30/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Hospitalization and readmission rates after a first-ever-in-a-lifetime stroke (FELS) are considered measures of quality of care and, importantly, may give valuable information to better allocate health-related resources. We aimed to investigate the hospitalization pattern and the unplanned readmissions or death of hospitalized (HospS) and non-hospitalized stroke (NHospS) patients 1 year after a FELS, based on a community register. Methods: Data about hospitalization and unplanned readmissions and case fatality 1 year after a FELS were retrieved from the population-based register undertaken in Northern Portugal (ACIN2), comprising all FELS in 2009–2011. We used the Kaplan–Meier method to estimate 1-year readmission/death-free survival and Cox proportional hazard models to identify independent factors for readmission/death. Results: Of the 720 FELS, 35.7% were not hospitalized. Unplanned readmission/death within 1 year occurred in 33.0 and 24.9% of HospS and NHospS patients, respectively. The leading causes of readmission were infections, recurrent stroke, and cardiovascular events. Stroke-related readmissions were observed in more than half of the patients in both groups. Male sex, age, pre- and post-stroke functional status, and diabetes were independent factors of readmission/death within 1 year. Conclusion: About one-third of stroke patients were not hospitalized, and the readmission/death rate was higher in HospS patients. Still, that readmission/death rate difference was likely due to other factors than hospitalization itself. Our research provides novel information that may help implement targeted health-related policies to reduce the burden of stroke and its complications.
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Affiliation(s)
- Pedro Abreu
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Rui Magalhães
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Diana Baptista
- Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Elsa Azevedo
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Manuel Correia
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal.,Department of Neurology, Hospital Santo António - Centro Hospitalar Universitário do Porto, Porto, Portugal
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Association Between Hospital Accreditation and Outcomes: The Analysis of Inhospital Mortality From the National Claims Data of the Universal Coverage Scheme in Thailand. Qual Manag Health Care 2021; 29:150-157. [PMID: 32590490 DOI: 10.1097/qmh.0000000000000256] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND In Thailand, hospital accreditation (HA) is widely recognized as one of the system tools to promote effective operation of universal health coverage. This nationwide study aims to examine the relationship between accredited statuses of the provincial hospitals and their mortality outcomes. METHOD A 5-year retrospective analysis of the Universal Coverage Scheme's claim dataset was conducted, using 1 297 869 inpatient discharges from 76 provincial hospital networks under the Ministry of Public Health. Mortality outcomes of 3 major acute care conditions, including acute myocardial infarction, acute stroke, and sepsis, were selected. RESULTS Using generalized estimating equations to adjust for area-based control variables, hospital networks with HA-accredited provincial hospitals showed significant associations with lower standardized mortality ratios of acute stroke and sepsis. CONCLUSION Our findings added supportive evidence that HA, as an organizational and health system management tool, could help promote hospital quality and safety in a developing country, leading to better outcomes.
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Araujo CAS, Siqueira MM, Malik AM. Hospital accreditation impact on healthcare quality dimensions: a systematic review. Int J Qual Health Care 2021; 32:531-544. [PMID: 32780858 DOI: 10.1093/intqhc/mzaa090] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/06/2020] [Accepted: 08/04/2020] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To systematically review the impact of hospital accreditation on healthcare quality indicators, as classified into seven healthcare quality dimensions. DATA SOURCE We searched eight databases in June 2020: EBSCO, PubMed, Web of Science, Emerald, ProQuest, Science Direct, Scopus and Virtual Health Library. Search terms were conceptualized into three groups: hospitals, accreditation and terms relating to healthcare quality. The eligibility criteria included academic articles that applied quantitative methods to examine the impact of hospital accreditation on healthcare quality indicators. STUDY SELECTION We applied the PICO framework to select the articles according to the following criteria: Population-all types of hospitals; Intervention-hospital accreditation; Comparison-quantitative method applied to compare accredited vs. nonaccredited hospitals, or hospitals before vs. after accreditation; Outcomes-regarding the seven healthcare quality dimensions. After a critical appraisal of the 943 citations initially retrieved, 36 studies were included in this review. RESULTS OF DATA SYNTHESIS Overall results suggest that accreditation may have a positive impact on efficiency, safety, effectiveness, timeliness and patient-centeredness. In turn, only one study analyzes the impact on access, and no study has investigated the impact on equity dimension yet. CONCLUSION Mainly due to the methodological shortcomings, the positive impact of accreditation on healthcare dimensions should be interpreted with caution. This study provides an up-to-date overview of the main themes examined in the literature, highlighting critical knowledge-gaps and methodological flaws. The findings may provide value to healthcare stakeholders in terms of improving their ability to assess the relevance of accreditation processes.
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Affiliation(s)
- Claudia A S Araujo
- COPPEAD Graduate School of Business, Federal University of Rio de Janeiro-RJ, Rio de Janeir, Brazil.,Fundação Getulio Vargas's Sao Paulo School of Business Administration-FGV/EAESP, São Paulo-SP, Rio de Janeir, Brazil
| | - Marina Martins Siqueira
- COPPEAD Graduate School of Business, Federal University of Rio de Janeiro-RJ, Rio de Janeir, Brazil
| | - Ana Maria Malik
- Fundação Getulio Vargas's Sao Paulo School of Business Administration-FGV/EAESP, São Paulo-SP, Rio de Janeir, Brazil
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Abreu P, Magalhães R, Baptista D, Azevedo E, Silva MC, Correia M. Readmissions and Mortality During the First Year After Stroke-Data From a Population-Based Incidence Study. Front Neurol 2020; 11:636. [PMID: 32793092 PMCID: PMC7393181 DOI: 10.3389/fneur.2020.00636] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 05/28/2020] [Indexed: 12/20/2022] Open
Abstract
Background: After a first-ever-in-a-lifetime stroke (FELS), hospital readmissions are common and associated with increased mortality and morbidity of stroke survivors, thus, raising the overall health burden of stroke. Population-based stroke studies on hospital readmissions are scarce despite it being an important healthcare service quality indicator. We evaluated unplanned readmissions or death during the first year after a FELS and their potential factors, based on a Portuguese community register. Methods: Data were retrieved from a population-based prospective register undertaken in Northern Portugal (ACIN2) in 2009–2011. Retrospective information about unplanned hospital readmissions and case fatality within 1 year after FELS index hospitalization (FELS-IH) was evaluated. Readmission/death-free survival 1 year after discharge was estimated using the Kaplan–Meyer method. Independent risk factors for readmission/death were identified using Cox proportional hazard models. Results: Unplanned readmission/death within 1 year occurred in 120 (31.6%) of the 389 hospitalized FELS survivors. In 31.2% and 33.5% of the cases, it occurred after ischemic stroke or intracerebral hemorrhage, respectively. Infections and cerebrovascular and cardiovascular diseases were the main causes of readmission. Of the readmissions, 65.3% and 52.5% were potentially avoidable or stroke related, respectively. The main cause of potentially avoidable readmissions was the continuation/recurrence of the event responsible for the initial admission or a closely related condition (71.2%). Male sex, age, previous and post-stroke functional status, and FELS-IH length of stay were independent factors of readmission/death within 1 year. Conclusions: Almost one-third of FELS survivors were readmitted/dead 1 year after their FELS-IH. This outcome persisted after the first months after stroke hospitalization in all stroke subtypes. More than half of readmissions were considered potentially avoidable or stroke related.
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Affiliation(s)
- Pedro Abreu
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina, Universidade Do Porto, Porto, Portugal
| | - Rui Magalhães
- Instituto de Ciências Biomédicas Abel Salazar, Universidade Do Porto, Porto, Portugal
| | - Diana Baptista
- Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina, Universidade Do Porto, Porto, Portugal
| | - Elsa Azevedo
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina, Universidade Do Porto, Porto, Portugal
| | - Maria Carolina Silva
- Instituto de Ciências Biomédicas Abel Salazar, Universidade Do Porto, Porto, Portugal
| | - Manuel Correia
- Instituto de Ciências Biomédicas Abel Salazar, Universidade Do Porto, Porto, Portugal.,Department of Neurology, Hospital Santo António-Centro Hospitalar Universitário Do Porto, Porto, Portugal
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Wilcock AD, Zachrison KS, Schwamm LH, Uscher-Pines L, Zubizarreta JR, Mehrotra A. Trends Among Rural and Urban Medicare Beneficiaries in Care Delivery and Outcomes for Acute Stroke and Transient Ischemic Attacks, 2008-2017. JAMA Neurol 2020; 77:863-871. [PMID: 32364573 PMCID: PMC7358912 DOI: 10.1001/jamaneurol.2020.0770] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/21/2020] [Indexed: 12/20/2022]
Abstract
Importance Over the last decade or so, there have been substantial investments in the development of stroke systems of care to improve access and quality of care in rural communities. Whether these have narrowed rural-urban disparities in care is unclear. Objective To describe trends among rural and urban patients with acute ischemic stroke or transient ischemic attack in the type of health care centers to which patients were admitted, what care was provided, and the outcomes patients experienced. Design, Setting, and Participants This descriptive observational study included 100% claims for beneficiaries of traditional fee-for-service Medicare from 2008 through 2017. All rural and urban areas in the US were included, defined by whether a beneficiary's residential zip code was in a metropolitan or nonmetropolitan area. All admissions in the US among patients with traditional Medicare who had a transient ischemic attack or acute stroke (N = 4.01 million) were eligible to be included in this study. Admissions for beneficiaries with end-stage kidney disease (n = 85 927 [2.14%]), beneficiaries with unidentified Rural-Urban Commuting Area codes (n = 12 797 [0.32%]), and beneficiaries not continuously enrolled in traditional Medicare in the 12 months before and 3 months after their admission (n = 442 963 [11.0%]) were excluded. Exposures Residence in an urban or rural area; admission to a hospital with a transient ischemic attack or acute stroke. Main Outcomes and Measures Discharge from a certified stroke center, receiving a neurology consultation during admission, treatment with alteplase, days institutionalized, and 90-day mortality. Results The final sample included 3.47 million admissions from 2008 through 2017. In this sample, 2.01 million patients (58.0%) were female, and the mean (SD) age was 78.6 (10.5) years. In 2008, 24 681 patients (25.2%) and 161 217 patients (60.6%) in rural and urban areas, respectively, were cared for at a certified stroke center (disparity, -35.4%). By 2017, this disparity was -26.6%, having narrowed by 8.7 percentage points (95% CI, 6.6-10.8 percentage points). There was also narrowing in the rural-urban disparity in neurologist evaluation during admission (6.3% [95% CI, 4.2%-8.4%]). However, the rural-urban disparity widened or was similar with regard to receiving alteplase (0.5% [95% CI, 0.1%-0.8%]), mean days in an institution from admission (0.5 [95% CI, 0.2-0.8] days), and mortality at 90 days (0.3% [95% CI, -0.02% to 0.6%]), respectively. Conclusions and Relevance In the last decade, care for rural residents with acute ischemic stroke and transient ischemic attack has shifted to certified stroke centers and now more likely includes neurologist input. However, disparities in access to treatments, such as alteplase, and outcomes persist, highlighting that work still is needed to extend improvements in stroke care to all US residents.
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Affiliation(s)
- Andrew D. Wilcock
- Center for Health Services Research, Department of Family Medicine, The Larner College of Medicine, University of Vermont, Burlington
| | - Kori S. Zachrison
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Massachusetts General Hospital, Boston
| | - Lee H. Schwamm
- Massachusetts General Hospital, Boston
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | | | - Jose R. Zubizarreta
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Development of a Joint Commission Disease-Specific Care Certification Program for Parkinson Disease in an Acute Care Hospital. J Neurosci Nurs 2020; 51:313-319. [PMID: 31626076 DOI: 10.1097/jnn.0000000000000472] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with Parkinson disease (PD) admitted to the hospital for any reason are at a higher risk of hospital-related complications. Frequent causes include delays in administering PD medications or use of contraindicated medications. The Joint Commission Disease-Specific Care (DSC) program has been used to establish a systematic approach to the care of specific inpatient populations. Once obtained, this certification demonstrates a commitment to patient care and safety, which is transparent to the public and can improve quality of care. METHODS We formalized our efforts to improve the care of hospitalized patients with PD by pursuing Joint Commission DSC. An interprofessional team was assembled to include nurses, therapists, physicians, pharmacists, performance improvement specialists, and data analysts. The team identified quality metrics based on clinical guidelines. In addition, a large educational campaign was undertaken. Application to the Joint Commission for DSC resulted in a successful June 15, 2018 site visit. To our knowledge, this is the first DSC program in PD in an acute care hospital. CONCLUSION Using the established platform of DSC certification from the Joint Commission, we developed a program based on relevant metrics that aims to address medication management of patients with PD admitted to the hospital. Our hope is to improve the care of this vulnerable patient population.
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Man S, Schold JD, Uchino K. Case Fatality Decline from 2009 to 2013 among Medicare Beneficiaries with Ischemic Stroke. J Stroke Cerebrovasc Dis 2020; 29:104559. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 11/09/2019] [Accepted: 11/21/2019] [Indexed: 11/25/2022] Open
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Liao HH, Wang PC, Yeh EH, Lin CJ, Chao TH. Impact of disease-specific care certification on clinical outcome and healthcare performance of myocardial infarction in Taiwan. J Chin Med Assoc 2020; 83:156-163. [PMID: 31834024 DOI: 10.1097/jcma.0000000000000237] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The relationship between certification for specific disease care and clinical outcome was not well known. Previous studies regarding the effect of certification for acute stroke centers were limited by their cross-sectional design. This study aimed to investigate the effect of disease-specific care (DSC) certification on healthcare performance and clinical outcome of acute myocardial infarction (AMI). METHODS This retrospective, longitudinal, controlled study was performed by analyzing the nationwide Taiwan Clinical Performance Indicators dataset from 2011 to 2018. Hospitals undergoing DSC certification for coronary care and reporting AMI indicators 1 year before, during, and 1 year after certification were included in group C, whereas hospitals not seeking DSC certification but reporting AMI indicators during the same period were included in group U. The primary endpoint was in-hospital mortality of AMI. RESULTS In total, 20 hospitals (9 in group C and 11 in group U) and up to 16 173 AMI cases were included for analysis. In-hospital mortality was similar between both groups at baseline. However, the in-hospital mortality was significantly improved during and after certification periods in comparison with that at baseline in group C (6.8% vs 8.4%, p = 0.04; 6.7% vs 8.4%, p = 0.02), whereas there was no significant change in group U, resulting in a statistically significant difference between both groups during and after certification periods (odds ratio = 0.74 [95% CI = 0.60-0.91] and 0.78 [95% CI = 0.64-0.96]). Compared with group U, the improvement in healthcare performance indicators, such as door-to-electrocardiography time <10 minutes, blood testing for low-density lipoprotein cholesterol level, prescribing a beta-blockade or a P2Y12 receptor inhibitor during hospitalization, prescribing a statin on discharge, and consultation for cardiac rehabilitation, was significant in group C. CONCLUSION The current study demonstrated the beneficial effect of DSC certification on clinical outcome of AMI probably mediated through quality improvement during the healthcare process.
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Affiliation(s)
- Hsun-Hsiang Liao
- Joint Commission of Taiwan, Chief Executive Officer Office, New Taipei City, Taiwan, ROC
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan, ROC
| | - Pa-Chun Wang
- Joint Commission of Taiwan, Chief Executive Officer Office, New Taipei City, Taiwan, ROC
- Department of Otolaryngology, Cathay General Hospital, Taipei, Taiwan, ROC
- School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan, ROC
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan, ROC
| | - En-Hui Yeh
- Division of Quality Improvement, Joint Commission of Taiwan, New Taipei City, Taiwan, ROC
| | - Chii-Jeng Lin
- Department of Orthopedics, College of Medicine and Hospital, National Cheng Kung University, Tainan, Taiwan, ROC
- President Office, Joint Commission of Taiwan, New Taipei City, Taiwan, ROC
| | - Ting-Hsing Chao
- Department of Internal Medicine, College of Medicine and Hospital, National Cheng Kung University, Tainan, Taiwan, ROC
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Shkirkova K, Wang TT, Vartanyan L, Liebeskind DS, Eckstein M, Starkman S, Stratton S, Pratt FD, Hamilton S, Kim-Tenser M, Conwit R, Saver JL, Sanossian N. Quality of Acute Stroke Care at Primary Stroke Centers Before and After Certification in Comparison to Never-Certified Hospitals. Front Neurol 2020; 10:1396. [PMID: 32038463 PMCID: PMC6987385 DOI: 10.3389/fneur.2019.01396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 12/19/2019] [Indexed: 11/19/2022] Open
Abstract
Background and Purpose: Primary stroke center (PSC) certification is associated with improvements in stroke care and outcome. However, these improvements may reflect a higher baseline level of care delivery in hospitals eventually achieving certification. This study examines whether advancements in acute stroke care at PSCs are due to certification or factors intrinsic to the hospital. Methods: Data was obtained from the Field Administration of Stroke Therapy-Magnesium (FAST-MAG) trial with participation of 40 Emergency Medical System agencies, 315 ambulances, and 60 acute receiving hospitals in Los Angeles and Orange Counties. Subjects were transported to one of three types of destinations: PSC certified hospitals (PSCs), hospitals that were not PSCs at time of enrollment but would later become certified (pre-PSCs), and hospitals that would never be certified (non-PSCs). Metrics of acute stroke care quality included time arrival to imaging, use of intravenous tPA, and arrival to treatment. Results: Of 1,700 cases, 856(50%) were at certified PSCs, 529(31%) were at pre-PSCs, and 315 (19%) were at non-PSCs. Mean (SD) was 33min (±76.1) at PSCs, 47(±86.6) at pre-PSCs, and 49(±71.7) at non-PSCs. Of 1,223 cerebral ischemia cases, rate of tPA utilization was 43% at PSCs, 27% at pre-PSCs, and 28% at non-PSCs. Mean ED arrival to thrombolysis was 71(±32.7) at PSC, 98(±37.6) at pre-PSC, and 95(±45.0) at non-PSCs. PSCs had improved time to imaging (p = 0.014), percent tPA use (p < 0.001), and time to treatment (p = 0.003). Conclusions: Stroke care at hospitals prior to PSC certification is equivalent to care at non-PSCs. Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT00059332.
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Affiliation(s)
- Kristina Shkirkova
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Theodore T Wang
- Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Lily Vartanyan
- Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - David S Liebeskind
- Department of Neurology, UCLA Comprehensive Stroke Center, Los Angeles, CA, United States
| | - Marc Eckstein
- Department of Emergency Medicine, University of Southern California, Los Angeles, CA, United States
| | - Sidney Starkman
- Department of Neurology, UCLA Comprehensive Stroke Center, Los Angeles, CA, United States
| | - Samuel Stratton
- Department of Community Health Sciences, University of California, Los Angeles, Los Angeles, CA, United States
| | - Franklin D Pratt
- Los Angeles County Department of Public Health, Los Angeles, CA, United States
| | - Scott Hamilton
- Department of Neurology, Stanford Stroke Center, School of Medicine, Stanford University, Palo Alto, CA, United States
| | - May Kim-Tenser
- Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Robin Conwit
- National Institutes of Health, Bethesda, MD, United States
| | - Jeffrey L Saver
- Department of Neurology, UCLA Comprehensive Stroke Center, Los Angeles, CA, United States
| | - Nerses Sanossian
- Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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Lichtman JH, Leifheit EC, Wang Y, Goldstein LB. Hospital Quality Metrics: “America's Best Hospitals” and Outcomes After Ischemic Stroke. J Stroke Cerebrovasc Dis 2019; 28:430-434. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.10.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 10/03/2018] [Accepted: 10/13/2018] [Indexed: 11/27/2022] Open
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Pross C, Berger E, Siegel M, Geissler A, Busse R. Stroke units, certification, and outcomes in German hospitals: a longitudinal study of patient-based 30-day mortality for 2006-2014. BMC Health Serv Res 2018; 18:880. [PMID: 30466414 PMCID: PMC6249823 DOI: 10.1186/s12913-018-3664-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 10/30/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Treatment of stroke patients in stroke units has increased and studies have shown improved outcomes. However, a large share of patients in Germany is still treated in hospitals without stroke unit. The effects of stroke unit service line, and total hospital quality certification on outcomes remain unclear. METHODS We employ annual hospital panel data for 1100-1300 German hospitals from 2006 to 2014, which includes structural data and 30-day standardized mortality. We estimate hospital- and time-fixed effects regressions with three main independent variables: (1) stroke unit care, (2) stroke unit certification, and (3) total hospital quality certification. RESULTS Our results confirm the trend of decreasing stroke mortality ratios, although to a much lesser degree than previous studies. Descriptive analysis illustrates better stroke outcomes for non-certified and certified stroke units and hospitals with total hospital quality certification. In a fixed effects model, having a stroke unit has a significant quality-enhancing effect, lowering stroke mortality by 5.6%, while there is no significant improvement effect for stroke unit certification or total hospital quality certification. CONCLUSIONS Patients and health systems may benefit substantially from stroke unit treatment expansion as installing a stroke unit appears more meaningful than getting it certified or obtaining a total hospital quality certification. Health systems should thus prioritize investment in stroke unit infrastructure and centralize stroke care in stroke units. They should also prioritize patient-based 30-day mortality data as it allows a more realistic representation of mortality than admission-based data.
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Affiliation(s)
- Christoph Pross
- Department of Health Care Management, Berlin University of Technology, Administrative office H80, Str. des 17. Juni 135, 10623 Berlin, Germany
| | - Elke Berger
- Department of Health Care Management, Berlin University of Technology, Administrative office H80, Str. des 17. Juni 135, 10623 Berlin, Germany
| | - Martin Siegel
- Department of Empirical Health Economics, Berlin University of Technology, Berlin, Germany
| | - Alexander Geissler
- Department of Health Care Management, Berlin University of Technology, Administrative office H80, Str. des 17. Juni 135, 10623 Berlin, Germany
| | - Reinhard Busse
- Department of Health Care Management, Berlin University of Technology, Administrative office H80, Str. des 17. Juni 135, 10623 Berlin, Germany
- European Observatory on Health Systems and Policies, Brussels, Belgium
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Lam MB, Figueroa JF, Feyman Y, Reimold KE, Orav EJ, Jha AK. Association between patient outcomes and accreditation in US hospitals: observational study. BMJ 2018; 363:k4011. [PMID: 30337294 PMCID: PMC6193202 DOI: 10.1136/bmj.k4011] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2018] [Indexed: 12/04/2022]
Abstract
OBJECTIVES To determine whether patients admitted to US hospitals that are accredited have better outcomes than those admitted to hospitals reviewed through state surveys, and whether accreditation by The Joint Commission (the largest and most well known accrediting body with an international presence) confers any additional benefits for patients compared with other independent accrediting organizations. DESIGN Observational study. SETTING 4400 hospitals in the United States, of which 3337 were accredited (2847 by The Joint Commission) and 1063 underwent state based review between 2014 and 2017. PARTICIPANTS 4 242 684 patients aged 65 years and older admitted for 15 common medical and six common surgical conditions and survey respondents of the Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS). MAIN OUTCOME MEASURES Risk adjusted mortality and readmission rates at 30 days and HCAHPS patient experience scores. Hospital admissions were identified from Medicare inpatient files for 2014, and accreditation information was obtained from the Centers for Medicare and Medicaid Services and The Joint Commission. RESULTS Patients treated at accredited hospitals had lower 30 day mortality rates (although not statistically significant lower rates, based on the prespecified P value threshold) than those at hospitals that were reviewed by a state survey agency (10.2% v 10.6%, difference 0.4% (95% confidence interval 0.1% to 0.8%), P=0.03), but nearly identical rates of mortality for the six surgical conditions (2.4% v 2.4%, 0.0% (-0.3% to 0.3%), P=0.99). Readmissions for the 15 medical conditions at 30 days were significantly lower at accredited hospitals than at state survey hospitals (22.4% v 23.2%, 0.8% (0.4% to 1.3%), P<0.001) but did not differ for the surgical conditions (15.9% v 15.6%, 0.3% (-1.2% to 1.6%), P=0.75). No statistically significant differences were seen in 30 day mortality or readmission rates (for both the medical or surgical conditions) between hospitals accredited by The Joint Commission and those accredited by other independent organizations. Patient experience scores were modestly better at state survey hospitals than at accredited hospitals (summary star rating 3.4 v 3.2, 0.2 (0.1 to 0.3), P<0.001). Among accredited hospitals, The Joint Commission did not have significantly different patient experience scores compared to other independent organizations (3.1 v 3.2, 0.1 (-0.003 to 0.2), P=0.06). CONCLUSIONS US hospital accreditation by independent organizations is not associated with lower mortality, and is only slightly associated with reduced readmission rates for the 15 common medical conditions selected in this study. There was no evidence in this study to indicate that patients choosing a hospital accredited by The Joint Commission confer any healthcare benefits over choosing a hospital accredited by another independent accrediting organization.
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Affiliation(s)
- Miranda B Lam
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana Farber Cancer Institute, Boston, MA, USA
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA 02115, USA
| | - Jose F Figueroa
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Yevgeniy Feyman
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA 02115, USA
| | - Kimberly E Reimold
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA 02115, USA
| | - E John Orav
- Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Ashish K Jha
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA 02115, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Kriegel J, Riedl A, Tuttle-Weidinger L, Stöbich AM. Future strategic topics in the business model of hospitals in Austria. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2018. [DOI: 10.1080/20479700.2018.1429234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Johannes Kriegel
- Fakultät für Gesundheit und Soziales, FH-OÖ Studienbetriebs GmbH, Linz, Austria
| | - Anton Riedl
- University of Applied Sciences Upper Austria, School of Applied Health and Social Sciences, Linz, Austria
| | - Linda Tuttle-Weidinger
- University of Applied Sciences Upper Austria, School of Applied Health and Social Sciences, Linz, Austria
| | - Anna-Maria Stöbich
- University of Applied Sciences Upper Austria, School of Applied Health and Social Sciences, Linz, Austria
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Man S, Schold JD, Uchino K. Impact of Stroke Center Certification on Mortality After Ischemic Stroke. Stroke 2017; 48:2527-2533. [DOI: 10.1161/strokeaha.116.016473] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 06/10/2017] [Accepted: 06/21/2017] [Indexed: 12/30/2022]
Affiliation(s)
- Shumei Man
- From the Clinical Neuroscience Institute, Miami Valley Hospital, Wright State University Boonshoft School of Medicine Dayton, OH (S.M.); Department of Quantitative Health Sciences, Cleveland Clinic, OH (J.D.S.); and Cerebrovascular Center, Neurological Institute, Cleveland Clinic, OH (K.U.)
| | - Jesse D. Schold
- From the Clinical Neuroscience Institute, Miami Valley Hospital, Wright State University Boonshoft School of Medicine Dayton, OH (S.M.); Department of Quantitative Health Sciences, Cleveland Clinic, OH (J.D.S.); and Cerebrovascular Center, Neurological Institute, Cleveland Clinic, OH (K.U.)
| | - Ken Uchino
- From the Clinical Neuroscience Institute, Miami Valley Hospital, Wright State University Boonshoft School of Medicine Dayton, OH (S.M.); Department of Quantitative Health Sciences, Cleveland Clinic, OH (J.D.S.); and Cerebrovascular Center, Neurological Institute, Cleveland Clinic, OH (K.U.)
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Lilly FR, Culpepper J, Stuart M, Steinwachs D. Stroke survivors with severe mental illness: Are they at-risk for increased non-psychiatric hospitalizations? PLoS One 2017; 12:e0182330. [PMID: 28800605 PMCID: PMC5553814 DOI: 10.1371/journal.pone.0182330] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 07/17/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND This study examined outcomes for two groups of stroke survivors treated in Veteran Health Administration (VHA) hospitals, those with a severe mental illness (SMI) and those without prior psychiatric diagnoses, to examine risk of non-psychiatric medical hospitalizations over five years after initial stroke. METHODS This retrospective cohort study included 523 veterans who survived an initial stroke hospitalization in a VHA medical center during fiscal year 2003. The survivors were followed using administrative data documenting inpatient stroke treatment, patient demographics, disease comorbidities, and VHA hospital admissions. Multivariate Poisson regression was used to examine the relationship between patients with and without SMI diagnosis preceding the stroke and their experience with non-psychiatric medical hospitalizations after the stroke. RESULTS The study included 100 patients with SMI and 423 without SMI. Unadjusted means for pre-stroke non-psychiatric hospitalizations were higher (p = 0.0004) among SMI patients (1.47 ± 0.51) compared to those without SMI (1.00 ± 1.33), a difference which persisted through the first year post-stroke (SMI: 2.33 ± 2.46; No SMI: 1.74 ± 1.86; p = 0.0004). Number of non-psychiatric hospitalizations were not significantly different between the two groups after adjustment for patient sociodemographic, comorbidity, length of stay and inpatient stroke treatment characteristics. Antithrombotic medications significantly lowered risk (OR = 0.61; 95% CI: 0.49-0.73) for stroke-related readmission within 30 days of discharge. CONCLUSIONS No significant differences in medical hospitalizations were present after adjusting for comorbid and sociodemographic characteristics between SMI and non-SMI stroke patients in the five-year follow-up. However, unadjusted results continue to draw attention to disparities, with SMI patients experiencing more non-psychiatric hospitalizations both prior to and up to one year after their initial stroke. Additionally, stroke survivors discharged on antithrombotic medications were at lower risk of re-admission within 30 days suggesting the VHA should continue to focus on effective stroke management irrespective of SMI.
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Affiliation(s)
- Flavius Robert Lilly
- Graduate School, University of Maryland, Baltimore, Maryland, United States of America
| | - Joel Culpepper
- Veterans Affairs Maryland Health Care System, Baltimore, Maryland, United States of America
| | - Mary Stuart
- Department of Sociology, Anthropology, and Health Administration and Policy, University of Maryland, Baltimore County, Baltimore, Maryland, United States of America
| | - Donald Steinwachs
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Musallam E, Johantgen M, Connerney I. Hospital Disease-Specific Care Certification Programs and Quality of Care: A Narrative Review. Jt Comm J Qual Patient Saf 2017; 42:364-8. [PMID: 27456418 DOI: 10.1016/s1553-7250(16)42051-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Disease-specific care certification (DSCC) programs have been developed to improve the quality and performance of programs or services that may be based within or associated with a hospital or other health care organization. A comprehensive summary of evidence for DSCC programs and their reported effect on the quality of care was prepared in a narrative review, the first of its kind on this topic. METHODS A systematic search was performed to identify articles that reported about DSCC. Any article that reported DSCC and certifications, published between 2003 and August 2015 (with an update in March 2016), and conducted in the United States was included. Databases searched included PubMed, MEDLINE, and CINAHL. RESULTS The articles were reviewed in terms of four topics: early development of DSCC, the journey toward DSCC, the relationship between DSCC and organizing process of care, and the relationship between DSCC and outcomes of care. Fifteen articles noted a positive relationship between DSCC programs and quality of care, only 6 of which reported empirical data. Therefore, a systematic review and meta-analysis were not warranted. Only 3 articles involved use of sophisticated statistical modeling with adequate control variables to investigate the effect of DSCC, which makes it difficult to conclude that the change in hospitals' or patients' outcomes were related to the certification. CONCLUSIONS The majority (13) of the articles focused on Joint Commission DSCC, with the remaining assessing Society of Cardiovascular Patient Care "accreditation" (certification). Only two studies, each study using a cross-sectional design, that empirically examined the relationship between DSCC and outcomes of care-mortality of care and readmission. More research studies are needed to evaluate the effectiveness of DSCC programs in improving outcomes of care, particularly patient-centered outcome measures, such as patient satisfaction and self-care.
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Affiliation(s)
- Eyad Musallam
- Center for Health Outcomes Research, School of Nursing, University of Maryland, Baltimore, USA
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Alberts MJ, Range J, Spencer W, Cantwell V, Hampel MJ. Availability of endovascular therapies for cerebrovascular disease at primary stroke centers. Interv Neuroradiol 2016; 23:64-68. [PMID: 27895242 DOI: 10.1177/1591019916678199] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background Endovascular therapies (EVTs) are useful for treating cerebrovascular disease. There are few data about the availability of such services at primary stroke centers (PSCs). Our hypothesis was that some of these services may be available at some PSCs. Methods We conducted an internet-based survey of hospitals certified as PSCs by the Joint Commission. The survey inquired about EVTs such as intra-arterial (IA) lytics, IA mechanical clot removal, coiling of aneurysms, and cervical arterial stenting, physician training, coverage models, hospital type, and outcomes. Chi-square analyses were used to detect differences between academic and community PSCs. Results Data were available from 352 PSCs, of which 75% were community hospitals, 23% academic medical centers, and 80% were non-profit; almost half (48%) see 300 or more patients annually with ischemic stroke. A majority (60%) provided some or all EVTs on site, while 29% had none on site and no plans to add them. Among the respondents offering EVTs, 95% offered stenting of neck vessels, 86% IA lytics, 80% IA mechanical, and 74% aneurysm coiling. The majority (>55%) that did offer such services provided them 24/7/365. Most endovascular coverage was provided by interventional neuroradiologists (60%), fellowship trained endovascular neurosurgeons (42%), and interventional radiologists (41%). The majority of hospitals (81%) did not participate in an audited national registry. Conclusions A variety of EVT services are offered at many PSCs by interventionalists with diverse types of training. The availability of such services is clinically relevant now with the proven efficacy of mechanical thrombectomy for ischemic stroke.
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Affiliation(s)
- Mark J Alberts
- 1 UT Southwestern Medical Center, Department of Neurology and Neurotherapeutics, USA
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Le ST, Josephson SA, Puttgen HA, Gibson L, Guterman EL, Leicester HM, Graf CL, Probasco JC. Many Neurology Readmissions Are Nonpreventable. Neurohospitalist 2016; 7:61-69. [PMID: 28400898 DOI: 10.1177/1941874416674409] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Reducing unplanned hospital readmissions has become a national focus due to the Centers for Medicare and Medicaid Services' (CMS) penalties for hospitals with high rates. A first step in reducing unplanned readmission is to understand which patients are at high risk for readmission, which readmissions are planned, and how well planned readmissions are currently captured in comparison to patient-level chart review. METHODS We examined all 5455 inpatient neurology admissions over a 2-year period to University of California San Francisco Medical Center and Johns Hopkins Hospital via chart review. We collected information such as patient age, procedure codes, diagnosis codes, all-payer diagnosis-related group, observed length of stay (oLOS), and expected length of stay. We performed multivariate logistic modeling to determine predictors of readmission. Discharge summaries were reviewed for evidence that a subsequent readmission was planned. RESULTS A total of 353 (6.5%) discharges were readmitted within 30 days. Fifty-five (15.6%) of the 353 readmissions were planned, most often for a neurosurgical procedure (41.8%) or immunotherapy (23.6%). Only 8 of these readmissions would have been classified as planned using current CMS methodology. Patient age (odds ratio [OR] = 1.01 for each 10-year increase, P < .001) and estimated length of stay (OR = 1.04, P = .002) were associated with a greater likelihood of readmission, whereas index admission oLOS was not. CONCLUSIONS Many neurologic readmissions are planned; however, these are often classified by current CMS methodology as unplanned and penalized accordingly. Modifications of the CMS lists for potentially planned neurological and neurosurgical procedures and for acute discharge neurologic diagnoses should be considered.
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Affiliation(s)
- Sidney T Le
- University of California San Francisco, San Francisco, CA, USA
| | | | - Hans A Puttgen
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lorrie Gibson
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elan L Guterman
- University of California San Francisco, San Francisco, CA, USA
| | | | - Carla L Graf
- University of California San Francisco, San Francisco, CA, USA
| | - John C Probasco
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Rivkin MJ, Bernard TJ, Dowling MM, Amlie-Lefond C. Guidelines for Urgent Management of Stroke in Children. Pediatr Neurol 2016; 56:8-17. [PMID: 26969237 DOI: 10.1016/j.pediatrneurol.2016.01.016] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 01/18/2016] [Indexed: 01/09/2023]
Abstract
Stroke in children carries lasting morbidity. Once recognized, it is important to evaluate and treat children with acute stroke efficiently and accurately. All children should receive neuroprotective measures. It is reasonable to consider treatment with advanced thrombolytic and endovascular agents. Delivery of such care requires purposeful institutional planning and organization in pediatric acute care centers. Primary stroke centers established for adults provide an example of the multidisciplinary approach that can be applied to the evaluation and treatment of children who present with acute stroke. The organizational infrastructure of these centers can be employed and adapted for treatment of children with acute stroke. It is likely that care for children with acute stroke can best be delivered by regional pediatric primary stroke centers dedicated to the care of children with pediatric stroke.
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Affiliation(s)
- Michael J Rivkin
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts; Department of Psychiatry, Boston Children's Hospital, Boston, Massachusetts; Department of Radiology, Boston Children's Hospital, Boston, Massachusetts; Department of Neurology, Harvard Medical School, Boston, Massachusetts.
| | - Timothy J Bernard
- Department of Pediatrics, Hemophilia and Thrombosis Center, Aurora, Colorado; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Michael M Dowling
- Division of Pediatric Neurology, University of Texas Southwestern Medical Center Dallas, Dallas, Texas; Department of Pediatrics, University of Texas Southwestern Medical Center Dallas, Dallas, Texas; Department of Neurology, University of Texas Southwestern Medical Center Dallas, Dallas, Texas
| | - Catherine Amlie-Lefond
- Department of Neurology, Seattle Children's Hospital, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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Roberson S, Dutton M, Macdonald M, Odoi A. Does Place of Residence or Time of Year Affect the Risk of Stroke Hospitalization and Death? A Descriptive Spatial and Temporal Epidemiologic Study. PLoS One 2016; 11:e0145224. [PMID: 26799559 PMCID: PMC4723130 DOI: 10.1371/journal.pone.0145224] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 11/30/2015] [Indexed: 11/18/2022] Open
Abstract
Background Identifying geographic areas with significantly high risks of stroke is important for informing public health prevention and control efforts. The objective of this study was to investigate geographic and temporal patterns of stroke hospitalization and mortality risks so as to identify areas and seasons with significantly high burden of the disease in Florida. The information obtained will be useful for resource allocation for disease prevention and control. Methods Stroke hospitalization and mortality data from 1992 to 2012 were obtained from the Florida Agency for Health Care Administration. Age-adjusted stroke hospitalization and mortality risks for time periods 1992–94, 1995–97, 1998–2000, 2001–03, 2004–06, 2007–09 and 2010–12 were computed at the county spatial scale. Global Moran’s I statistics were computed for each of the time periods to test for evidence of global spatial clustering. Local Moran indicators of spatial association (LISA) were also computed to identify local areas with significantly high risks. Results There were approximately 1.5 million stroke hospitalizations and over 196,000 stroke deaths during the study period. Based on global Moran’s I tests, there was evidence of significant (p<0.05) global spatial clustering of stroke mortality risks but no evidence (p>0.05) of significant global clustering of stroke hospitalization risks. However, LISA showed evidence of local spatial clusters of both hospitalization and mortality risks with significantly high risks being observed in the north while the south had significantly low risks of stroke deaths. There were decreasing temporal trends and seasonal patterns of both hospitalization and mortality risks with peaks in the winter. Conclusions Although stroke hospitalization and mortality risks have declined in the past two decades, disparities continue to exist across Florida and it is evident from the results of this study that north Florida may, in fact, be part of the stroke belt despite not being in any of the traditional stroke belt states. These findings are useful for guiding public health efforts to reduce/eliminate inequities in stroke outcomes and inform policy decisions. There is need to continually identify populations with significantly high risks of stroke to better guide the targeting of limited resources to the highest risk populations.
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Affiliation(s)
- Shamarial Roberson
- Florida Department of Health, Bureau of Chronic Disease Prevention, Tallahassee, Florida, United States of America
| | - Matthew Dutton
- Florida Agricultural and Mechanical University, Tallahassee, Florida, United States of America
| | - Megan Macdonald
- Florida Department of Health, Bureau of Chronic Disease Prevention, Tallahassee, Florida, United States of America
| | - Agricola Odoi
- University of Tennessee, Knoxville, Tennessee, United States of America
- * E-mail:
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Ballard DW, Kim AS, Huang J, Park DK, Kene MV, Chettipally UK, Iskin HR, Hsu J, Vinson DR, Mark DG, Reed ME. Implementation of Computerized Physician Order Entry Is Associated With Increased Thrombolytic Administration for Emergency Department Patients With Acute Ischemic Stroke. Ann Emerg Med 2015; 66:601-10. [PMID: 26362574 PMCID: PMC5111545 DOI: 10.1016/j.annemergmed.2015.07.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 06/16/2015] [Accepted: 07/07/2015] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE Electronic health record systems with computerized physician order entry and condition-specific order sets are intended to standardize patient management and minimize errors of omission. However, the effect of these systems on disease-specific process measures and patient outcomes is not well established. We seek to evaluate the effect of computerized physician order entry electronic health record implementation on process measures and short-term health outcomes for patients hospitalized with acute ischemic stroke. METHODS We conducted a quasi-experimental cohort study of patients hospitalized for acute ischemic stroke with concurrent controls that took advantage of the staggered implementation of a comprehensive computerized physician order entry electronic health record across 16 medical centers within an integrated health care delivery system from 2007 to 2012. The study population included all patients admitted to the hospital from the emergency department (ED) for acute ischemic stroke, with an initial neuroimaging study within 2.5 hours of ED arrival. We evaluated the association between the availability of a computerized physician order entry electronic health record and the rates of ED intravenous tissue plasminogen activator administration, hospital-acquired pneumonia, and inhospital and 90-day mortality, using doubly robust estimation models to adjust for demographics, comorbidities, secular trends, and concurrent primary stroke center certification status at each center. RESULTS Of 10,081 eligible patients, 6,686 (66.3%) were treated in centers after the computerized physician order entry electronic health record had been implemented. Computerized physician order entry was associated with significantly higher rates of intravenous tissue plasminogen activator administration (rate difference 3.4%; 95% confidence interval 0.8% to 6.0%) but not with significant rate differences in pneumonia or mortality. CONCLUSION For patients hospitalized for acute ischemic stroke, computerized physician order entry use was associated with increased use of intravenous tissue plasminogen activator.
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Affiliation(s)
- Dustin W Ballard
- Kaiser Permanente San Rafael Medical Center, San Rafael, CA; Kaiser Permanente Division of Research, Oakland, CA.
| | - Anthony S Kim
- Department of Neurology, University of California at San Francisco, San Francisco, CA
| | - Jie Huang
- Kaiser Permanente Division of Research, Oakland, CA
| | - David K Park
- Kaiser Permanente San Leandro Medical Center, San Leandro, CA
| | - Mamata V Kene
- Kaiser Permanente San Leandro Medical Center, San Leandro, CA
| | - Uli K Chettipally
- Kaiser Permanente South San Francisco Medical Center, South San Francisco, CA
| | | | - John Hsu
- Mongan Institute for Health Policy, Massachusetts General Hospital, Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - David R Vinson
- Kaiser Permanente Division of Research, Oakland, CA; Kaiser Permanente Roseville Medical Center, Roseville, CA
| | - Dustin G Mark
- Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Mary E Reed
- Kaiser Permanente Division of Research, Oakland, CA
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de Havenon A, Sultan-Qurraie A, Hannon P, Tirschwell D. Development of regional stroke programs. Curr Neurol Neurosci Rep 2015; 15:544. [PMID: 25763758 DOI: 10.1007/s11910-015-0544-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The organization of stroke care has undergone a dramatic evolution in the USA over the last two decades. Beginning with the recommendation for Primary Stroke Centers (PSCs) in 1994, there has been a concerted effort by physicians, the American Heart Association/American Stroke Association (AHA/ASA), National Institutes of Health (NIH), and state legislatures to advance an evidence-based system of care with several tiers of stroke centers. At the apex of this structure are Regional Stroke Centers (RSCs), which do not have official recognition like PSCs and Comprehensive Stroke Centers (CSCs), but their existence as a hub for the many disparate spokes of stroke care in their region is increasingly necessary. Observational evidence suggests that this approach is improving the delivery of stroke care and reducing costs in the USA. Similar efforts are being made in Europe and Asia with encouraging results. The RSC model has the potential to lead to more uniform evidence-based stroke medicine, but many challenges exist.
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Affiliation(s)
- Adam de Havenon
- Department of Neurology, University of Utah, 175 N. Medical Dr, Salt Lake City, UT, 84132, USA,
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Rhudy JP, Bakitas MA, Hyrkäs K, Jablonski-Jaudon RA, Pryor ER, Wang HE, Alexandrov AW. Effectiveness of regionalized systems for stroke and myocardial infarction. Brain Behav 2015; 5:e00398. [PMID: 26516616 PMCID: PMC4614047 DOI: 10.1002/brb3.398] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 07/18/2015] [Accepted: 08/16/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Acute ischemic stroke (AIS) and ST-segment elevation myocardial infarction (STEMI) are ischemic emergencies. Guidelines recommend care delivery within formally regionalized systems of care at designated centers, with bypass of nearby centers of lesser or no designation. We review the evidence of the effectiveness of regionalized systems in AIS and STEMI. METHODS Literature was searched using terms corresponding to designation of AIS and STEMI systems and from 2010 to the present. Inclusion criteria included report of an outcome on any dependent variable mentioned in the rationale for regionalization in the guidelines and an independent variable comparing care to a non- or pre-regionalized system. Designation was defined in the AIS case as certification by the Joint Commission as either a primary (PSC) or comprehensive (CSC) stroke center. In the STEMI case, the search was conducted linking "regionalization" and "myocardial infarction" or citation as a model system by any American Heart Association statement. RESULTS For AIS, 17 publications met these criteria and were selected for review. In the STEMI case, four publications met these criteria; the search was therefore expanded by relaxing the criteria to include any historical or anecdotal comparison to a pre- or nonregionalized state. The final yield was nine papers from six systems. CONCLUSION Although regionalized care results in enhanced process and reduced unadjusted rates of disparity in access and adverse outcomes, these differences tend to become nonsignificant when adjusted for delayed presentation and hospital arrival by means other than emergency medical services. The benefits of regionalized care occur along with a temporal trend of improvement due to uptake of quality initiatives and guideline recommendations by all systems regardless of designation. Further research is justified with a randomized registry or cluster randomized design to support or refute recommendations that regionalization should be the standard of care.
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Affiliation(s)
- James P Rhudy
- School of Nursing University of Alabama at Birmingham Alabama
| | - Marie A Bakitas
- School of Nursing University of Alabama at Birmingham Alabama
| | - Kristiina Hyrkäs
- Center for Nursing Research and Quality Outcomes Maine Medical Center Birmingham Alabama
| | | | - Erica R Pryor
- School of Nursing University of Alabama at Birmingham Alabama
| | - Henry E Wang
- Department of Emergency Medicine University of Alabama at Birmingham Birmingham Alabama
| | - Anne W Alexandrov
- College of Nursing University of Tennessee Health Sciences Center Memphis Tennessee
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Fehnel CR, Lee Y, Wendell LC, Thompson BB, Potter NS, Mor V. Post-Acute Care Data for Predicting Readmission After Ischemic Stroke: A Nationwide Cohort Analysis Using the Minimum Data Set. J Am Heart Assoc 2015; 4:e002145. [PMID: 26396202 PMCID: PMC4599502 DOI: 10.1161/jaha.115.002145] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [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 Reducing hospital readmissions is a key component of reforms for stroke care. Current readmission prediction models lack accuracy and are limited by data being from only acute hospitalizations. We hypothesized that patient-level factors from a nationwide post-acute care database would improve prediction modeling. METHODS AND RESULTS Medicare inpatient claims for the year 2008 that used International Classification of Diseases, Ninth Revision codes were used to identify ischemic stroke patients older than age 65. Unique individuals were linked to comprehensive post-acute care assessments through use of the Minimum Data Set (MDS). Logistic regression was used to construct risk-adjusted readmission models. Covariates were derived from MDS variables. Among 39 178 patients directly admitted to nursing homes after hospitalization due to acute stroke, there were 29 338 (75%) with complete MDS assessments. Crude rates of readmission and death at 30 days were 8448 (21%) and 2791 (7%), respectively. Risk-adjusted models identified multiple independent predictors of all-cause 30-day readmission. Model performance of the readmission model using MDS data had a c-statistic of 0.65 (95% CI 0.64 to 0.66). Higher levels of social engagement, a marker of nursing home quality, were associated with progressively lower odds of readmission (odds ratio 0.71, 95% CI 0.55 to 0.92). CONCLUSIONS Individual clinical characteristics from the post-acute care setting resulted in only modest improvement in the c-statistic relative to previous models that used only Medicare Part A data. Individual-level characteristics do not sufficiently account for the risk of acute hospital readmission.
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Affiliation(s)
- Corey R Fehnel
- Division of Neurocritical Care, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI (C.R.F., L.C.W., B.B.T., S.P.)
| | - Yoojin Lee
- Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (Y.L., V.M.)
| | - Linda C Wendell
- Division of Neurocritical Care, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI (C.R.F., L.C.W., B.B.T., S.P.)
| | - Bradford B Thompson
- Division of Neurocritical Care, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI (C.R.F., L.C.W., B.B.T., S.P.)
| | - N Stevenson Potter
- Division of Neurocritical Care, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI (C.R.F., L.C.W., B.B.T., S.P.)
| | - Vincent Mor
- Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (Y.L., V.M.)
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Uchino K, Man S, Schold JD, Katzan IL. Stroke Legislation Impacts Distribution of Certified Stroke Centers in the United States. Stroke 2015; 46:1903-8. [PMID: 26089328 DOI: 10.1161/strokeaha.114.008007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The number of certified primary stroke centers (PSCs) have increased dramatically during the past decade in the United States We aimed to understand the factors affecting PSC distribution in the United States, including the impact of state stroke legislation. METHODS PSCs certified by national organization or state until December 2013 were searched from available databases. The proportion of PSC among short-term general hospitals in each state was calculated and factors affecting its distribution were analyzed. RESULTS By the end of 2013, the proportion of PSC varied from 4% to 100% among the 50 states and District of Columbia. The 18 states that had legislation in designating stroke centers and regulating stroke triage had higher PSC percentages (median, 43%; range, 13%-100%) than the remaining states (median, 13%; range, 4%-75%; P<0.001). State stroke legislation, urbanization, state economic output, and larger hospital size independently increased the likelihood of a hospital to be stroke certified. From 2009 to 2013, states with stroke legislation had greater increase of PSC percentages when compared with the states without legislation (median increase, 16% versus 6%; P=0.0067). Among the 1505 stroke centers, 74% were certified by the Joint Commission, 20% by state, and 6% by other organizations. Stroke centers certified only by state were smaller in size by hospital bed count compared with those certified by the Joint Commission (P<0.001). CONCLUSIONS State stroke legislation, a generalizable intervention, increased the number of certified stroke centers in the United States, potentially improving accessibility of standardized care for patients with acute ischemic stroke.
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Affiliation(s)
- Ken Uchino
- From the Cerebrovascular Center, Neurological Insitute (K.U., S.M., I.L.K.) and Department of Quantitative Health Sciences (J.D.S.), Cleveland Clinic, OH.
| | - Shumei Man
- From the Cerebrovascular Center, Neurological Insitute (K.U., S.M., I.L.K.) and Department of Quantitative Health Sciences (J.D.S.), Cleveland Clinic, OH
| | - Jesse D Schold
- From the Cerebrovascular Center, Neurological Insitute (K.U., S.M., I.L.K.) and Department of Quantitative Health Sciences (J.D.S.), Cleveland Clinic, OH
| | - Irene L Katzan
- From the Cerebrovascular Center, Neurological Insitute (K.U., S.M., I.L.K.) and Department of Quantitative Health Sciences (J.D.S.), Cleveland Clinic, OH
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Brubakk K, Vist GE, Bukholm G, Barach P, Tjomsland O. A systematic review of hospital accreditation: the challenges of measuring complex intervention effects. BMC Health Serv Res 2015. [PMID: 26202068 PMCID: PMC4511980 DOI: 10.1186/s12913-015-0933-x] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background The increased international focus on improving patient outcomes, safety and quality of care has led stakeholders, policy makers and healthcare provider organizations to adopt standardized processes for evaluating healthcare organizations. Accreditation and certification have been proposed as interventions to support patient safety and high quality healthcare. Guidelines recommend accreditation but are cautious about the evidence, judged as inconclusive. The push for accreditation continues despite sparse evidence to support its efficiency or effectiveness. Methods We searched MEDLINE, EMBASE and The Cochrane Library using Medical Subject Headings (MeSH) indexes and keyword searches in any language. Studies were assessed using the Cochrane Risk of Bias Tool and AMSTAR framework. 915 abstracts were screened and 20 papers were reviewed in full in January 2013. Inclusion criteria included studies addressing the effect of hospital accreditation and certification using systematic reviews, randomized controlled trials, observational studies with a control group, or interrupted time series. Outcomes included both clinical outcomes and process measures. An updated literature search in July 2014 identified no new studies. Results The literature review uncovered three systematic reviews and one randomized controlled trial. The lone study assessed the effects of accreditation on hospital outcomes and reported inconsistent results. Excluded studies were reviewed and their findings summarized. Conclusion Accreditation continues to grow internationally but due to scant evidence, no conclusions could be reached to support its effectiveness. Our review did not find evidence to support accreditation and certification of hospitals being linked to measurable changes in quality of care as measured by quality metrics and standards. Most studies did not report intervention context, implementation, or cost. This might reflect the challenges in assessing complex, heterogeneous interventions such as accreditation and certification. It is also may be magnified by the impact of how accreditation is managed and executed, and the varied financial and organizational healthcare constraints. The strategies hospitals should impelment to improve patient safety and organizational outcomes related to accreditation and certification components remains unclear. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-0933-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kirsten Brubakk
- South-Eastern Norway Regional Health Authority, Hamar, Norway.
| | - Gunn E Vist
- Prevention, Health promotion and Organization Unit, Norwegian Knowledge Centre for the Healthcare Services, Oslo, Norway.
| | - Geir Bukholm
- Norwegian Institute of Public Health, Oslo, Norway.
| | - Paul Barach
- Wayne State University School of Medicine, Michigan, USA.
| | - Ole Tjomsland
- Department of Medicine and Health, South-Eastern Norway Regional Health Authority, Hamar, Norway.
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Skolarus LE, Meurer WJ, Shanmugasundaram K, Adelman EE, Scott PA, Burke JF. Marked Regional Variation in Acute Stroke Treatment Among Medicare Beneficiaries. Stroke 2015; 46:1890-6. [PMID: 26038520 DOI: 10.1161/strokeaha.115.009163] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 04/29/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Little is known about how regions vary in their use of thrombolysis (intravenous tissue-type plasminogen activator and intra-arterial treatment) for acute stroke. We sought to determine regional variation in thrombolysis treatment and investigate the extent to which regional variation is accounted for by patient demographics, regional factors, and elements of stroke systems of care. METHODS Retrospective cross-sectional study of all fee-for-service Medicare patients with ischemic stroke admitted via the Emergency Department from 2007 to 2010 who were assigned to 1 of 3436 hospital service areas. Multilevel logistic regression was used to estimate regional thrombolysis rates, determine the variation in thrombolysis treatment attributable to the region and estimate thrombolysis treatment rates and disability prevented under varied improvement scenarios. RESULTS There were 844 241 ischemic stroke admissions of which 3.7% received intravenous tissue-type plasminogen activator and 0.5% received intra-arterial stroke treatment without or without intravenous tissue-type plasminogen activator over the 4-year period. The unadjusted proportion of patients with ischemic stroke who received thrombolysis varied from 9.3% in the highest treatment quintile compared with 0% in the lowest treatment quintile. Measured demographic and stroke system factors were weakly associated with treatment rates. Region accounted for 7% to 8% of the variation in receipt of thrombolysis treatment. If all regions performed at the level of 75th percentile region, ≈7000 additional patients with ischemic stroke would be treated with thrombolysis. CONCLUSIONS There is substantial regional variation in thrombolysis treatment. Future studies to determine features of high-performing thrombolysis treatment regions may identify opportunities to improve thrombolysis rates.
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Affiliation(s)
- Lesli E Skolarus
- From the Stroke Program, University of Michigan, Ann Arbor (L.E.S., W.J.M., E.E.A., P.A.S., J.F.B.); Department of Emergency Medicine, Ann Arbor, MI (W.J.M., P.A.S.); and University of Michigan Medical School, Ann Arbor (K.S.)
| | - William J Meurer
- From the Stroke Program, University of Michigan, Ann Arbor (L.E.S., W.J.M., E.E.A., P.A.S., J.F.B.); Department of Emergency Medicine, Ann Arbor, MI (W.J.M., P.A.S.); and University of Michigan Medical School, Ann Arbor (K.S.)
| | - Krithika Shanmugasundaram
- From the Stroke Program, University of Michigan, Ann Arbor (L.E.S., W.J.M., E.E.A., P.A.S., J.F.B.); Department of Emergency Medicine, Ann Arbor, MI (W.J.M., P.A.S.); and University of Michigan Medical School, Ann Arbor (K.S.)
| | - Eric E Adelman
- From the Stroke Program, University of Michigan, Ann Arbor (L.E.S., W.J.M., E.E.A., P.A.S., J.F.B.); Department of Emergency Medicine, Ann Arbor, MI (W.J.M., P.A.S.); and University of Michigan Medical School, Ann Arbor (K.S.)
| | - Phillip A Scott
- From the Stroke Program, University of Michigan, Ann Arbor (L.E.S., W.J.M., E.E.A., P.A.S., J.F.B.); Department of Emergency Medicine, Ann Arbor, MI (W.J.M., P.A.S.); and University of Michigan Medical School, Ann Arbor (K.S.)
| | - James F Burke
- From the Stroke Program, University of Michigan, Ann Arbor (L.E.S., W.J.M., E.E.A., P.A.S., J.F.B.); Department of Emergency Medicine, Ann Arbor, MI (W.J.M., P.A.S.); and University of Michigan Medical School, Ann Arbor (K.S.).
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Falstie-Jensen AM, Larsson H, Hollnagel E, Norgaard M, Svendsen MLO, Johnsen SP. Compliance with hospital accreditation and patient mortality: a Danish nationwide population-based study. Int J Qual Health Care 2015; 27:165-74. [DOI: 10.1093/intqhc/mzv023] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2015] [Indexed: 01/15/2023] Open
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A Guideline for acute stroke: evaluation of New Jersey's practices. J Neurosci Nurs 2014; 46:E25-32. [PMID: 25365056 DOI: 10.1097/jnn.0000000000000099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to determine the effectiveness of processes and guidelines for the patient with acute stroke receiving care in New Jersey acute care hospitals in 2010. Lack of adherence to established protocols for acute ischemic stroke may significantly affect the outcomes of care. The lack of available literature providing evidence of prior practices for stroke care in the state of New Jersey precludes a comparison with current practices. This was a descriptive study utilizing an electronic survey developed by the researcher. A convenience sample was utilized for this study consisting of stroke healthcare professionals (N = 79) within the state of New Jersey. The survey yielded a response rate of 70%. Respondents provided information on level of education, average time in position, duties, issues impeding job performance, information related to hospital practices, and stroke core measure compliance within 30 days before the survey. Study results allow designated and nondesignated centers to address issues identified and change or revise protocols accordingly.
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Handschu R, Scibor M, Wacker A, Stark DR, Köhrmann M, Erbguth F, Oschmann P, Schwab S, Marquardt L. Feasibility of Certified Quality Management in a Comprehensive Stroke Care Network Using Telemedicine: STENO Project. Int J Stroke 2014; 9:1011-6. [DOI: 10.1111/ijs.12342] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 05/20/2014] [Indexed: 01/30/2023]
Abstract
Background Stroke care networks with and without telemedicine have been established in several countries over the last decade to provide specialized stroke expertise to patients in rural areas. Acute consultation is a first step in the management of stroke, but not the only one. Methods of standardization of care and treatment are much needed. So far, quality management systems have only been used for single stroke units. To the best of our knowledge, we are the first stroke network worldwide to aim for certification of a network-wide quality management system. Methods The Stroke Network Using Telemedicine in Northern Bavaria (STENO), currently with 20 associated medical institutions, is one of the world's largest stroke networks, caring for over 5000 stroke patients each year. In 2010, we initiated the implementation of a network-wide ‘total’ quality management system according to ISO standard 9001:2008 in cooperation with the German Stroke Society and a third-party certification organization (LGA InterCert). Results Certification according to ISO 9001:2008 was awarded in March 2011 and maintained over a complete certification cycle of 3 years without major deviation from the norm in three external third-party audits. Thrombolysis rate significantly increased from 8·2% (2009) to 12·8% (2012). Conclusions Certified quality management within a large stroke network using telemedicine is possible and might improve stroke care procedures and thrombolysis rates. Outcome studies comparing conventional stroke care and telestroke care are inevitable.
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Affiliation(s)
- René Handschu
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
- Department of Neurology, Klinikum Neumarkt, Neumarkt, Germany
| | - Mateusz Scibor
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Angela Wacker
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - David R. Stark
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Martin Köhrmann
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Frank Erbguth
- Department of Neurology, Nuremberg Municipal Academic Hospital, Nuremberg, Germany
| | - Patrick Oschmann
- Department of Neurology, Klinikum Hohe Warte Bayreuth, Bayreuth, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Lars Marquardt
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
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Rubin MN, Wellik KE, Channer DD, Demaerschalk BM. Systematic review of telestroke for post-stroke care and rehabilitation. Curr Atheroscler Rep 2014; 15:343. [PMID: 23761014 DOI: 10.1007/s11883-013-0343-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Telemedicine for acute stroke care is supported by a literature base. It remains unclear whether or not the use of telemedicine for other phases of stroke care is beneficial. The authors conducted a systematic review of the published literature on telemedicine for the purposes of providing post-stroke care. Studies were included if the title or abstract expressed use of two-way audio/video communication for post-stroke care. From an initial yield of 1,405 potentially eligible hits, two reviewers ultimately identified 24 unique manuscripts to undergo functionality, application, technology, and evaluative (F.A.T.E.) scoring. Each article was classified using a scoring rubric to assess the functionality, application, technology, and evaluative stage. It was found that most post-stroke telemedicine studies evaluated rehabilitation of adults. All primary data manuscripts were small and preliminary in scope and evaluative phase, and median F.A.T.E. score for primary data was 2. The use of telemedicine for post-stroke care is nascent and is primarily focused on post-stroke rehabilitation.
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Affiliation(s)
- Mark N Rubin
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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Katzan IL, Spertus J, Bettger JP, Bravata DM, Reeves MJ, Smith EE, Bushnell C, Higashida RT, Hinchey JA, Holloway RG, Howard G, King RB, Krumholz HM, Lutz BJ, Yeh RW. Risk adjustment of ischemic stroke outcomes for comparing hospital performance: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:918-44. [PMID: 24457296 DOI: 10.1161/01.str.0000441948.35804.77] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Stroke is the fourth-leading cause of death and a leading cause of long-term major disability in the United States. Measuring outcomes after stroke has important policy implications. The primary goals of this consensus statement are to (1) review statistical considerations when evaluating models that define hospital performance in providing stroke care; (2) discuss the benefits, limitations, and potential unintended consequences of using various outcome measures when evaluating the quality of ischemic stroke care at the hospital level; (3) summarize the evidence on the role of specific clinical and administrative variables, including patient preferences, in risk-adjusted models of ischemic stroke outcomes; (4) provide recommendations on the minimum list of variables that should be included in risk adjustment of ischemic stroke outcomes for comparisons of quality at the hospital level; and (5) provide recommendations for further research. METHODS AND RESULTS This statement gives an overview of statistical considerations for the evaluation of hospital-level outcomes after stroke and provides a systematic review of the literature for the following outcome measures for ischemic stroke at 30 days: functional outcomes, mortality, and readmissions. Data on outcomes after stroke have primarily involved studies conducted at an individual patient level rather than a hospital level. On the basis of the available information, the following factors should be included in all hospital-level risk-adjustment models: age, sex, stroke severity, comorbid conditions, and vascular risk factors. Because stroke severity is the most important prognostic factor for individual patients and appears to be a significant predictor of hospital-level performance for 30-day mortality, inclusion of a stroke severity measure in risk-adjustment models for 30-day outcome measures is recommended. Risk-adjustment models that do not include stroke severity or other recommended variables must provide comparable classification of hospital performance as models that include these variables. Stroke severity and other variables that are included in risk-adjustment models should be standardized across sites, so that their reliability and accuracy are equivalent. There is a pressing need for research in multiple areas to better identify methods and metrics to evaluate outcomes of stroke care. CONCLUSIONS There are a number of important methodological challenges in undertaking risk-adjusted outcome comparisons to assess the quality of stroke care in different hospitals. It is important for stakeholders to recognize these challenges and for there to be a concerted approach to improving the methods for quality assessment and improvement.
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Abstract
Cerebrovascular disease, including acute ischemic stroke, remains a major public health problem in the US and throughout the world. There has been a concerted effort to apply evidence-based practices to stroke care to improve primary and secondary prevention as well as poststroke outcomes. Geography and workforce shortages contribute to a disparity in stroke care, however, among the substantial proportion of the US population that lives outside the reach of an acute stroke–ready hospital or a primary or comprehensive stroke center. In an attempt to combat the rural-to-urban disparity and expand the availability of best stroke practices, Levine and Gorman proposed the development of telemedical outreach for acute stroke evaluation and management, which they called “telestroke.” Since then, the practice of telestroke has been found to have a high interrater agreement with a bedside assessment of the National Institutes of Health Stroke Scale score, to enhance correct thrombolysis decision making as compared with telephone-only consultation, and to be cost-effective. In light of these findings and the perception of benefit by acute stroke providers and patients, there has been growing interest in and a rapid expansion of telestroke networks in the US and internationally. There are legal and financial barriers to more widespread use of telemedicine in general, including telestroke. Further research is needed to understand the potential merits of telestroke infrastructure for the many phases of stroke care including poststroke hospitalization, prevention of complications, enhancing secondary prevention, and education of patients and providers.
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Affiliation(s)
- Mark N. Rubin
- 1Department of Neurology, Mayo Clinic, Jacksonville, Florida; and
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Lackland DT, Roccella EJ, Deutsch AF, Fornage M, George MG, Howard G, Kissela BM, Kittner SJ, Lichtman JH, Lisabeth LD, Schwamm LH, Smith EE, Towfighi A. Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association. Stroke 2014; 45:315-53. [PMID: 24309587 PMCID: PMC5995123 DOI: 10.1161/01.str.0000437068.30550.cf] [Citation(s) in RCA: 559] [Impact Index Per Article: 55.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden. METHODS Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and to indicate gaps in current knowledge. All members of the writing group had the opportunity to comment on this document and approved the final version. The document underwent extensive American Heart Association internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee. RESULTS The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both sexes and for all racial/ethnic and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among people <65 years of age represents a reduction in years of potential life lost. The decline in mortality results from reduced incidence of stroke and lower case-fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. Although it is difficult to calculate specific attributable risk estimates, efforts in hypertension control initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality. Although implemented later, diabetes mellitus and dyslipidemia control and smoking cessation programs, particularly in combination with treatment of hypertension, also appear to have contributed to the decline in stroke mortality. The potential effects of telemedicine and stroke systems of care appear to be strong but have not been in place long enough to indicate their influence on the decline. Other factors had probable effects, but additional studies are needed to determine their contributions. CONCLUSIONS The decline in stroke mortality is real and represents a major public health and clinical medicine success story. The repositioning of stroke from third to fourth leading cause of death is the result of true mortality decline and not an increase in mortality from chronic lung disease, which is now the third leading cause of death in the United States. There is strong evidence that the decline can be attributed to a combination of interventions and programs based on scientific findings and implemented with the purpose of reducing stroke risks, the most likely being improved control of hypertension. Thus, research studies and the application of their findings in developing intervention programs have improved the health of the population. The continued application of aggressive evidence-based public health programs and clinical interventions is expected to result in further declines in stroke mortality.
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Alberts MJ, Wechsler LR, Jensen MEL, Latchaw RE, Crocco TJ, George MG, Baranski J, Bass RR, Ruff RL, Huang J, Mancini B, Gregory T, Gress D, Emr M, Warren M, Walker MD. Formation and Function of Acute Stroke–Ready Hospitals Within a Stroke System of Care Recommendations From the Brain Attack Coalition. Stroke 2013; 44:3382-93. [DOI: 10.1161/strokeaha.113.002285] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background and Purpose—
Many patients with an acute stroke live in areas without ready access to a Primary or Comprehensive Stroke Center. The formation of care facilities that meet the needs of these patients might improve their care and outcomes and guide them and emergency responders to such centers within a stroke system of care.
Methods—
The Brain Attack Coalition conducted an electronic search of the English medical literature from January 2000 to December 2012 to identify care elements and processes shown to be beneficial for acute stroke care. We used evidence grading and consensus paradigms to synthesize recommendations for Acute Stroke–Ready Hospitals (ASRHs).
Results—
Several key elements for an ASRH were identified, including acute stroke teams, written care protocols, involvement of emergency medical services and emergency department, and rapid laboratory and neuroimaging testing. Unique aspects include the use of telemedicine, hospital transfer protocols, and drip and ship therapies. Emergent therapies include the use of intravenous tissue-type plasminogen activator and the reversal of coagulopathies. Although many of the care elements are similar to those of a Primary Stroke Center, compliance rates of ≥67% are suggested in recognition of the staffing, logistical, and financial challenges faced by rural facilities.
Conclusions—
ASRHs will form the foundation for acute stroke care in many settings. Recommended elements of an ASRH build on those proven to improve care and outcomes at Primary Stroke Centers. The ASRH will be a key component for patient care within an evolving stroke system of care.
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Affiliation(s)
- Mark J. Alberts
- From the Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas (M.J.A.); Department of Neurology, University of Pittsburgh, PA (L.R.W.); Department of Radiology and Medical Imaging (M.E.L.J.), Department of Neurology (D.G.), University of Virginia, Charlottesville; Department of Radiology, UC Davis Medical Center (R.E.L.); Department of Emergency Medicine, West Virginia University, Morgantown (T.J.C.); Centers for Disease Control and Prevention, Atlanta, GA (M.G.G
| | - Lawrence R. Wechsler
- From the Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas (M.J.A.); Department of Neurology, University of Pittsburgh, PA (L.R.W.); Department of Radiology and Medical Imaging (M.E.L.J.), Department of Neurology (D.G.), University of Virginia, Charlottesville; Department of Radiology, UC Davis Medical Center (R.E.L.); Department of Emergency Medicine, West Virginia University, Morgantown (T.J.C.); Centers for Disease Control and Prevention, Atlanta, GA (M.G.G
| | - Mary E. Lee Jensen
- From the Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas (M.J.A.); Department of Neurology, University of Pittsburgh, PA (L.R.W.); Department of Radiology and Medical Imaging (M.E.L.J.), Department of Neurology (D.G.), University of Virginia, Charlottesville; Department of Radiology, UC Davis Medical Center (R.E.L.); Department of Emergency Medicine, West Virginia University, Morgantown (T.J.C.); Centers for Disease Control and Prevention, Atlanta, GA (M.G.G
| | - Richard E. Latchaw
- From the Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas (M.J.A.); Department of Neurology, University of Pittsburgh, PA (L.R.W.); Department of Radiology and Medical Imaging (M.E.L.J.), Department of Neurology (D.G.), University of Virginia, Charlottesville; Department of Radiology, UC Davis Medical Center (R.E.L.); Department of Emergency Medicine, West Virginia University, Morgantown (T.J.C.); Centers for Disease Control and Prevention, Atlanta, GA (M.G.G
| | - Todd J. Crocco
- From the Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas (M.J.A.); Department of Neurology, University of Pittsburgh, PA (L.R.W.); Department of Radiology and Medical Imaging (M.E.L.J.), Department of Neurology (D.G.), University of Virginia, Charlottesville; Department of Radiology, UC Davis Medical Center (R.E.L.); Department of Emergency Medicine, West Virginia University, Morgantown (T.J.C.); Centers for Disease Control and Prevention, Atlanta, GA (M.G.G
| | - Mary G. George
- From the Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas (M.J.A.); Department of Neurology, University of Pittsburgh, PA (L.R.W.); Department of Radiology and Medical Imaging (M.E.L.J.), Department of Neurology (D.G.), University of Virginia, Charlottesville; Department of Radiology, UC Davis Medical Center (R.E.L.); Department of Emergency Medicine, West Virginia University, Morgantown (T.J.C.); Centers for Disease Control and Prevention, Atlanta, GA (M.G.G
| | - James Baranski
- From the Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas (M.J.A.); Department of Neurology, University of Pittsburgh, PA (L.R.W.); Department of Radiology and Medical Imaging (M.E.L.J.), Department of Neurology (D.G.), University of Virginia, Charlottesville; Department of Radiology, UC Davis Medical Center (R.E.L.); Department of Emergency Medicine, West Virginia University, Morgantown (T.J.C.); Centers for Disease Control and Prevention, Atlanta, GA (M.G.G
| | - Robert R. Bass
- From the Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas (M.J.A.); Department of Neurology, University of Pittsburgh, PA (L.R.W.); Department of Radiology and Medical Imaging (M.E.L.J.), Department of Neurology (D.G.), University of Virginia, Charlottesville; Department of Radiology, UC Davis Medical Center (R.E.L.); Department of Emergency Medicine, West Virginia University, Morgantown (T.J.C.); Centers for Disease Control and Prevention, Atlanta, GA (M.G.G
| | - Robert L. Ruff
- From the Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas (M.J.A.); Department of Neurology, University of Pittsburgh, PA (L.R.W.); Department of Radiology and Medical Imaging (M.E.L.J.), Department of Neurology (D.G.), University of Virginia, Charlottesville; Department of Radiology, UC Davis Medical Center (R.E.L.); Department of Emergency Medicine, West Virginia University, Morgantown (T.J.C.); Centers for Disease Control and Prevention, Atlanta, GA (M.G.G
| | - Judy Huang
- From the Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas (M.J.A.); Department of Neurology, University of Pittsburgh, PA (L.R.W.); Department of Radiology and Medical Imaging (M.E.L.J.), Department of Neurology (D.G.), University of Virginia, Charlottesville; Department of Radiology, UC Davis Medical Center (R.E.L.); Department of Emergency Medicine, West Virginia University, Morgantown (T.J.C.); Centers for Disease Control and Prevention, Atlanta, GA (M.G.G
| | - Barbara Mancini
- From the Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas (M.J.A.); Department of Neurology, University of Pittsburgh, PA (L.R.W.); Department of Radiology and Medical Imaging (M.E.L.J.), Department of Neurology (D.G.), University of Virginia, Charlottesville; Department of Radiology, UC Davis Medical Center (R.E.L.); Department of Emergency Medicine, West Virginia University, Morgantown (T.J.C.); Centers for Disease Control and Prevention, Atlanta, GA (M.G.G
| | - Tammy Gregory
- From the Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas (M.J.A.); Department of Neurology, University of Pittsburgh, PA (L.R.W.); Department of Radiology and Medical Imaging (M.E.L.J.), Department of Neurology (D.G.), University of Virginia, Charlottesville; Department of Radiology, UC Davis Medical Center (R.E.L.); Department of Emergency Medicine, West Virginia University, Morgantown (T.J.C.); Centers for Disease Control and Prevention, Atlanta, GA (M.G.G
| | - Daryl Gress
- From the Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas (M.J.A.); Department of Neurology, University of Pittsburgh, PA (L.R.W.); Department of Radiology and Medical Imaging (M.E.L.J.), Department of Neurology (D.G.), University of Virginia, Charlottesville; Department of Radiology, UC Davis Medical Center (R.E.L.); Department of Emergency Medicine, West Virginia University, Morgantown (T.J.C.); Centers for Disease Control and Prevention, Atlanta, GA (M.G.G
| | - Marian Emr
- From the Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas (M.J.A.); Department of Neurology, University of Pittsburgh, PA (L.R.W.); Department of Radiology and Medical Imaging (M.E.L.J.), Department of Neurology (D.G.), University of Virginia, Charlottesville; Department of Radiology, UC Davis Medical Center (R.E.L.); Department of Emergency Medicine, West Virginia University, Morgantown (T.J.C.); Centers for Disease Control and Prevention, Atlanta, GA (M.G.G
| | - Margo Warren
- From the Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas (M.J.A.); Department of Neurology, University of Pittsburgh, PA (L.R.W.); Department of Radiology and Medical Imaging (M.E.L.J.), Department of Neurology (D.G.), University of Virginia, Charlottesville; Department of Radiology, UC Davis Medical Center (R.E.L.); Department of Emergency Medicine, West Virginia University, Morgantown (T.J.C.); Centers for Disease Control and Prevention, Atlanta, GA (M.G.G
| | - Michael D. Walker
- From the Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas (M.J.A.); Department of Neurology, University of Pittsburgh, PA (L.R.W.); Department of Radiology and Medical Imaging (M.E.L.J.), Department of Neurology (D.G.), University of Virginia, Charlottesville; Department of Radiology, UC Davis Medical Center (R.E.L.); Department of Emergency Medicine, West Virginia University, Morgantown (T.J.C.); Centers for Disease Control and Prevention, Atlanta, GA (M.G.G
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Suri MFK, Qureshi AI. Readmission within 1 month of discharge among patients with acute ischemic stroke: results of the University HealthSystem Consortium Stroke Benchmarking study. JOURNAL OF VASCULAR AND INTERVENTIONAL NEUROLOGY 2013; 6:47-51. [PMID: 24358417 PMCID: PMC3868247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND The University HealthSystem Consortium (UHC) recently conducted a benchmarking project to identify variations in processes of care and clinical resource management, identify new patterns in practice, and distinguish opportunities for improvement among UHC hospitals. METHODS We performed this analysis to determine the rate of and factors associated with readmission within 1 month of discharge among patients with acute ischemic stroke. A retrospective review of 40 consecutive ischemic stroke cases meeting inclusion criteria and discharge between January 1st and June 30th, 2004 was conducted in 32 hospitals. We performed a multivariate analysis to identify demographic and clinical factors associated with readmission among patients with ischemic stroke. RESULTS A total of 1018 patients (mean age 66 years, range 18-98 years), who were discharged from the hospital and had follow-up available, were analyzed. A total of 90 (9%) of these patients were readmitted within 1 month of discharge. Common reasons for readmission were recurrent stroke (24%), infection (12%), chest pain or myocardial infarction (10%), worsening of stroke symptoms (7%), arrhythmias (7%), and congestive heart failure (3%). In univariate analysis, older patients (P = 0.03) and those discharged home without health care were more likely to be readmitted (P = 0.04). In the multivariate analysis, age was the only predictor for readmission. For each decade older age, there was a 19% increase in odds of readmission. Patient's race/ethnicity, presence of cardiovascular risk factors, and severity of stroke, insurance status, neurology consultation, discharge destination were not associated with readmission. CONCLUSIONS In the present multicenter study, 9% of the discharged patients with ischemic stroke were readmitted within a 1 month. Several etiologies for readmission were identified to assist in implementing quality improvement strategies.
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Affiliation(s)
- M Fareed K Suri
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, MN, USA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, MN, USA
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Affiliation(s)
- Larry B. Goldstein
- From the Department of Neurology, Duke Stroke Center, Duke University Medical Center and Durham VAMC, Durham, NC
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Ponomarev D, Miller C, Govan L, Haig C, Wu O, Langhorne P. Complications following incident stroke resulting in readmissions: an analysis of data from three Scottish health surveys. Int J Stroke 2013; 10:911-7. [PMID: 24206656 DOI: 10.1111/ijs.12191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 08/05/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Stroke is widely recognized as the major contributor to morbidity and mortality in the United Kingdom. We analyzed the data obtained from the three consecutive Scottish Health Surveys and the Scottish Morbidity records, with the aim of identifying risk factors for, and timing of, common poststroke complications. METHODS There were 19434 individuals sampled during three Scottish Health Surveys in 1995, 1998, and 2001. For these individuals their morbidity and mortality outcomes were obtained in 2007. Incident stroke prevalence, risk factors for a range of poststroke complications, and average times until such complications in the sample were established. RESULTS Of the total of 168 incident stroke admissions (0·86% of the survey), 16·1% people died during incident stroke hospitalization. Of the remaining 141 stroke survivors, 75·2% were rehospitalized at least once. The most frequent reason for readmission after stroke was a cardiovascular complication (28·6%), median time until event 1412 days, followed by infection (17·3%, median 1591 days). The risk of cardiovascular readmission was higher in those with 'poor' self-assessed health (odds ratio 7·70; 95% confidence interval 1·64-43·27), smokers (odds ratio 4·24; 95% confidence interval 1·11-21·59), and doubled with every five years increase in age (odds ratio 1·97; 95% confidence interval 1·46-2·65). 'Poor' self-assessed health increased chance of readmission for infection (odds ratio 14·11; 95% confidence interval 2·27-276·56). CONCLUSIONS Cardiovascular events and infections are the most frequent poststroke complications resulting in readmissions. The time period until event provides a possibility to focus monitoring on those people at risk of readmission and introduce preventative measures, thereby reducing readmission-associated costs.
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Affiliation(s)
- Dmitry Ponomarev
- Department of Anesthesiology, Novosibirsk Research Institute of Circulation Pathology, Novosibirsk, Russian Federation
| | - Claire Miller
- School of Mathematics and Statistics, University of Glasgow, Glasgow, UK
| | - Lindsay Govan
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Caroline Haig
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Olivia Wu
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Lichtman JH, Leifheit-Limson EC, Jones SB, Wang Y, Goldstein LB. Preventable readmissions within 30 days of ischemic stroke among Medicare beneficiaries. Stroke 2013; 44:3429-35. [PMID: 24172581 DOI: 10.1161/strokeaha.113.003165] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The Centers for Medicare and Medicaid Services proposes to use 30-day hospital readmissions after ischemic stroke as part of the Hospital Inpatient Quality Reporting Program for payment determination beginning in 2016. The proportion of poststroke readmissions that is potentially preventable is unknown. METHODS Thirty-day readmissions for all Medicare fee-for-service beneficiaries aged≥65 years discharged alive with a primary diagnosis of ischemic stroke (International Classification of Diseases, Ninth Revision, Clinical Modification 433, 434, 436) between December 2005 and November 2006 were analyzed. Preventable readmissions were identified based on 14 Prevention Quality Indicators developed for use with administrative data by the US Agency for Healthcare Research and Quality. National, hospital-level, and regional preventable readmission rates were estimated. Random-effects logistic regression was also used to determine patient-level factors associated with preventable readmissions. RESULTS Among 307 887 ischemic stroke discharges, 44 379 (14.4%) were readmitted within 30 days; 5322 (1.7% of all discharges) were the result of a preventable cause (eg, pneumonia), and 39 057 (12.7%) were for other reasons (eg, cancer). In multivariate analysis, older age and cardiovascular-related comorbid conditions were strong predictors of preventable readmissions. Preventable readmission rates were highest in the Southeast, Mid-Atlantic, and US territories and lowest in the Mountain and Pacific regions. CONCLUSIONS On the basis of Agency for Healthcare Research and Quality Prevention Quality Indicators, we found that a small proportion of readmissions after ischemic stroke were classified as preventable. Although other causes of readmissions not reflected in the Agency for Healthcare Research and Quality measures could also be avoidable, hospital-level programs intended to reduce all-cause readmissions and costs should target high-risk patients.
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Affiliation(s)
- Judith H Lichtman
- From the Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (J.H.L., E.C.L.-L., S.B.J.); Department of Biostatistics, Harvard School of Public Health, Boston, MA (Y.W.); and Department of Neurology, Duke Comprehensive Stroke Center, Duke University and Durham VAMC, Durham, NC (L.B.G.)
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Fonarow GC, Liang L, Smith EE, Reeves MJ, Saver JL, Xian Y, Hernandez AF, Peterson ED, Schwamm LH. Comparison of performance achievement award recognition with primary stroke center certification for acute ischemic stroke care. J Am Heart Assoc 2013; 2:e000451. [PMID: 24125846 PMCID: PMC3835260 DOI: 10.1161/jaha.113.000451] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background Hospital certification and recognition programs represent 2 independent but commonly used systems to distinguish hospitals, yet they have not been directly compared. This study assessed acute ischemic stroke quality of care measure conformity by hospitals receiving Primary Stroke Center (PSC) certification and those receiving the American Heart Association's Get With The Guidelines‐Stroke (GWTG‐Stroke) Performance Achievement Award (PAA) recognition. Methods and Results The patient and hospital characteristics as well as performance/quality measures for acute ischemic stroke from 1356 hospitals participating in the GWTG‐Stroke Program 2010–2012 were compared. Hospitals were classified as PAA+/PSC+ (hospitals n=410, patients n=169 302), PAA+/PSC− (n=415, n=129 454), PAA−/PSC+ (n=88, n=26 386), and PAA−/PSC− (n=443, n=75 565). A comprehensive set of stroke measures were compared with adjustment for patient and hospital characteristics. Patient characteristics were similar by PAA and PSC status but PAA−/PSC− hospitals were more likely to be smaller and nonteaching. Measure conformity was highest for PAA+/PSC+ and PAA+/PSC− hospitals, intermediate for PAA−/PSC+ hospitals, and lowest for PAA−/PSC− hospitals (all‐or‐none care measure 91.2%, 91.2%, 84.3%, and 76.9%, respectively). After adjustment for patient and hospital characteristics, PAA+/PSC+, PAA+/PSC−, and PAA−/PSC+ hospitals had 3.15 (95% CIs 2.86 to 3.47); 3.23 (2.93 to 3.56) and 1.72 (1.47 to 2.00), higher odds for providing all indicated stroke performance measures to patients compared with PAA−/PSC− hospitals. Conclusions While both PSC certification and GWTG‐Stroke PAA recognition identified hospitals providing higher conformity with care measures for patients hospitalized with acute ischemic stroke, PAA recognition was a more robust identifier of hospitals with better performance.
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Affiliation(s)
- Gregg C. Fonarow
- Division of Cardiology, University of California, Los Angeles, CA (G.C.F.)
- Correspondence to: Gregg C. Fonarow, MD, Ahmanson‐UCLA Cardiomyopathy Center, UCLA Medical Center, 10833 LeConte Avenue, Room 47‐123 CHS, Los Angeles, CA 90095‐1679. E‐mail:
| | - Li Liang
- Duke Clinical Research Center, Durham, NC (L.L., Y.X., A.F.H., E.D.P.)
| | - Eric E. Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.)
| | - Mathew J. Reeves
- Department of Epidemiology, Michigan State University, East Lansing, MI (M.J.R.)
| | - Jeffrey L. Saver
- Division of Neurology, University of California, Los Angeles, CA (J.L.S.)
| | - Ying Xian
- Duke Clinical Research Center, Durham, NC (L.L., Y.X., A.F.H., E.D.P.)
| | | | - Eric D. Peterson
- Duke Clinical Research Center, Durham, NC (L.L., Y.X., A.F.H., E.D.P.)
| | - Lee H. Schwamm
- Division of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.)
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Inoue T, Fushimi K. Stroke care units versus general medical wards for acute management of stroke in Japan. Stroke 2013; 44:3142-7. [PMID: 23988645 DOI: 10.1161/strokeaha.113.001684] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The Japanese stroke guideline recommends the use of stroke care units (SCUs) for acute stroke treatment, but few SCUs have been established and the evidence supporting their use is limited. The aim of this study was to evaluate the efficacy of SCUs compared with general medical wards (GMWs). METHODS A multicenter observational study was conducted using a large administrative database involving 52 hospitals; patients with either intracerebral hemorrhage or cerebral infarction were included. In-hospital mortality was the primary end point, and this parameter as well as the proportion of patients with a modified Rankin Scale score of ≤2 at discharge were compared between patients who were treated at SCUs and GMWs. Propensity score matching was performed to correct for selection bias. RESULTS A total of 6977 patients were identified, of which 4527 patients were admitted to SCUs and 2450 patients were admitted to GMWs. The in-hospital mortality of patients with intracerebral hemorrhage was 14.8% and 24.1% in SCUs and GMWs, respectively (P=0.0004); the mortality of patients with cerebral infarction was 3.6% and 5.7%, respectively (P=0.003). Multivariate analysis in propensity score-matched pairs indicated significantly lower risk of death in the SCU group among patients with both intracerebral hemorrhage (odds ratio, 0.36; P=0.0007) and cerebral infarction (odds ratio, 0.60; P=0.02). However, the proportions of patients with a modified Rankin Scale score of ≤2 were not significantly different between SCUs and GMWs. CONCLUSIONS SCUs were associated with a reduced risk of in-hospital mortality of stroke patients compared with GMWs alone.
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Affiliation(s)
- Takahiro Inoue
- From the Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
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Silva GS, Schwamm LH. Review of Stroke Center Effectiveness and Other Get with the Guidelines Data. Curr Atheroscler Rep 2013; 15:350. [DOI: 10.1007/s11883-013-0350-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Mullen MT, Judd S, Howard VJ, Kasner SE, Branas CC, Albright KC, Rhodes JD, Kleindorfer DO, Carr BG. Disparities in evaluation at certified primary stroke centers: reasons for geographic and racial differences in stroke. Stroke 2013; 44:1930-5. [PMID: 23640827 PMCID: PMC3747032 DOI: 10.1161/strokeaha.111.000162] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 04/01/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Evaluation at primary stroke centers (PSCs) has the potential to improve outcomes for patients with stroke. We looked for differences in evaluation at Joint Commission certified PSCs by race, education, income, and geography (urban versus nonurban; Southeastern Stroke Belt versus non-Stroke Belt). METHODS Community-dwelling, black and white participants from the national Reasons for Geographic And Racial Differences in Stroke (REGARDS) prospective population-based cohort were enrolled between January 2003 and October 2007. Participants were contacted at 6-month intervals for suspected stroke events. For suspected stroke events, it was determined whether the evaluating hospital was a certified PSC. RESULTS Of 1000 suspected strokes, 204 (20.4%) strokes were evaluated at a PSC. A smaller proportion of women than men (17.8% versus 23.0%; P=0.04), those with a previous stroke (15.1% versus 21.6%; P=0.04), those living in the Stroke Belt (14.7% versus 27.3%; P<0.001), and those in a nonurban area (9.1% versus 23.1%; P<0.001) were evaluated at a PSC. There were no differences by race, education, or income. In multivariable analysis, subjects were less likely to be evaluated at a PSC if they lived in a nonurban area (odds ratio, 0.39; 95% confidence interval, 0.22-0.67) or lived in the Stroke Belt (odds ratio, 0.54; 95% confidence interval, 0.38-0.77) or had a previous stroke (odds ratio, 0.46; 95% confidence interval, 0.27-0.78). CONCLUSIONS Disparities in evaluation by PSCs are predominately related to geographic factors but not to race, education, or low income. Despite an increased burden of cerebrovascular disease in the Stroke Belt, subjects there were less likely to be evaluated at certified hospitals.
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Affiliation(s)
- Michael T Mullen
- Department of Neurology, University of Pennsylvania, Philadelphia, PA 19104,
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Rajamani K, Millis S, Watson S, Mada F, Salowich-Palm L, Hinton S, Chaturvedi S. Thrombolysis for acute ischemic stroke in Joint Commission-certified and -noncertified hospitals in Michigan. J Stroke Cerebrovasc Dis 2013; 22:49-54. [PMID: 21852156 DOI: 10.1016/j.jstrokecerebrovasdis.2011.06.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 06/02/2011] [Accepted: 06/05/2011] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The Joint Commission (JC) for Accreditation of Healthcare Organizations has devised disease specific certification programs for hospitals, including stroke. JC certification as a primary stroke center (PSC) suggests that the hospital has critical measures in place to ensure improving stroke outcomes over the long term. In this study, we focused on the delivery of care for patients with acute ischemic and compared differences in JC-certified and -noncertified centers in Michigan. METHODS We performed a systematic chart review of patients with acute ischemic stroke from 10 Michigan hospitals, half of whom were JC-certified PSCs. Sixty charts were randomly chosen from 1 calendar year from each hospital. An experienced nurse performed the data abstraction, and data analysis was performed with the Fisher exact test. RESULTS A total of 602 charts--of which 302 were from JC-certified PSCs--were chosen for the study. The 2 groups were similar with regard to stroke risk factors except that there were significantly more patients with atrial fibrillation in noncertified centers and there were more African American patients in JC-certified PSCs. Significantly more patients were considered for thrombolytic therapy in JC-certified PSCs compared to noncertified centers (90.4% v 66%; P = .0001). Overall, 3.8% of patients had received thrombolytic therapy without any significant difference between JC-certified PSCs and noncertified centers (4.6% v 3%; adjusted odds ratio 1.64; 95% confidence interval 0.64-4.19; P = .87). However, thrombolysis rates among eligible patients was significantly higher in the JC-certified PSCs (48.2% v 8.8%; P = .0001). The most common reason documented for not giving thrombolytic therapy was late arrival outside the therapeutic window, which was more common in JC-certified PSCs (72.8% v 55.6%; P = .0001) compared to noncertified centers. Seventy-four percent of patients from JC-certified PSCs were discharged home or to inpatient rehabilitation facility compared to 71% (P = .38) from noncertified hospitals. The mean length of stay was marginally shorter in JC-certified PSCs compared to noncertified centers (5.53 v 6.25 days; P = .08). CONCLUSIONS Rates of thrombolysis administration for acute stroke patients across Michigan were low in both JC-certified and noncertified hospitals, although better processes were in place in JC-certified PSCs. While there was no overall difference in the administration of thrombolytic treatment, a greater number of the eligible patients received thrombolysis in the certified centers. There was a tendency to shorter lengths of stay at JC-certified PSCs, but there was no significant difference in discharge to home, inpatient rehabilitation, or inpatient mortality in this study.
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Affiliation(s)
- Kumar Rajamani
- Comprehensive Stroke Program, Wayne State University School of Medicine, Detroit, MI 48201, USA.
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Abstract
BACKGROUND The use of 2-way audiovisual (AV) technology for delivery of acute stroke evaluation and management, termed "telestroke," is supported by a rapidly growing literature base. A systematic review that provides a comprehensive, easily digestible overview of telestroke science and practice is lacking. PURPOSE To conduct a systematic review of the published literature on telemedical consultation for the purposes of providing acute stroke evaluation and management. DATA SOURCES The Ovid Medline, Embase, PsychINFO, CINAHL, PubMed, and Cochrane databases were searched with numerous keywords relevant to telestroke from January 1996 through July 2012. STUDY SELECTION Studies were included if the title or abstract expressed use of 2-way AV communication for acute stroke evaluation and management. DATA EXTRACTION Each article was classified using a novel scoring rubric to assess the level of Functionality, Application, Technology, and Evaluative stage (FATE). DATA ANALYSIS The search yielded 1405 potentially eligible articles, which were independently reviewed by 2 investigators. There were 344 unique studies that met eligibility criteria and underwent full-text review. Ultimately, 145 unique studies underwent FATE assessment and scoring. RESULTS Most telestroke studies evaluated functionality in the context of acute stroke assessment of adults in emergency departments. Nearly half of all published articles on telestroke were narrative reviews. After exclusion of these reviews, the median FATE score for telestroke primary data was 4. CONCLUSION Telestroke technology is now part of mainstream clinical stroke practice in North America and internationally. Telestroke reliability, validity, efficacy, safety, clinical, and cost-effectiveness studies reflect maturity in the field, and new post-implementation studies in the pre-hospital setting present welcome and sophisticated advancements in the field.
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Affiliation(s)
- Mark N Rubin
- Department of Neurology, Mayo Clinic, Rochester, MN 85254, USA
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Schwamm LH. When in rome, do like the Romans: certifying stroke centers with the rod of aesculapius or the medical caduceus of hermes? J Am Heart Assoc 2013; 2:e000120. [PMID: 23557752 PMCID: PMC3647263 DOI: 10.1161/jaha.113.000120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.)
- Correspondence to: Lee H. Schwamm, MD, FAHA, Vice Chairman, Department of Neurology‐ACC 720, C. Miller Fisher Endowed Chair, Massachusetts General Hospital, Professor of Neurology, Harvard Medical School, MGH, 55 Fruit Street, Boston MA 02114. E‐mail:
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