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Shirakura Y, Shobugawa Y, Saito R. Geographic variation in inpatient medical expenditure among older adults aged 75 years and above in Japan: a three-level multilevel analysis of nationwide data. Front Public Health 2024; 12:1306013. [PMID: 38481853 PMCID: PMC10933056 DOI: 10.3389/fpubh.2024.1306013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/18/2024] [Indexed: 05/07/2024] Open
Abstract
Introduction In Japan, a country at the forefront of population ageing, significant geographic variation has been observed in inpatient medical expenditures for older adults aged 75 and above (IMEP75), both at the small- and large-area levels. However, our understanding of how different levels of administrative (geographic) units contribute to the overall geographic disparities remains incomplete. Thus, this study aimed to assess the degree to which geographic variation in IMEP75 can be attributed to municipality-, secondary medical area (SMA)-, and prefecture-level characteristics, and identify key factors associated with IMEP75. Methods Using nationwide aggregate health insurance claims data of municipalities for the period of April 2018 to March 2019, we conducted a multilevel linear regression analysis with three levels: municipalities, SMA, and prefectures. The contribution of municipality-, SMA-, and prefecture-level correlates to the overall geographic variation in IMEP75 was evaluated using the proportional change in variance across six constructed models. The effects of individual factors on IMEP75 in the multilevel models were assessed by estimating beta coefficients with their 95% confidence intervals. Results We analysed data of 1,888 municipalities, 344 SMAs, and 47 prefectures. The availability of healthcare resources at the SMA-level and broader regions to which prefectures belonged together explained 57.3% of the overall geographic variance in IMEP75, whereas the effects of factors influencing healthcare demands at the municipality-level were relatively minor, contributing an additional explanatory power of 2.5%. Factors related to long-term and end-of-life care needs and provision such as the proportion of older adults certified as needing long-term care, long-term care benefit expenditure per recipient, and the availability of hospital beds for psychiatric and chronic care and end-of-life care support at home were associated with IMEP75. Conclusion To ameliorate the geographic variation in IMEP75 in Japan, the reallocation of healthcare resources across SMAs should be considered, and drivers of broader regional disparities need to be further explored. Moreover, healthcare systems for older adults must integrate an infrastructure of efficient long-term care and end-of-life care delivery outside hospitals to alleviate the burden on inpatient care.
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Affiliation(s)
- Yuki Shirakura
- Division of International Health (Public Health), Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
- Department of Active Ageing, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Yugo Shobugawa
- Department of Active Ageing, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Reiko Saito
- Division of International Health (Public Health), Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
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Arriola KJ, Merken TM, Bigger L, Haardörfer R, Hermstad A, Owolabi S, Daniel J, Kegler M. Understanding the relationship between social capital, health, and well-being in a southern rural population. J Rural Health 2024; 40:162-172. [PMID: 37438857 DOI: 10.1111/jrh.12782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 05/31/2023] [Accepted: 07/02/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE Social capital is thought to contribute to health and well-being, but its application to a rural context is poorly understood. This study seeks to examine how different forms of social capital relate to health and well-being among rural residents and the extent to which race and degree of rurality moderates these relationships. METHODS Data from a population-based survey of 6 counties in rural Georgia (n = 1,385) are used. We examined 3 forms of social capital (diversity of interaction, civic engagement, and voting behavior) in relation to 3 health and well-being measures (overall life satisfaction, general health status, and 30-day physical health). FINDINGS Interacting with more diverse social networks was associated with higher overall life satisfaction for White but not Black participants (P ≤ .001). For those living in more rural communities, interacting with a more diverse social network was more strongly associated with greater general health as compared to those who lived "in town" (P ≤ .01). Greater civic engagement and voting behavior were associated with greater general health for White but not Black participants (Ps < .05). Likewise, voting in all 3 elections was associated with greater overall life satisfaction and fewer days of poor physical health for White but not Black participants (Ps ≤ .05). CONCLUSION Social capital may be associated with positive health and well-being among those living in rural areas, but it may vary by race and degree of community rurality, suggesting the need to further understand how social capital operates in a rural context.
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Affiliation(s)
- Kimberly Jacob Arriola
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Tatenda Mangurenje Merken
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lauren Bigger
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Regine Haardörfer
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - April Hermstad
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Shade Owolabi
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Jerry Daniel
- Master of Social Work Program, Albany State University, Albany, Georgia, USA
| | - Michelle Kegler
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Zachrison KS, Nielsen VM, de la Ossa NP, Madsen TE, Cash RE, Crowe RP, Odom EC, Jauch EC, Adeoye OM, Richards CT. Prehospital Stroke Care Part 1: Emergency Medical Services and the Stroke Systems of Care. Stroke 2023; 54:1138-1147. [PMID: 36444720 PMCID: PMC11050637 DOI: 10.1161/strokeaha.122.039586] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Acute stroke care begins before hospital arrival, and several prehospital factors are critical in influencing overall patient care and poststroke outcomes. This topical review provides an overview of the state of the science on prehospital components of stroke systems of care and how emergency medical services systems may interact in the system to support acute stroke care. Topics include layperson recognition of stroke, prehospital transport strategies, networked stroke care, systems for data integration and real-time feedback, and inequities that exist within and among systems.
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Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (K.S.Z., R.E.C.)
| | | | - Natalia Perez de la Ossa
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias I Pujol, Badalona, Spain and Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain (N.P.d.l.O)
| | - Tracy E Madsen
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI (T.E.M.)
| | - Rebecca E Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (K.S.Z., R.E.C.)
| | | | - Erika C Odom
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (E.C.O.)
| | - Edward C Jauch
- Department of Research, University of North Carolina Health Sciences at Mountain Area Health Education Center, Asheville, NC (E.C.J.)
| | - Opeolu M Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO (O.M.A.)
| | - Christopher T Richards
- Division of EMS, Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH (C.T.R.)
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Chari SV, Cui ER, Fehl HE, Fernandez AR, Brice JH, Patel MD. Community socioeconomic and urban-rural differences in emergency medical services times for suspected stroke in North Carolina. Am J Emerg Med 2023; 63:120-126. [PMID: 36370608 PMCID: PMC10425758 DOI: 10.1016/j.ajem.2022.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/19/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Our objectives were to describe time intervals of EMS encounters for suspected stroke patients in North Carolina (NC) and evaluate differences in EMS time intervals by community socioeconomic status (SES) and rurality. METHODS This cross-sectional study used statewide data on EMS encounters of suspected stroke in NC in 2019. Eligible patients were adults requiring EMS transport to a hospital following a 9-1-1 call for stroke-like symptoms. Incident street addresses were geocoded to census tracts and linked to American Community Survey SES data and to rural-urban commuting area (RUCA) codes. Community SES was defined as high, medium, or low based on tertiles of an SES index. Urban, suburban, and rural tracts were defined by RUCA codes 1, 2-6, and 7-10, respectively. Multivariable quantile regression was used to estimate how the median and 90th percentile of EMS time intervals varied by community SES and rurality, adjusting for each other; patient age, gender, and race/ethnicity; and incident characteristics. RESULTS We identified 17,117 eligible EMS encounters of suspected stroke from 2028 census tracts. The population was 65% 65+ years old; 55% female; and 69% Non-Hispanic White. Median response, scene, and transport times were 8 (interquartile range, IQR 6-11) min, 16 (IQR 12-20) min, and 14 (IQR 9-22) minutes, respectively. In quantile regression adjusted for patient demographics, minimal differences were observed for median response and scene times by community SES and rurality. The largest median differences were observed for transport times in rural (6.7 min, 95% CI 5.8, 7.6) and suburban (4.7 min, 95% CI 4.2, 5.1) tracts compared to urban tracts. Adjusted rural-urban differences in 90th percentile transport times were substantially greater (16.0 min, 95% CI 14.5, 17.5). Low SES was modesty associated with shorter median (-3.3 min, 95% CI -3.8, -2.9) and 90th percentile (-3.0 min, 95% CI -4.0, -2.0) transport times compared to high SES tracts. CONCLUSIONS While community-level factors were not strongly associated with EMS response and scene times for stroke, transport times were significantly longer rural tracts and modestly shorter in low SES tracts, accounting for patient demographics. Further research is needed on the role of community socioeconomic deprivation and rurality in contributing to delays in prehospital stroke care.
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Affiliation(s)
- Srihari V Chari
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Eric R Cui
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Haylie E Fehl
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Antonio R Fernandez
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA; ESO, Austin, TX, USA
| | - Jane H Brice
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Mehul D Patel
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
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O’Connell GC, Walsh KB, Smothers CG, Ruksakulpiwat S, Armentrout BL, Winkelman C, Milling TJ, Warach SJ, Barr TL. Use of deep artificial neural networks to identify stroke during triage via subtle changes in circulating cell counts. BMC Neurol 2022; 22:206. [PMID: 35659609 PMCID: PMC9164330 DOI: 10.1186/s12883-022-02726-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 05/17/2022] [Indexed: 11/10/2022] Open
Abstract
Background The development of tools that could help emergency department clinicians recognize stroke during triage could reduce treatment delays and improve patient outcomes. Growing evidence suggests that stroke is associated with several changes in circulating cell counts. The aim of this study was to determine whether machine-learning can be used to identify stroke in the emergency department using data available from a routine complete blood count with differential. Methods Red blood cell, platelet, neutrophil, lymphocyte, monocyte, eosinophil, and basophil counts were assessed in admission blood samples collected from 160 stroke patients and 116 stroke mimics recruited from three geographically distinct clinical sites, and an ensemble artificial neural network model was developed and tested for its ability to discriminate between groups. Results Several modest but statistically significant differences were observed in cell counts between stroke patients and stroke mimics. The counts of no single cell population alone were adequate to discriminate between groups with high levels of accuracy; however, combined classification using the neural network model resulted in a dramatic and statistically significant improvement in diagnostic performance according to receiver-operating characteristic analysis. Furthermore, the neural network model displayed superior performance as a triage decision making tool compared to symptom-based tools such as the Cincinnati Prehospital Stroke Scale (CPSS) and the National Institutes of Health Stroke Scale (NIHSS) when assessed using decision curve analysis. Conclusions Our results suggest that algorithmic analysis of commonly collected hematology data using machine-learning could potentially be used to help emergency department clinicians make better-informed triage decisions in situations where advanced imaging techniques or neurological expertise are not immediately available, or even to electronically flag patients in which stroke should be considered as a diagnosis as part of an automated stroke alert system.
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Newly-identified blood biomarkers of neurological damage are correlated with infarct volume in patients with acute ischemic stroke. J Clin Neurosci 2021; 94:107-113. [PMID: 34863423 DOI: 10.1016/j.jocn.2021.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 08/26/2021] [Accepted: 10/11/2021] [Indexed: 11/22/2022]
Abstract
Our group recently performed a genome-wide informatic analysis that highlighted eight brain-enriched proteins with strong potential to serve as blood biomarkers of neurological injury (GFAP, MBP, β-synuclein, OPALIN, MT-3, SNAP-25, KIF5A, MOBP), including six that have yet to be widely investigated. In this study, our aim was to determine whether the circulating levels of these proteins could be used to approximate the extent of neural tissue damage in ischemic stroke. To address this aim, blood was collected from 43 ischemic stroke patients immediately upon hospital admission. The serum levels of the eight candidate proteins were measured via ELISA, infarct volume was assessed via manual tracing of neuroradiological images, and correlational analysis was performed to examine potential associative relationships. The serum levels of all eight proteins exhibited positive correlations with infarct volume, however the strongest associations were observed in a subset of four proteins known to originate from neurons specifically (MT-3, SNAP-25, KIF5A, β-synuclein). Combining the serum levels of these neuron-originating proteins using principal components analysis produced a single composite value that was more strongly correlated with infarct volume than the levels of any single protein considered in isolation (r = 0.48, p < 0.001). Measures of these proteins could potentially be used to provide a minimally invasive approximation of lesion size when advanced imaging techniques are not available, or when imaging results are inconclusive.
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Maeda M, Fukuda H, Matsuo R, Ago T, Kitazono T, Kamouchi M. Regional Disparity of Reperfusion Therapy for Acute Ischemic Stroke in Japan: A Retrospective Analysis of Nationwide Claims Data from 2010 to 2015. J Am Heart Assoc 2021; 10:e021853. [PMID: 34622661 PMCID: PMC8751889 DOI: 10.1161/jaha.121.021853] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background We aimed to determine whether a regional disparity exists in usage of reperfusion therapy (intravenous recombinant tissue plasminogen activator [IV rt‐PA] and endovascular thrombectomy [EVT]) and post‐reperfusion 30‐day mortality in patients with acute ischemic stroke, and which regional factors are associated with their usage. Methods and Results We retrospectively investigated 69 948 patients (mean age±SD, 74.9±12.0 years; women, 41.4%) with acute ischemic stroke treated with reperfusion therapy between April 2010 and March 2016 in Japan using nationwide claims data. Regional disparity was evaluated using Gini coefficients for age‐ and sex‐adjusted usage of reperfusion therapy and 30‐day post‐reperfusion in‐hospital death ratio in 47 administrative regions. The association between regional factors and reperfusion therapy usage was evaluated with fixed‐effects regression models. During the study period, Gini coefficients showed low inequality (0.11–0.15) for use of IV rt‐PA monotherapy and IV rt‐PA and/or EVT and extreme inequality (0.49) for EVT usage in 2010, which became moderate inequality (0.25) by 2015. The densities of stroke centers and endovascular specialists, as well as market concentration, were associated with increased usage of reperfusion therapy whereas the proportion of rural residents and delayed ambulance transport were negatively associated with usage. Inequality in the standardized death ratio after EVT was extreme (0.86) in 2010 but became moderate (0.29) by 2015; inequality was low to moderate (0.17–0.23) for IV rt‐PA monotherapy and IV rt‐PA and/or EVT. Conclusions Scrutinizing existing data sources revealed regional disparity in reperfusion therapy for acute ischemic stroke and its associated regional factors in Japan.
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Affiliation(s)
- Megumi Maeda
- Department of Health Care Administration and ManagementGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Haruhisa Fukuda
- Department of Health Care Administration and ManagementGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
- Center for Cohort StudiesGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Ryu Matsuo
- Department of Health Care Administration and ManagementGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
- Department of Medicine and Clinical ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Tetsuro Ago
- Department of Medicine and Clinical ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Takanari Kitazono
- Center for Cohort StudiesGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
- Department of Medicine and Clinical ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Masahiro Kamouchi
- Department of Health Care Administration and ManagementGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
- Center for Cohort StudiesGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
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Rural-Urban Disparities in Intracerebral Hemorrhage Mortality in the USA: Preliminary Findings from the National Inpatient Sample. Neurocrit Care 2021; 32:715-724. [PMID: 32232726 PMCID: PMC7223184 DOI: 10.1007/s12028-020-00950-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Objectives To compare in-hospital mortality between intracerebral hemorrhage (ICH) patients in rural hospitals to those in urban hospitals of the USA. Methods We used the National Inpatient Sample to retrospectively identify all cases of ICH in the USA over the period 2004–2014. We used multivariable-adjusted models to compare odds of mortality between rural and urban hospitals. Joinpoint regression was used to evaluate trends in age- and sex-adjusted mortality in rural and urban hospitals over time. Results From 2004 to 2014, 5.8% of ICH patients were admitted in rural hospitals. Rural patients were older (mean [SE] 76.0 [0.44] years vs. 68.8 [0.11] years in urban), more likely to be white and have Medicare insurance. Age- and sex-adjusted mortality was greater in rural hospitals (32.2%) compared to urban patients (26.5%) (p value < 0.001). After multivariable adjustment, patients hospitalized in rural hospitals had two times the odds of in-hospital death compared to patients in urban hospitals (OR 2.07, 95% CI 1.77–2.41. p value < 0.001). After joinpoint regression, mortality declined in urban hospitals by an average of 2.8% per year (average annual percentage change, [AAPC] − 2.8%, 95% CI − 3.7 to − 1.8%), but rates in rural hospitals remained unchanged (AAPC − 0.54%, 95% CI − 1.66 to 0.58%). Conclusions Despite current efforts to reduce disparity in stroke care, ICH patients hospitalized in rural hospitals had two times the odds of dying compared to those in urban hospitals. In addition, the ICH mortality gap between rural and urban centers is increasing. Further studies are needed to identify and reverse the causes of this disparity. Electronic supplementary material The online version of this article (10.1007/s12028-020-00950-2) contains supplementary material, which is available to authorized users.
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Holcombe A, Mohr N, Farooqui M, Dandapat S, Dai B, Zevallos CB, Quispe-Orozco D, Siddiqui F, Ortega-Gutierrez S. Patterns of Care and Clinical Outcomes in Patients with Cerebral Sinus Venous Thrombosis. J Stroke Cerebrovasc Dis 2020; 29:105313. [PMID: 32992183 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/04/2020] [Accepted: 09/07/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVES To explore the association between rurality, transfer patterns and level of care with clinical outcomes of CVST patients in a rural Midwestern state. MATERIALS AND METHODS CVST patients admitted to the hospitals between 2005 and 2014 were identified by inpatient diagnosis codes from statewide administrative claims dataset. Records were linked across interhospital transfers using probabilistic linkage. Rurality was defined by Rural-Urban Commuting Areas using the 2-category approximation. Driving distances were estimated using GoogleMaps Application Programming Interface. Hospital stroke certification was defined by the Joint Commission. Severity of CVST was estimated by cost of care corrected for inflation and cost-to-charge ratios. Outcome was discharge disposition and total length of stay (LOS). Wilcoxon rank-sum, Chi-square, Fisher's exact tests and linear and logistic regressions were used. RESULTS 168 CVST patients were identified (79.8% female; median age = 32, IQR = 24.0-45.5). Median LOS was four days (IQR = 2-7) and patients traveled a median of 8.1 miles (IQR = 2.5-28.5) to the first hospital; 42% of patients were transferred to a second hospital, 5% to a third. More than half (58.3%) bypassed the nearest hospital. 86% visit a primary or comprehensive stroke center (CSC) during their acute care. Rurality was not significantly associated with LOS or discharge disposition after adjusting for age, sex and cost of care. Patients in CSC demonstrated greater likelihood of being discharged home compared to at a primary stroke center after adjusting for age and disease severity (p = 0.008). CONCLUSIONS While rurality was not significantly associated with LOS or disposition outcome, care at a CSC increases likelihood of being discharge home.
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Affiliation(s)
- Andrea Holcombe
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Nicholas Mohr
- Department of Emergency Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Sudeepta Dandapat
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Biyue Dai
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Cynthia B Zevallos
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Darko Quispe-Orozco
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Fazeel Siddiqui
- Department of Neuroscience, Metro Health, University of Michigan, Wyoming, MI, United States
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery, and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States.
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Abstract
OBJECTIVE. In recent decades, teleradiology has expanded considerably, and many radiology practices now engage in intraorganizational or extraorganizational teleradiology. In this era of patient primacy, optimizing patient care and care delivery is paramount. This article provides an update on recent changes, current challenges, and future opportunities centered around the ability of teleradiology to improve temporal and geographic imaging access. We review licensing and regulations and discuss teleradiology in providing services to rural areas and assisting with disaster response, including the response to the coronavirus disease (COVID-19) pandemic. CONCLUSION. Teleradiology can help increase imaging efficiency and mitigate both geographic and temporal discrepancies in imaging care. Technologic limitations and regulatory hurdles hinder the optimal practice of teleradiology, and future attention to these issues may help ensure broader patient access to high-quality imaging across the United States.
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11
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Georgakakos PK, Swanson MB, Ahmed A, Mohr NM. Rural Stroke Patients Have Higher Mortality: An Improvement Opportunity for Rural Emergency Medical Services Systems. J Rural Health 2020; 38:217-227. [PMID: 32757239 DOI: 10.1111/jrh.12502] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE Early recognition and prompt prehospital care is a cornerstone of acute stroke treatment. Residents of rural areas have worse access to stroke services than urban residents. The purpose of this study was to (1) describe US trends in rural-urban stroke mortality and (2) identify possible factors associated with rural-urban stroke case-fatality disparities. METHODS This study was a nationwide retrospective cohort study of stroke admissions. The primary exposure was rurality of patient's residence. The primary outcome was death during hospital encounter. The secondary outcome was discharge to a care facility or home healthcare. Univariable and multivariable logistic regressions estimated the odds of mortality by subject rurality among stroke subjects. FINDINGS Rural stroke subjects had higher mortality than nonrural counterparts (18.6% rural vs 16.9% nonrural). After adjustment for patient and hospital factors, patient rurality was associated with increased odds of mortality (aOR = 1.11; 95% CI: 1.06-1.15; P < .001). For the secondary outcome of discharge to home, rural stroke subjects were less likely to be discharged to a care facility than nonrural stroke visits (aOR 0.94; 95% CI: 0.91-0.97; P < .001). Results were similar after adjusting for thrombolytics administration and transfer status. CONCLUSIONS Rural stroke patients have higher mortality than their urban counterparts likely due to their increased burden of chronic disease, lower health literacy, and reduced access to prompt prehospital care. There may be an opportunity for emergency medical services systems to assist in increasing stroke awareness for both patients and clinicians and to establish response patterns to expedite emergency care.
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Affiliation(s)
- Peter K Georgakakos
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Morgan B Swanson
- University of Iowa Carver College of Medicine, Iowa City, Iowa.,Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
| | - Azeemuddin Ahmed
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa.,Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa.,Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa
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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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Mashni SK, O'Neal CR, Abner E, Lee J, Fraser JF. Time Intervals for Direct Versus Transfer Cases of Thrombectomy for Stroke in a Primarily Rural System of Care. J Stroke Cerebrovasc Dis 2020; 29:104689. [PMID: 32151476 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/27/2019] [Accepted: 01/21/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Early treatment is the key to a successful recovery for ischemic stroke patients. From time of onset, a patient's chances of permanent disability only increase until they can receive reperfusion intervention. OBJECTIVE We sought to identify potential delays that occur during evaluation and treatment of patients in a rural regional health system. METHODS We conducted a single-center retrospective review of all patients that arrived at our comprehensive stroke center (CSC) between July 2011 and March 2017, and received thrombectomy, with or without prior treatment with intravenous recombinant tissue plasminogen activator. RESULTS One hundred and fifty-four patients met our criteria for inclusion. Patients were divided into 2 groups: Direct (patients brought to our CSC from scene) and Transfer (patients taken to an outside hospital then transferred to our CSC). The median time to CSC for Direct patients was 82 (range: 15-863) minutes after onset of symptoms, compared to 237 (range: 98-1215) minutes for the Transfer group. The median time for Transfer patients to reach an outside hospital was 74 (range: 5-840) minutes, with an additional average time of 90 minutes in the outside hospital prior to transferred to our CSC. CONCLUSIONS Based on our findings, patients brought directly to our CSC saved a significant amount of time, which may improve functional outcomes. Both groups (Direct and Transfer) spent a similar amount of time between last known normal and emergency medical services arrival, highlighting the need for increased awareness among the public to activate the stroke system of care.
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Affiliation(s)
| | - Charles R O'Neal
- Kentucky Board of Emergency Medical Services, Lexington, Kentucky
| | - Erin Abner
- Department of Epidemiology, University of Kentucky, Lexington, Kentucky
| | - Jessica Lee
- Department of Neurology, University of Kentucky, Lexington, Kentucky
| | - Justin F Fraser
- Department of Neurology, University of Kentucky, Lexington, Kentucky; Department of Neurological Surgery, University of Kentucky, Lexington, Kentucky; Department of Neuroscience, University of Kentucky, Lexington, Kentucky; Department of Radiology, University of Kentucky, Lexington, Kentucky; Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, Kentucky.
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14
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Shen YC, Chen G, Hsia RY. Community and Hospital Factors Associated With Stroke Center Certification in the United States, 2009 to 2017. JAMA Netw Open 2019; 2:e197855. [PMID: 31348507 PMCID: PMC6661722 DOI: 10.1001/jamanetworkopen.2019.7855] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The increased number of stroke centers in the United States may not be equitably distributed across all populations. Anecdotal reports suggest there may be differential proliferation in wealthier and urban communities. OBJECTIVE To examine hospital characteristics and economic conditions of communities surrounding hospitals with and without stroke centers. DESIGN, SETTING, AND PARTICIPANTS This cohort study included all general, short-term, acute hospitals in the continental United States and used merged data from the Joint Commission, Det Norske Veritas, Healthcare Facilities Accreditation Program, state health departments, the Centers for Medicare & Medicaid Services, the American Hospital Association, the Dartmouth Atlas of Health Care, and the US Census Bureau from January 1, 2009, to September 30, 2017, to compare hospital and community characteristics of stroke-certified and non-stroke-certified hospitals and assessed characteristics of early and late adopters of stroke certification. MAIN OUTCOMES AND MEASURES Stroke center certification was the primary outcome. Risk factors were grouped into 3 categories: economic and financial, hospital, and community characteristics. Survival analyses were performed using a Cox proportional hazards regression model. RESULTS The study included 4546 US hospitals. During the study period, 1689 hospitals (37.2%) were stroke certified (961 adopted certification on or before January 1, 2009, 728 afterward). After controlling for other area and hospital characteristics, hospitals in low-income hospital service areas and the lower tertile of profit-margin distribution were less likely to adopt stroke certification (hazard ratio [HR], 0.62; 95% CI, 0.52-0.74 and HR, 0.87; 95% CI, 0.78-0.98, respectively). Urban hospitals had a higher likelihood of stroke certification than rural hospitals (HR, 12.79; 95% CI, 10.64-15.37). CONCLUSIONS AND RELEVANCE This study found that stroke centers have proliferated unevenly across geographic localities, where hospitals in high-income hospital service areas and with higher profit margins have a greater likelihood of being stroke certified. These findings suggest that market-driven factors may be associated with stroke center certification.
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Affiliation(s)
- Yu-Chu Shen
- Graduate School of Business and Public Policy, Naval Postgraduate School, Monterey, California
- National Bureau of Economic Research, Cambridge, Massachusetts
| | | | - Renee Y. Hsia
- Department of Emergency Medicine, University of California at San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco
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15
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Patel MD, Honvoh G, Fernandez AR, Cadena R, Kelly ER, McDaniel P, Brice JH. Availability of Hospital Resources and Specialty Services for Stroke Care in North Carolina. South Med J 2019; 112:331-337. [PMID: 31158888 DOI: 10.14423/smj.0000000000000986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Effective regionalization of acute stroke care requires assessment and coordination of limited hospital resources. We described the availability of stroke-specific hospital resources (neurology specialty physicians and neuro-intensive care unit [neuro-ICU] bed capacity) for North Carolina overall and by region and population density. We also assessed daily trends in hospital bed availability. METHODS This statewide descriptive study was conducted with data from the State Medical Asset Resource Tracking Tool (SMARTT), a Web-based system used by North Carolina to track available medical resources within the state. The SMARTT system was queried for stroke-specific physician and bed resources at each North Carolina hospital during a 1-year period (June 2015-May 2016), including daily availability of neuro-ICU beds. We compared hospital resources by geographic region and population density (metropolitan, urban, and rural). RESULTS Data from 108 acute care hospitals located in 75 of 100 counties in North Carolina were included in the analysis. Fifty-seven percent of hospitals had no neurology specialty physicians. Western and eastern North Carolina had the lowest prevalence of these physicians. Most hospitals (88%) had general ICUs, whereas only 17 hospitals (16%) had neuro-ICUs. Neuro-ICUs were concentrated in metropolitan areas and in central North Carolina. On average, there were 276 general ICU and 27 neuro-ICU beds available statewide each day. Daily neuro-ICU bed availability was lowest in eastern and southeastern regions and during the week compared with weekends. CONCLUSIONS In North Carolina, stroke-specific hospital subspecialists and resources are not distributed evenly across the state. Daily bed availability, particularly in neuro-ICUs, is lacking in rural areas and noncentral regions and appears to decrease on weekdays. Regionalization of stroke care needs to consider the geographic distribution and daily variability of hospital resources.
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Affiliation(s)
- Mehul D Patel
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
| | - Gilson Honvoh
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
| | - Antonio R Fernandez
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
| | - Rhonda Cadena
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
| | - Emma R Kelly
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
| | - Philip McDaniel
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
| | - Jane H Brice
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
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Factors Impacting Patient Outcomes Associated with Use of Emergency Medical Services Operating in Urban Versus Rural Areas: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16101728. [PMID: 31100851 PMCID: PMC6572626 DOI: 10.3390/ijerph16101728] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 05/14/2019] [Accepted: 05/14/2019] [Indexed: 12/02/2022]
Abstract
The goal of this systematic review was to examine the existing literature base regarding the factors impacting patient outcomes associated with use of emergency medical services (EMS) operating in urban versus rural areas. A specific subfocus on low and lower-middle-income countries was planned but acknowledged in advance as being potentially limited by a lack of available data. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed during the preparation of this systematic review. A comprehensive literature search of PubMed, EBSCO (Elton B. Stephens Company) host, Web of Science, ProQuest, Embase, and Scopus was conducted through May 2018. To appraise the quality of the included papers, the Critical Appraisal Skills Programme Checklists (CASP) were used. Thirty-one relevant and appropriate studies were identified; however, only one study from a low or lower-middle-income country was located. The research indicated that EMS in urban areas are more likely to have shorter prehospital times, response times, on-scene times, and transport times when compared to EMS operating in rural areas. Additionally, urban patients with out-of-hospital cardiac arrest or trauma were found to have higher survival rates than rural patients. EMS in urban areas were generally associated with improved performance measures in key areas and associated higher survival rates than those in rural areas. These findings indicate that reducing key differences between rural and urban settings is a key factor in improving trauma patient survival rates. More research in rural areas is required to better understand the factors which can predict these differences and underpin improvements. The lack of research in this area is particularly evident in low- and lower-middle-income countries.
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17
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Javor A, Ferrari J, Posekany A, Asenbaum-Nan S. Stroke risk factors and treatment variables in rural and urban Austria: An analysis of the Austrian Stroke Unit Registry. PLoS One 2019; 14:e0214980. [PMID: 30970026 PMCID: PMC6457636 DOI: 10.1371/journal.pone.0214980] [Citation(s) in RCA: 5] [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: 10/30/2018] [Accepted: 03/24/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Differences in stroke risk factors and treatment variables between rural and urban regions in Austria were analyzed retrospectively as European data on this topic are scarce. RESEARCH DESIGN AND METHODS We performed statistical analysis using group comparisons and time series analysis of data of the Austrian Stroke Unit Registry between 2005 and 2016. 87411 patients were divided into three groups (rural, intermediate, urban) according to the degree of urbanisation classification of the European Commission/Eurostat. RESULTS Patients in the rural group were significantly younger, more often female, had a lower pre-stroke disability, and were more frequently transported by an emergency physician. Vascular risk factors were significantly higher in urban patients, leading to a higher rate of microangiopathic etiology. Onset-to-door (ODT) and Onset-to-treatment times were significantly higher in the rural group, but ODTs decreased over time. Door-to-needle times and time to first vascular imaging were significantly lower in the rural group. Intravenous thrombolysis and rehabilitation rates were lower in urban patients. DISCUSSION AND IMPLICATIONS Contrary to previous literature predominantly from outside of Europe, vascular risk factors were higher in Austrian urban patients. Further, rural patients had higher intravenous thrombolysis and rehabilitation rates maybe because of lower pre-stroke disability. ODTs in rural patients were generally higher, but they decreased over time, which might be a consequence of better education of the public in noticing early stroke signs, better transportation and education of emergency medical personnel, better advance notification to the receiving hospital and implementation of Stroke Units in rural areas.
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Affiliation(s)
- Andrija Javor
- Department of Neurology, General Hospital Amstetten, Amstetten, Austria
| | - Julia Ferrari
- Department of Neurology, Hospital St. John´s of God, Vienna, Austria
| | - Alexandra Posekany
- Department of Clinical Neuroscience, Danube University Krems, Krems an der Donau, Austria
- Gesundheit Österreich GmbH/BIQG, Vienna, Austria
| | - Susanne Asenbaum-Nan
- Department of Neurology, General Hospital Amstetten, Amstetten, Austria
- * E-mail:
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18
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Dwyer M, Rehman S, Ottavi T, Stankovich J, Gall S, Peterson G, Ford K, Kinsman L. Urban-rural differences in the care and outcomes of acute stroke patients: Systematic review. J Neurol Sci 2018; 397:63-74. [PMID: 30594105 DOI: 10.1016/j.jns.2018.12.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/14/2018] [Accepted: 12/16/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To describe literature pertaining to urban-rural differences in both the quality of care and outcomes of acute stroke patients. METHODS We systematically searched CINAHL, PubMed, ProQuest Dissertations & Theses, and Scopus for published and unpublished literature until 9th December 2017. Studies were included if they compared the acute care provided to, or outcomes of, patients hospitalised for stroke in urban versus rural settings. Abstract, full-text review, and data extraction were conducted in duplicate. Findings are presented in the form of narrative syntheses. RESULTS A total of 28 studies were included in the review (16 on care, 12 on outcomes). With few exceptions, studies addressing the provision of care suggested that rural patients have less access to most aspects of acute stroke care. Studies reporting urban-rural differences in patient outcomes were inconsistent in their findings, however, few of these studies were primarily focused on the issue of urban-rural disparities. Overall, study findings did not appear to differ in line with study quality ratings, stroke subtypes included, or how inter-facility patient transfers were accounted for. CONCLUSIONS There is convincing, albeit not unanimous, evidence to suggest that stroke patients in rural areas receive less acute care than their urban counterparts. Despite this, the available data and methodology have largely not been used to study urban-rural differences in patient outcomes. PROSPERO registration information: URL: https://www.crd.york.ac.uk/prospero. Unique identifier: CRD42017073262.
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Zhang D, Wang G, Zhu W, Thapa JR, Switzer JA, Hess DC, Smith ML, Ritchey MD. Expansion Of Telestroke Services Improves Quality Of Care Provided In Super Rural Areas. Health Aff (Millwood) 2018; 37:2005-2013. [DOI: 10.1377/hlthaff.2018.05089] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Donglan Zhang
- Donglan Zhang is an assistant professor in the Department of Health Policy and Management, University of Georgia, in Athens
| | - Guijing Wang
- Guijing Wang is an economist at the Centers for Disease Control and Prevention, in Atlanta, Georgia
| | - Weiming Zhu
- Weiming Zhu is an epidemiologist at ProSphere Tek, Inc., in Alexandria, Virginia
| | - Janani R. Thapa
- Janani R. Thapa is an assistant professor in the Department of Health Policy and Management, University of Georgia
| | - Jeffrey A. Switzer
- Jeffrey A. Switzer is an assistant professor in the Department of Neurology, Augusta University, in Georgia
| | - David C. Hess
- David C. Hess is a professor in the Department of Neurology and dean of the Medical College of Georgia, Augusta University
| | - Matthew L. Smith
- Matthew L. Smith is an associate professor in the Department of Environmental and Occupational Health, Texas A&M University, in College Station
| | - Matthew D. Ritchey
- Matthew D. Ritchey is a senior scientist in the Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention
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20
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Seabury S, Bognar K, Xu Y, Huber C, Commerford SR, Tayama D. Regional disparities in the quality of stroke care. Am J Emerg Med 2017; 35:1234-1239. [DOI: 10.1016/j.ajem.2017.03.046] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 03/17/2017] [Accepted: 03/18/2017] [Indexed: 11/24/2022] Open
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Development of a Chronic Disease Management Program for Stroke Survivors Using Intervention Mapping: The Stroke Coach. Arch Phys Med Rehabil 2017; 98:1195-1202. [PMID: 28219685 DOI: 10.1016/j.apmr.2017.01.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 01/06/2017] [Accepted: 01/13/2017] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To describe the systematic development of the Stroke Coach, a theory- and evidence-based intervention to improve control of lifestyle behavior risk factors in patients with stroke. DESIGN Intervention development. SETTING Community. PARTICIPANTS Individuals who have had a stroke. INTERVENTIONS We used intervention mapping to guide the development of the Stroke Coach. Intervention mapping is a systematic process used for intervention development and composed of steps that progress from the integration of theory and evidence to the organization of realistic strategies to facilitate the development of a practical intervention supported by empirical evidence. Social cognitive theory was the underlying premise for behavior change, whereas control theory methods were directed toward sustaining the changes to ensure long-term health benefits. Practical evidence-based strategies were linked to behavioral determinants to improve stroke risk factor control. MAIN OUTCOME MEASURES Not applicable. RESULTS The Stroke Coach is a patient-centered, community-based, telehealth intervention to promote healthy lifestyles after stroke. Over 6 months, participants receive seven 30- to 60-minute telephone sessions with a lifestyle coach who provides education, facilitates motivation for lifestyle modification, and empowers participants to self-management their stroke risk factors. Participants also receive a self-management manual and a self-monitoring kit. CONCLUSIONS Through the use of intervention mapping, we developed a theoretically sound and evidence-grounded intervention to improve risk factor control in patients with stroke. If empirical evaluation of the Stroke Coach produces positive results, the next step will be to develop an implementation intervention to ensure successful uptake and delivery of the program in community and outpatient settings.
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22
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Abstract
What began as a grant-funded demonstration project, as a means of bridging the gap in rural health care, has developed into a critical access hospital system comprising 1328 facilities across 45 states. A critical access hospital is not just a safety net for health care in a rural community. Such hospitals may also provide specialized services such as same-day surgery, infusion therapy, and intensive care. For hospitals located near the required minimum of 35 miles from a tertiary care center, management of critically ill patients may be a matter of stabilization and transfer. Critical access hospitals in more rural areas are often much farther from tertiary care; some of these hospitals are situated within frontier areas of the United States. This article describes the development of critical access hospitals, provision of care and services, challenges to critical care in critical access hospitals, and suggestions to address gaps in research and collaborative care.
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Affiliation(s)
- Teresa J Seright
- Teresa J. Seright is Associate Dean for UG Programs in the College of Nursing, Montana State University. She has maintained critical care certification (CCRN) through direct patient care in the emergency/trauma center and catheterization laboratory at Trinity Health, Minot, North Dakota, and the emergency department and recovery room at Bozeman Deaconess Hospital, Bozeman, Montana.Charlene A. Winters is a professor in the College of Nursing, Montana State University, focusing on issues related to rural health and rural health care practice.
| | - Charlene A Winters
- Teresa J. Seright is Associate Dean for UG Programs in the College of Nursing, Montana State University. She has maintained critical care certification (CCRN) through direct patient care in the emergency/trauma center and catheterization laboratory at Trinity Health, Minot, North Dakota, and the emergency department and recovery room at Bozeman Deaconess Hospital, Bozeman, Montana.Charlene A. Winters is a professor in the College of Nursing, Montana State University, focusing on issues related to rural health and rural health care practice
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Pan Y, Chen R, Li Z, Li H, Zhao X, Liu L, Wang C, Wang Y, Wang Y. Socioeconomic Status and the Quality of Acute Stroke Care: The China National Stroke Registry. Stroke 2016; 47:2836-2842. [PMID: 27758939 DOI: 10.1161/strokeaha.116.013292] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 08/22/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The association of socioeconomic status (SES) with quality of stroke care is not well understood, and few studies have examined the association with different indicators of SES simultaneously. We assessed the impacts of low levels of education, occupation, and income on the quality of stroke care. METHODS We examined data from the China National Stroke Registry recording consecutive stroke patients between September 2007 and August 2008. Baseline low SES was measured using educational level <6 years, occupation as manual workers or no job, and average family income per capita at ≤¥1000 per month. Compliance with 11 performances was summarized in a composite score defined as the proportion of all needed care given. Poor quality of care was defined as having a composite score of 0.71 or less. RESULTS Among 12 270 patients with ischemic stroke, 38.6% had <6 educational years, 37.6% had manual workers/no job, and 34.7% had income ≤¥1000 per month. There was an increased chance of receiving poor quality of care in patients with low education (adjusted odds ratio 1.15, 95% confidence interval 1.03-1.28), low occupation (adjusted odds ratio 1.16, 95% confidence interval 1.01-1.32), and low income (adjusted odds ratio 1.18, 95% confidence interval 1.06-1.30), respectively. People with low SES had poor performances on some aspects of care quality. Combined effects existed among these SES indicators; those with low SES from all 3 indicators had the poorest quality of care. CONCLUSIONS There was a social gradient in the quality of stroke care. Continuous efforts of socioeconomic improvement will increase the quality of acute stroke care.
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Affiliation(s)
- Yuesong Pan
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Center of Stroke, Beijing Institute for Brain Disorders, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China (Y.P.); and Centre for Health and Social Care Improvement, Faculty of Education Health and Wellbeing, University of Wolverhampton, United Kingdom (R.C.)
| | - Ruoling Chen
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Center of Stroke, Beijing Institute for Brain Disorders, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China (Y.P.); and Centre for Health and Social Care Improvement, Faculty of Education Health and Wellbeing, University of Wolverhampton, United Kingdom (R.C.).
| | - Zixiao Li
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Center of Stroke, Beijing Institute for Brain Disorders, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China (Y.P.); and Centre for Health and Social Care Improvement, Faculty of Education Health and Wellbeing, University of Wolverhampton, United Kingdom (R.C.)
| | - Hao Li
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Center of Stroke, Beijing Institute for Brain Disorders, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China (Y.P.); and Centre for Health and Social Care Improvement, Faculty of Education Health and Wellbeing, University of Wolverhampton, United Kingdom (R.C.)
| | - Xingquan Zhao
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Center of Stroke, Beijing Institute for Brain Disorders, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China (Y.P.); and Centre for Health and Social Care Improvement, Faculty of Education Health and Wellbeing, University of Wolverhampton, United Kingdom (R.C.)
| | - Liping Liu
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Center of Stroke, Beijing Institute for Brain Disorders, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China (Y.P.); and Centre for Health and Social Care Improvement, Faculty of Education Health and Wellbeing, University of Wolverhampton, United Kingdom (R.C.)
| | - Chunxue Wang
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Center of Stroke, Beijing Institute for Brain Disorders, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China (Y.P.); and Centre for Health and Social Care Improvement, Faculty of Education Health and Wellbeing, University of Wolverhampton, United Kingdom (R.C.)
| | - Yilong Wang
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Center of Stroke, Beijing Institute for Brain Disorders, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China (Y.P.); and Centre for Health and Social Care Improvement, Faculty of Education Health and Wellbeing, University of Wolverhampton, United Kingdom (R.C.).
| | - Yongjun Wang
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Center of Stroke, Beijing Institute for Brain Disorders, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (Y.P., Z.L., H.L., X.Z., L.L., C.W., Yilong Wang, Yongjun Wang); Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China (Y.P.); and Centre for Health and Social Care Improvement, Faculty of Education Health and Wellbeing, University of Wolverhampton, United Kingdom (R.C.).
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Cohen SA, Cook SK, Kelley L, Foutz JD, Sando TA. A Closer Look at Rural-Urban Health Disparities: Associations Between Obesity and Rurality Vary by Geospatial and Sociodemographic Factors. J Rural Health 2016; 33:167-179. [PMID: 27557442 DOI: 10.1111/jrh.12207] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 05/10/2016] [Accepted: 07/05/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Obesity affects over one-third of older adults in the United States. Both aging and obesity contribute to an increased risk for chronic disease, early mortality, and additional health care utilization. Obesity rates are higher in rural areas than in urban areas, although findings are mixed. The objectives of this study are to assess potential nonlinearity in the association between rurality and obesity, and to evaluate the potential for socioeconomic status and geographic area to moderate the associations between rurality and obesity. METHODS Using a representative sample of adults aged 65 and above from the Behavioral Risk Factor Surveillance System, obesity (BMI ≥ 30 kg/m2 ) was modeled against the primary exposure of rural-urban status, as measured by the Index of Relative Rurality. Binary logistic regression models were used to estimate the odds of obesity by rurality both as a continuous variable and by decile of rurality. Models were then stratified by per-capita income and state to assess potential moderation by these factors. RESULTS The prevalence of obesity in older adults was highest in intermediate rurality areas (OR in rurality decile #5 1.134, 95% CI: 1.086-1.184) and lowest in the most rural and most urban areas. Obesity was highest in low- and middle-income areas, regardless of rural-urban status. In high-income areas, obesity among older adults was highest in areas of intermediate rurality and lowest in the most rural areas (OR 0.726, 95% CI: 0.606-0.870) and more urban areas, showing a J-shaped association. There were substantial differences in the associations between rurality and obesity in older adults among states. CONCLUSION Associations between rurality and obesity varied by degree of rurality, socioeconomic status, and geography. Therefore, traditional "one-size-fits-all" approaches to reducing rural-urban health disparities in older adults may be more effective if tailored to the area-specific rural-urban gradients in health.
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Affiliation(s)
- Steven A Cohen
- Health Studies Program, Department of Kinesiology, University of Rhode Island, Kingston, Rhode Island
| | - Sarah K Cook
- Center on Society and Health, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Lauren Kelley
- Center on Society and Health, Virginia Commonwealth University School of Medicine, Richmond, Virginia.,Division of Epidemiology, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
| | - Julia D Foutz
- Division of Epidemiology, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
| | - Trisha A Sando
- Division of Epidemiology, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
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Moloczij N, Mosley I, Moss KM, Bagot KL, Bladin CF, Cadilhac DA. Is telemedicine helping or hindering the delivery of stroke thrombolysis in rural areas? A qualitative analysis. Intern Med J 2016; 45:957-64. [PMID: 25904209 DOI: 10.1111/imj.12793] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 04/15/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fast diagnosis and delivery of treatment to patients experiencing acute stroke can reduce subsequent disability. While telemedicine can improve rural community access to specialists and facilitate timely diagnosis and treatment decisions, it is not widely used for stroke in Australia. AIM Identifying the barriers and facilitators to clinician engagement with, and utilisation of, telemedicine consultations could expedite implementation in rural and remote locations. METHODS Purposive sampling was used to identify and recruit medical and nursing staff varying in telemedicine experience across one hospital department. Twenty-four in-depth, face-to-face interviews were conducted examining aspects surrounding stroke telemedicine uptake. Inductive qualitative thematic analysis was undertaken, and two further researchers verified coding. RESULTS The main barriers identified were contrasting opinions about the utility of thrombolysis for treating acute stroke, lack of confidence in the telemedicine system, perceived limited need for specialist advice and concerns about receiving advice from an unfamiliar doctor. Facilitators included assistance with diagnosis and treatment, the need for a user-friendly system and access to specialists for complex cases. CONCLUSIONS Acceptability of telemedicine for acute stroke was multifaceted and closely aligned with regional clinician beliefs about the value of thrombolysis for stroke, highlighting an important area for education. Addressing beliefs about treatment efficacy and other perceived barriers is important for establishing a stroke telemedicine programme.
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Affiliation(s)
- N Moloczij
- Medical and Cognitive Research Unit, Austin Health, Heidelberg, Victoria, Australia
| | - I Mosley
- National Trauma Research Institute, Alfred Health, Melbourne, Victoria, Australia
| | - K M Moss
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| | - K L Bagot
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| | - C F Bladin
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia.,Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - D A Cadilhac
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia.,Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
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Kidney Cancer in Rural Illinois: Lower Incidence Yet Higher Mortality Rates. Urology 2016; 94:90-5. [PMID: 27215485 DOI: 10.1016/j.urology.2016.05.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 04/29/2016] [Accepted: 05/03/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine if rural status was associated with kidney and renal pelvis cancer (KCa) incidence and mortality in Illinois while controlling for known KCa risk factors and access to care variables. MATERIALS AND METHODS Age-adjusted KCa incidence rates from 1991 to 2010 were calculated from Illinois State Cancer Registry data. Age-adjusted KCa mortality rates were obtained from health statistics embedded within SEER*Stat. Rural Urban Continuum Codes designated Illinois' 102 counties as urban, rural adjacent to, and rural non-adjacent to a metropolitan area. County-level demographics and physician density were obtained from the Area Health Resource File. Behavioral Risk Factor Surveillance System data were used for smoking, obesity, and hypertension prevalence. Analysis of variance, correlation, and regression analyses were used. RESULTS The incidence of KCa was found to be higher among urban compared to rural counties after controlling for known risk factors (P < .01). A larger proportion of cases were diagnosed at a localized stage in urban counties (<0.01). Mortality rates were significantly higher in rural counties (P = .02). The final regression model found rural status, higher incidence rate, fewer with localized stage at diagnosis, and lower urologist density to be variables significantly associated with higher KCa mortality. CONCLUSION KCa incidence was higher in urban counties whereas mortality was higher in rural counties. The higher number of KCa cases diagnosed at a localized stage in urban counties and lower urologist density in rural counties suggest that poorer access to care may contribute to higher KCa mortality in rural Illinois. Telemedicine may be an opportunity to improve this disparity.
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Middleton S, Lydtin A, Comerford D, Cadilhac DA, McElduff P, Dale S, Hill K, Longworth M, Ward J, Cheung NW, D'Este C. From QASC to QASCIP: successful Australian translational scale-up and spread of a proven intervention in acute stroke using a prospective pre-test/post-test study design. BMJ Open 2016; 6:e011568. [PMID: 27154485 PMCID: PMC4861111 DOI: 10.1136/bmjopen-2016-011568] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES To embed an evidence-based intervention to manage FEver, hyperglycaemia (Sugar) and Swallowing (the FeSS protocols) in stroke, previously demonstrated in the Quality in Acute Stroke Care (QASC) trial to decrease 90-day death and dependency, into all stroke services in New South Wales (NSW), Australia's most populous state. DESIGN Pre-test/post-test prospective study. SETTING 36 NSW stroke services. METHODS Our clinical translational initiative, the QASC Implementation Project (QASCIP), targeted stroke services to embed 3 nurse-led clinical protocols (the FeSS protocols) into routine practice. Clinical champions attended a 1-day multidisciplinary training workshop and received standardised educational resources and ongoing support. Using the National Stroke Foundation audit collection tool and processes, patient data from retrospective medical record self-reported audits for 40 consecutive patients with stroke per site pre-QASCIP (1 July 2012 to 31 December 2012) were compared with prospective self-reported data from 40 consecutive patients with stroke per site post-QASCIP (1 November 2013 to 28 February 2014). Inter-rater reliability was substantial for 10 of 12 variables. PRIMARY OUTCOME MEASURES Proportion of patients receiving care according to the FeSS protocols pre-QASCIP to post-QASCIP. RESULTS All 36 (100%) NSW stroke services participated, nominating 100 site champions who attended our educational workshops. The time from start of intervention to completion of post-QASCIP data collection was 8 months. All (n=36, 100%) sites provided medical record audit data for 2144 patients (n=1062 pre-QASCIP; n=1082 post-QASCIP). Pre-QASCIP to post-QASCIP, proportions of patients receiving the 3 targeted clinical behaviours increased significantly: management of fever (pre: 69%; post: 78%; p=0.003), hyperglycaemia (pre: 23%; post: 34%; p=0.0085) and swallowing (pre: 42%; post: 51%; p=0.033). CONCLUSIONS We obtained unprecedented statewide scale-up and spread to all NSW stroke services of a nurse-led intervention previously proven to improve long-term patient outcomes. As clinical leaders search for strategies to improve quality of care, our initiative is replicable and feasible in other acute care settings.
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Affiliation(s)
- Sandy Middleton
- Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, Sydney, New South Wales, Australia
| | - Anna Lydtin
- Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, Sydney, New South Wales, Australia
| | - Daniel Comerford
- NSW Agency for Clinical Innovation, Chatswood, New South Wales, Australia
| | - Dominique A Cadilhac
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Patrick McElduff
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Simeon Dale
- Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, Sydney, New South Wales, Australia
| | - Kelvin Hill
- National Stroke Foundation, Melbourne, Victoria, Australia
| | - Mark Longworth
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Jeanette Ward
- University of Notre Dame, Broom Campus, Broome, Western Australia, Australia
- University of Ottawa, Ottawa, Canada
| | - N Wah Cheung
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Cate D'Este
- National Centre for Epidemiology and Population Health (NCEPH), Australian National University, Canberra, Australian Capital Territory, Australia
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Evidence-Based Policy Making: Assessment of the American Heart Association’s Strategic Policy Portfolio. Circulation 2016; 133:e615-53. [DOI: 10.1161/cir.0000000000000410] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Iihara K. Comprehensive Stroke Care Capabilities in Japan: A Neurovascular Surgeon's Perspective. Neurosurgery 2015; 62 Suppl 1:107-16. [PMID: 26181928 DOI: 10.1227/neu.0000000000000806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Curran HJ, Hubacek J, Southern D, Galbraith D, Knudtson ML, Ghali WA, Graham MM. The effect of a regional care model on cardiac catheterization rates in patients with Acute Coronary Syndromes. BMC Health Serv Res 2014; 14:550. [PMID: 25496485 PMCID: PMC4230349 DOI: 10.1186/s12913-014-0550-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 10/24/2014] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Patients with ACS often present to community hospitals without on-site cardiac catheterization and revascularization therapies. Transfer to specialized cardiac procedural centers is necessary to provide access to these procedures. We evaluated process of care within a regional care model by comparing cardiac catheterization and revascularization rates and outcomes in ACS patients presenting to community and interventional hospitals. METHODS We evaluated a total of 6154 patients with ACS admitted to Southern Alberta hospitals (where a distinct regional care model for ACS exists) between January 1, 2005 and December 31, 2009. We compared cardiac catheterization and revascularization rates during index hospitalization among patients admitted to community and interventional hospitals. Thirty day and 1-year survival were also evaluated. RESULTS Catheterization was performed more often in patients presenting to community hospitals compared to the interventional facility (respectively 69.5% and 51.4%, p < 0.0001). Catheterization within 72 hours of admission occurred in 48% of patients presenting to the interventional center and in 68.3% of community patients (P < 0.0001). In patients undergoing catheterization, revascularization (PCI and/or CABG) was also performed more frequently in the community group (74.5% vs 56.1%, P < 0.0001). Risk adjusted mortality rates were the same for patients undergoing cardiac catheterization regardless of hospital of initial presentation. CONCLUSION ACS patients presenting to community centers associated with a regional care model had effective access to cardiac catheterization and revascularization. These findings support the importance of regional initiatives and processes of care that facilitate access to cardiac catheterization for all ACS patients.
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Affiliation(s)
- Helen J Curran
- />Division of Cardiology, Dalhousie University, room 2145, Halifax Infirmary, 1796 Summer Street, Halifax, B3H 3A7 Nova Scotia Canada
| | - Jaroslav Hubacek
- />The New Brunswick Heart Center, Saint John, New Brunswick Canada
| | - Danielle Southern
- />Centre for Health and Policy Studies University of Calgary, Calgary, Alberta Canada
| | - Diane Galbraith
- />The APPROACH Project Office, University of Calgary, Calgary, Alberta Canada
| | - Merril L Knudtson
- />Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta Canada
| | - William A Ghali
- />Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta Canada
| | - Michelle M Graham
- />Department of Medicine and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta Canada
- />Division of Cardiology, University of Alberta Hospital, 8440-112 Street, Edmonton, T6G 2R7 Alberta Canada
| | - on behalf of the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Investigators
- />Division of Cardiology, Dalhousie University, room 2145, Halifax Infirmary, 1796 Summer Street, Halifax, B3H 3A7 Nova Scotia Canada
- />The New Brunswick Heart Center, Saint John, New Brunswick Canada
- />Centre for Health and Policy Studies University of Calgary, Calgary, Alberta Canada
- />The APPROACH Project Office, University of Calgary, Calgary, Alberta Canada
- />Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta Canada
- />Department of Medicine and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta Canada
- />Division of Cardiology, University of Alberta Hospital, 8440-112 Street, Edmonton, T6G 2R7 Alberta Canada
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Iihara K, Nishimura K, Kada A, Nakagawara J, Toyoda K, Ogasawara K, Ono J, Shiokawa Y, Aruga T, Miyachi S, Nagata I, Matsuda S, Ishikawa KB, Suzuki A, Mori H, Nakamura F. The Impact of Comprehensive Stroke Care Capacity on the Hospital Volume of Stroke Interventions: A Nationwide Study in Japan: J-ASPECT Study. J Stroke Cerebrovasc Dis 2014; 23:1001-18. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.08.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 08/08/2013] [Accepted: 08/21/2013] [Indexed: 11/30/2022] Open
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Wu TC, Lyerly MJ, Albright KC, Ward E, Hassler A, Messier J, Wolff C, Brannas CC, Savitz SI, Carr BG. Impact of Telemedicine on Access to Acute Stroke Care in the State of Texas. Ann Clin Transl Neurol 2013; 1:27-33. [PMID: 24535938 PMCID: PMC3925075 DOI: 10.1002/acn3.20] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background To examine the impact of telemedicine (TM) on access to acute stroke care and expertise in the state of Texas. Methods Texas hospitals were surveyed using a standard questionnaire and categorized as: (1) stand-alone Primary Stroke Centers (PSC) not using TM for acute stroke care, (2) PSC using TM for acute stroke care, (3) non-PSC hospitals using TM for acute stroke care, or (4) non-PSC hospitals not using TM for acute stroke care. Population data were obtained from the U.S. Census Bureau and the Neilson Claritas Demographic Estimation Program. Access within 60 min to a designated facility was calculated at the block group level. Results Over 75% of Texans had 60-min access to a stand-alone PSC. Including PSC using TM increased access by 6.5%. Adding non-PSC that use TM for acute stroke care provided 60-min access for an additional 2% of Texans, leaving 16% of Texans without 60-min access to acute stroke care. Approximately 62% of Texans had 60-min access to more than one type of facility that provided acute stroke care. Conclusion The use of TM in the state of Texas brought 60-min access to >2 million Texans who otherwise would not have had access to acute stroke expertise. Our findings demonstrate that using TM for acute stroke has the ability to provide neurologically underserved areas access to acute stroke care.
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Affiliation(s)
- Tzu-Ching Wu
- Stroke Program, Department of Neurology, University of Texas-Houston Memorial Hermann Medical CenterHouston, Texas 77030
- Correspondence Tzu-Ching Wu, Department of Neurology, The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.120, Houston, TX 77030. Tel: +1 713-500-7082; Fax: +1 713-500-0660; E-mail:
| | - Michael J Lyerly
- Department of Neurology, School of Medicine, University of Alabama at BirminghamBirmingham, Alabama 35294
| | - Karen C Albright
- Department of Epidemiology, School of Public Health, University of Alabama at BirminghamBirmingham, Alabama 35294
- Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (COERE), University of Alabama at BirminghamBirmingham, Alabama 35294
- Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities (CERED) Minority Health and Health Disparities Research Center (MHRC), University of Alabama at BirminghamBirmingham, Alabama 35294
| | - Eric Ward
- Stroke Program, Department of Neurology, University of Texas-Houston Memorial Hermann Medical CenterHouston, Texas 77030
| | - Amanda Hassler
- Stroke Program, Department of Neurology, University of Texas-Houston Memorial Hermann Medical CenterHouston, Texas 77030
| | - Jessica Messier
- Stroke Program, Department of Neurology, University of Texas-Houston Memorial Hermann Medical CenterHouston, Texas 77030
| | - Catherine Wolff
- Department of Clinical Epidemiology and Biostatistics, University of PennsylvaniaPhiladelphia, Pennsylvania 19104
| | - Charles C Brannas
- Department of Clinical Epidemiology and Biostatistics, University of PennsylvaniaPhiladelphia, Pennsylvania 19104
| | - Sean I Savitz
- Stroke Program, Department of Neurology, University of Texas-Houston Memorial Hermann Medical CenterHouston, Texas 77030
| | - Brendan G Carr
- Department of Clinical Epidemiology and Biostatistics, University of PennsylvaniaPhiladelphia, Pennsylvania 19104
- Department of Emergency Medicine, University of PennsylvaniaPhiladelphia, Pennsylvania 19104
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Patel MD, Brice JH, Evenson KR, Rose KM, Suchindran CM, Rosamond WD. Emergency medical services capacity for prehospital stroke care in North Carolina. Prev Chronic Dis 2013; 10:E149. [PMID: 24007677 PMCID: PMC3767834 DOI: 10.5888/pcd10.130035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction Prior assessments of emergency medical services (EMS) stroke capacity found deficiencies in education and training, use of protocols and screening tools, and planning for the transport of patients. A 2001 survey of North Carolina EMS providers found many EMS systems lacked basic stroke services. Recent statewide efforts have sought to standardize and improve prehospital stroke care. The objective of this study was to assess EMS stroke care capacity in North Carolina and evaluate statewide changes since 2001. Methods In June 2012, we conducted a web-based survey on stroke education and training and stroke care practices and policies among all EMS systems in North Carolina. We used the McNemar test to assess changes from 2001 to 2012. Results Of 100 EMS systems in North Carolina, 98 responded to our survey. Most systems reported providing stroke education and training (95%) to EMS personnel, using a validated stroke scale or screening tool (96%), and having a hospital prenotification policy (98%). Many were suboptimal in covering basic stroke educational topics (71%), always communicating stroke screen results to the destination hospital (46%), and always using a written destination plan (49%). Among 70 EMS systems for which we had data for 2001 and 2012, we observed significant improvements in education on stroke scales or screening tools (61% to 93%, P < .001) and use of validated stroke scales or screening tools (23% to 96%, P < .001). Conclusion Major improvements in EMS stroke care, especially in prehospital stroke screening, have occurred in North Carolina in the past decade, whereas other practices and policies, including use of destination plans, remain in need of improvement.
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Affiliation(s)
- Mehul D Patel
- Department of Epidemiology, Cardiovascular Disease Program, 137 E Franklin St., Chapel Hill, NC 27514, USA.
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Geographic information systems and chronic kidney disease: racial disparities, rural residence and forecasting. J Nephrol 2013; 26:3-15. [PMID: 23065915 DOI: 10.5301/jn.5000225] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2012] [Indexed: 11/20/2022]
Abstract
The dynamics of health and health care provision in the United States vary substantially across regions, and there is substantial regional heterogeneity in population density, age distribution, disease prevalence, race and ethnicity, poverty and the ability to access care. Geocoding and geographic information systems (GIS) are important tools to link patient or population location to information regarding these characteristics. In this review, we provide an overview of basic GIS concepts and provide examples to illustrate how GIS techniques have been applied to the study of kidney disease, and in particular to understanding the interplay between race, poverty, rural residence and the planning of renal services for this population. The interplay of socioeconomic status and renal disease outcomes remains an important area for investigation and recent publications have explored this relationship utilizing GIS techniques to incorporate measures of socioeconomic status and racial composition of neighborhoods. In addition, there are many potential challenges in providing care to rural patients with chronic kidney disease including long travel times and sparse renal services such as transplant and dialysis centers. Geospatially fluent analytic approaches can also inform system level analyses of health care systems and these approaches can be applied to identify an optimal distribution of dialysis facilities. GIS analysis could help untangle the complex interplay between geography, socioeconomic status, and racial disparities in chronic kidney disease, and could inform policy decisions and resource allocation as the population ages and the prevalence of renal disease increases.
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Cadilhac DA, Purvis T, Kilkenny MF, Longworth M, Mohr K, Pollack M, Levi CR. Evaluation of rural stroke services: does implementation of coordinators and pathways improve care in rural hospitals? Stroke 2013; 44:2848-53. [PMID: 23950561 DOI: 10.1161/strokeaha.113.001258] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The quality of hospital care for stroke varies, particularly in rural areas. In 2007, funding to improve stroke care became available as part of the Rural Stroke Project (RSP) in New South Wales (Australia). The RSP included the employment of clinical coordinators to establish stroke units or pathways and protocols, and more clinical staff. We aimed to describe the effectiveness of RSP in improving stroke care and patient outcomes. METHODS A historical control cohort design was used. Clinical practice and outcomes at 8 hospitals were compared using 2 medical record reviews of 100 consecutive ischemic or intracerebral hemorrhage patients ≥12 months before RSP and 3 to 6 months after RSP was implemented. Descriptive statistics and multivariable analyses of patient outcomes are presented. RESULTS SAMPLE pre-RSP n=750; mean age 74 (SD, 13) years; women 50% and post-RSP n=730; mean age 74 (SD, 13) years; women 46%. Many improvements in stroke care were found after RSP: access to stroke units (pre 0%; post 58%, P<0.001); use of aspirin within 24 hours of ischemic stroke (pre 59%; post 71%, P<0.001); use of care plans (pre 15%; post 63%, P<0.001); and allied health assessments within 48 hours (pre 65%; post 82% P<0.001). After implementation of the RSP, patients directly admitted to an RSP hospital were 89% more likely to be discharged home (adjusted odds ratio, 1.89; 95% confidence interval, 1.34-2.66). CONCLUSIONS Investment in clinical coordinators who implemented organizational change, together with increased clinician resources, effectively improved stroke care in rural hospitals, resulting in more patients being discharged home.
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Affiliation(s)
- Dominique A Cadilhac
- From the Translational Public Health Unit, Stroke and Ageing Research Centre, Department of Medicine, Southern Clinical School, Monash University, Clayton, Australia (D.A.C., T.P., M.K.); Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia (D.A.C., T.P., M.K.); Stroke Services New South Wales, New South Wales Agency for Clinical Innovation, New South Wales, Australia (M.L.); Wagga Wagga Base Hospital, Wagga Wagga, New South Wales, Australia (K.M.); Hunter Stroke Service, Hunter New England Area Health, Rankin Park Centre, New South Wales, Australia (M.P.); Centre for Brain and Mental Health Research, University of Newcastle and Hunter Medical Research Institute, New Lambton, New South Wales, Australia (C.L.); and John Hunter Hospital, Newcastle, New South Wales, Australia (C.L.)
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Habeych ME, García-Habeych JM, Castilla-Puentes RC. Different neurological conditions between urban and rural samples from central Colombia. J Neurol Sci 2012; 320:56-60. [PMID: 22831764 DOI: 10.1016/j.jns.2012.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Revised: 05/25/2012] [Accepted: 06/23/2012] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Despite availability of neuroepidemiological data, urban-rural differences on neurological diseases have almost never been considered. Our goal is to identify differences in the frequency of neurological conditions between a rural and an urban sample from central Colombia. METHODS We compared frequencies of neurological encounters of an urban sample from Bogotá (N=2932), to our rural sample from Tunja (N=2664), collected both circa to 2000. The classification of neurological conditions used is based on the 9th revision of the International Classification of Diseases, clinical modification. A clustered sampling was used. Information collection was performed in a format designed for this purpose and already used in Colombia. RESULTS Highly significant statistical differences (p<0.0001) were found for cerebrovascular diseases, seizure disorder, headache, Parkinson's disease and other movement disorders, and, inflammatory (infectious) conditions. Neurodevelopmental disorders (p=0.0029), dizziness and balance problems (p=0.0018), and neuropathies (p=0.0007), also showed statistically significant differences. CONCLUSIONS Our study showed significant differences on all categories and diagnostics between the samples. Cerebrovascular disease the most frequent reason of neurological consultation in the rural sample could be confounded by sociodemographic (aging of the population, urbanization process), or the concomitant presence of medical (chronic pulmonary) and/or environmental (air pollution) conditions.
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Affiliation(s)
- Miguel E Habeych
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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Casey MM, Moscovice I, Klingner J, Prasad S. Rural relevant quality measures for critical access hospitals. J Rural Health 2012; 29:159-71. [PMID: 23551646 DOI: 10.1111/j.1748-0361.2012.00420.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE To identify current and future relevant quality measures for Critical Access Hospitals (CAHs). METHODS Three criteria (patient volume, internal usefulness for quality improvement, and external usefulness for public reporting and payment reform) were used to analyze quality measures for their relevance for CAHs. A 6-member panel with expertise in rural hospital quality measurement and improvement provided input regarding the final measure selection. FINDINGS The relevant quality measures for CAHs include measures that are ready for reporting now and measures that need specifications to be finalized and/or a data reporting mechanism to be established. They include inpatient measures for specific medical conditions, global measures that address appropriate care across multiple medical conditions, and Emergency Department measures. CONCLUSIONS All CAHs should publicly report on relevant quality measures. Acceptance of a single consolidated set of quality measures with common specifications for CAHs by all entities involved in regulation, accreditation, and payment; a phased process to implement the relevant measures; and the provision of technical assistance would help CAHs meet the challenge of reporting.
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Affiliation(s)
- Michelle M Casey
- Rural Health Research Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN 55414, USA.
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Choi HY, Cha MJ, Nam HS, Kim YD, Hong KS, Heo JH. Stroke units and stroke care services in Korea. Int J Stroke 2012; 7:336-40. [PMID: 22510228 DOI: 10.1111/j.1747-4949.2012.00788.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Organized stroke care systems improve stroke outcomes, but require resources and quality-improvement programs. This study was aimed at understanding the current status of stroke care services and stroke units in Korea. An on-line survey to investigate stroke services was conducted using a structured questionnaire for physicians who were in charge of stroke services or neurology departments of Korean hospitals that had neurology resident training programs. Of the 86 neurology training hospitals in Korea, 67 (78·0%) participated in this study. Brain computed tomography and computed tomography angiography were available 24 h a day and seven days a week (24/7) in all hospitals. More than 95% of hospitals offered transcranial Doppler, carotid duplex sonography, echocardiography, and conventional catheter angiography. Intravenous thrombolysis and hemicraniectomy for ischemic brain edema were provided 24/7 in all hospitals, and 50 hospitals (74·6%) were capable of intra-arterial thrombolysis. Stent or angioplasty was more frequently performed than endarterectomy. Performance measures were monitored in 57 hospitals (85·1%). Twenty-nine (43·3%) hospitals had stroke units. Stroke units were more common as the number of beds in the hospital increased (P = 0·001). When compared with hospitals without stroke units, stroke coordinators, use of general management protocol and education program for stroke team were more frequently available in the hospitals with stroke units. Most neurology training hospitals in Korea offered competent acute stroke care services. However, stroke units have not been widely implemented. Encouragement and support at the government or national stroke society level would promote the implementation of stroke units with little additional effort.
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Affiliation(s)
- Hye-Yeon Choi
- Department of Neurology, Kyung Hee University College of Medicine, Kangdong Hospital, Seoul, Korea
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