Cost Avoidance Associated With Optimal Stroke Care in Canada

The Clinical Usefulness of the Practice Resource for Driving after Stroke (PReDAS)

Occupational Therapists (OTs) have identified a critical need for organized, evidence-based resources to approach driving post-stroke. The Practice Resource for Driving After Stroke (PReDAS) is a resource to support the clinical reasoning and practice of health professionals for addressing driving in acute stroke care. The purpose of this pilot study is to evaluate the usefulness of the PReDAS to support clinician and patient decision-making about return to driving after stroke/Transient Ischemic Attack (TIA) in the acute care hospital setting. OTs, physicians, and patients diagnosed with stroke/TIA were surveyed regarding their experience with the PReDAS in acute care. Patient participants were also contacted for a follow-up questionnaire. OT, physician and patient stakeholders reported the PReDAS was useful to support decision-making for driving. The majority of patients recalled information provided in acute care and abstained from driving as advised. This study provides preliminary support for the clinical usefulness of the PReDAS.

Considerations for at-home upper-limb rehabilitation technology following stroke: Perspectives of stroke survivors and therapists

Introduction

This study investigated the needs of stroke survivors and therapists, and how they may contrast, for the design of robots for at-home post stroke rehabilitation therapy, in the Ontario, Canada, context.

Methods

Individual interviews were conducted with stroke survivors (n = 10) and therapists (n = 6). The transcripts were coded using thematic analysis inspired by the WHO International Classification of Functioning, Disability, and Health.

Results

Design recommendations, potential features, and barriers were identified from the interviews. Stroke survivors and therapists agreed on many of the needs for at-home robotic rehabilitation; however, stroke survivors had more insights into their home environment, barriers, and needs relating to technology, while therapists had more insights into therapy methodology and patient safety and interaction. Both groups felt a one-size-fits-all approach to rehabilitation robot design is inappropriate. Designs could address a broader range of impairments by incorporating household items and breaking activities down into their component motions. Designs should incorporate hand and wrist supports and activities. Designs should monitor trunk and shoulder motion and consider incorporating group activities.

Conclusion

While therapists can provide insight in the early stages of design of rehabilitation technology, stroke survivors' perspectives are crucial to designing for the home environment.

Moving from traditional to more advanced treatments in stroke care is cost-effective: A case study from Greece

OBJECTIVES

Stroke is the most common cause of disability in high-income countries. Several countries offer a limited range of advanced treatments with implications for outcomes, disability and costs. This study estimates the burden of disability that could have been avoided through the transition from traditional (no intravenous thrombolytic therapy (IVT), or endovascular thrombectomy (EVT)) to modern stroke treatments (treatment in stroke units, IVT and EVT). We perform a cost-effectiveness analysis comparing best practice with traditional stroke care, using Greece as a case study.

MATERIALS AND METHODS

A Markov model was used to calculate costs and Quality Adjusted Life Years (QALYs) for each treatment strategy, using a lifetime horizon. Data for model inputs were derived from meta-analyses of trials, and national and international cost databases. Sensitivity analyses were also performed to address potential uncertainty and test the robustness of the findings.

RESULTS

Incremental effectiveness comprised 0.22 QALYs per patient and year. Best practice was cost-effective for more than 90% of all iterations (ICER for the baseline scenario: €2,109.25/QALY). Sensitivity analysis demonstrated that the findings remain robust. Considering the stroke incidence in Greece, the annual additional cost to implement best practice was calculated to be between 0.07%-0.15% of the total health expenditure.

CONCLUSION

Best practice stroke treatment was cost-effective and affordable in a case study based on Greece. The results could be leveraged by including effects of preventive policies and rehabilitation. They also highlight the importance of adopting modern treatment strategies from a cost-effectiveness perspective, apart from the improved clinical outcomes.

Priorities among effective clinical preventive services in British Columbia, Canada

Background

Despite the long-standing experience of rating the evidence for clinical preventive services, the delivery of effective clinical preventive services in Canada and elsewhere is less than optimal. We outline an approach used in British Columbia to assist in determining which effective clinical preventive services are worth doing.

Methods

We calculated the clinically preventable burden and cost-effectiveness for 28 clinical preventive services that received a ‘strong or conditional (weak) recommendation for’ by the Canadian Task Force on Preventive Health Care or an ‘A’ or ‘B’ rating by the United States Preventive Services Task Force. Clinically preventable burden is the total quality adjusted life years that could be gained if the clinical preventive services were delivered at recommended intervals to a British Columbia birth cohort of 40,000 individuals over the years of life that the service is recommended. Cost-effectiveness is the net cost per quality adjusted life year gained.

Results

Clinical preventive services with the highest population impact and best value for money include services that address tobacco use in adolescents and adults, exclusive breastfeeding, and screening for hypertension and other cardiovascular disease risk factors followed by appropriate pharmaceutical treatment. In addition, alcohol misuse screening and brief counseling, one-time screening for hepatitis C virus infection in British Columbia adults born between 1945 and 1965, and screening for type 2 diabetes approach these high-value clinical preventive services.

Conclusions

These results enable policy makers to say with some confidence what preventive manoeuvres are worth doing but further work is required to determine the best way to deliver these services to all those eligible and to establish what supportive services are required. After all, if a clinical preventive service is worth doing, it is worth doing well.

Cost-Effectiveness of Monitoring Patients Post-Stroke With Mobile ECG During the Hospital Stay

Background

The effectiveness of a nurse‐led in‐hospital monitoring protocol with mobile ECG (iECG) was investigated for detecting atrial fibrillation in patients post‐ischemic stroke or post‐transient ischemic attack. The study aimed to assess the cost‐effectiveness of using iECG during the initial hospital stay compared with standard 24‐hour Holter monitoring.

Methods and Results

A Markov microsimulation model was constructed to simulate the lifetime health outcomes and costs. The rate of atrial fibrillation detection in iECG and Holter monitoring during the in‐hospital phase and characteristics of modeled population (ie, age, sex, CHA2DS2‐VASc) were informed by patient‐level data. Costs related to recurrent stroke, stroke management, medications (new oral anticoagulants), and rehabilitation were included. The cost‐effectiveness analysis outcome was calculated as an incremental cost per quality‐adjusted life‐year gained. As results, monitoring patients with iECG post‐stroke during the index hospitalization was associated with marginally higher costs (A$31 196) and greater benefits (6.70 quality‐adjusted life‐years) compared with 24‐hour Holter surveillance (A$31 095 and 6.66 quality‐adjusted life‐years) over a 20‐year time horizon, with an incremental cost‐effectiveness ratio of $3013/ quality‐adjusted life‐years. Monitoring patients with iECG also contributed to lower recurrence of stroke and stroke‐related deaths (140 recurrent strokes and 20 deaths avoided per 10 000 patients). The probabilistic sensitivity analyses suggested iECG is highly likely to be a cost‐effective intervention (100% probability).

Conclusions

A nurse‐led iECG monitoring protocol during the acute hospital stay was found to improve the rate of atrial fibrillation detection and contributed to slightly increased costs and improved health outcomes. Using iECG to monitor patients post‐stroke during initial hospitalization is recommended to complement routine care.

Improving stroke care in Nova Scotia, Canada: a population-based project spanning 14 years

Stroke is a complex disorder that challenges healthcare systems. An audit of in-hospital stroke care in the province of Nova Scotia, Canada, in 2004-2005 indicated that many aspects of care delivery fell short of national best practice recommendations. Stroke care in Nova Scotia was reorganised using a combination of interventions to facilitate systems change and quality improvement. The focus was mainly on implementing evidence-based stroke unit care, augmenting thrombolytic therapy and enhancing dysphagia assessment. Key were the development of a provincial network to facilitate ongoing collaboration and structured information exchange, the creation of the stroke coordinator and stroke physician champion roles, and the implementation of a registry to capture information about adults hospitalised because of stroke or transient ischaemic attack. To evaluate the interventions, a longitudinal analysis compared the audit results with registry data for 2012, 2015 and 2019. The proportion of patients receiving multidisciplinary stroke unit care rose from 22.4% in 2005 to 74.0% in 2019. The proportion of patients who received alteplase increased steadily from 3.2% to 18.5%, and the median delay between hospital arrival and alteplase administration decreased from 102 min to 56 min, without an increase in intracranial haemorrhage. Dysphagia screening increased from 41.4% to 77.4%. More patients were transferred from acute care to a dedicated in-patient rehabilitation unit, and fewer were discharged to residential or long-term care. These enhancements did not prolong length-of-stay in acute care. The network was a critical success factor; competing priorities in the healthcare system were the main challenge to implementing change. A multidimensional, multiyear, improvement intervention yielded substantial and sustained improvements in the process and structure of stroke care in Nova Scotia.

Implantable cardiac monitors to detect atrial fibrillation after cryptogenic stroke: a systematic review and economic evaluation

BACKGROUND

Cryptogenic stroke is a stroke for which no cause is identified after standard diagnostic tests. Long-term implantable cardiac monitors may be better at diagnosing atrial fibrillation and provide an opportunity to reduce the risk of stroke recurrence with anticoagulants.

OBJECTIVES

The objectives were to assess the diagnostic test accuracy, clinical effectiveness and cost-effectiveness of three implantable monitors [BioMonitor 2-AF™ (Biotronik SE & Co. KG, Berlin, Germany), Confirm Rx™ (Abbott Laboratories, Lake Bluff, IL, USA) and Reveal LINQ™ (Medtronic plc, Minneapolis, MN, USA)] in patients who have had a cryptogenic stroke and for whom no atrial fibrillation is detected after 24 hours of external electrocardiographic monitoring.

DATA SOURCES

MEDLINE, EMBASE, The Cochrane Library, Database of Abstracts of Reviews of Effects and Health Technology Assessment databases were searched from inception until September 2018.

REVIEW METHODS

A systematic review was undertaken. Two reviewers agreed on studies for inclusion and performed quality assessment using the Cochrane Risk of Bias 2.0 tool. Results were discussed narratively because there were insufficient data for synthesis. A two-stage de novo economic model was developed: (1) a short-term patient flow model to identify cryptogenic stroke patients who have had atrial fibrillation detected and been prescribed anticoagulation treatment (rather than remaining on antiplatelet treatment) and (2) a long-term Markov model that captured the lifetime costs and benefits of patients on either anticoagulation or antiplatelet treatment.

RESULTS

One randomised controlled trial, Cryptogenic Stroke and underlying Atrial Fibrillation (CRYSTAL-AF) (Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014;370:2478-86), was identified, and no diagnostic test accuracy study was identified. The CRYSTAL-AF trial compared the Reveal™ XT (a Reveal LINQ predecessor) (Medtronic plc) monitor with standard of care monitoring. Twenty-six single-arm observational studies for the Reveal devices were also identified. The only data for BioMonitor 2-AF or Confirm Rx were from mixed population studies supplied by the companies. Atrial fibrillation detection in the CRYSTAL-AF trial was higher with the Reveal XT than with standard monitoring at all time points. By 36 months, atrial fibrillation was detected in 19% of patients with an implantable cardiac monitor and in 2.3% of patients receiving conventional follow-up. The 26 observational studies demonstrated that, even in a cryptogenic stroke population, atrial fibrillation detection rates are highly variable and most cases are asymptomatic; therefore, they probably would not have been picked up without an implantable cardiac monitor. Device-related adverse events, such as pain and infection, were low in all studies. The de novo economic model produced incremental cost effectiveness ratios comparing implantable cardiac monitors with standard of care monitoring to detect atrial fibrillation in cryptogenic stroke patients based on data for the Reveal XT device, which can be related to Reveal LINQ. The BioMonitor 2-AF and Confirm RX were included in the analysis by making a strong assumption of equivalence with Reveal LINQ. The results indicate that implantable cardiac monitors could be considered cost-effective at a £20,000-30,000 threshold. When each device is compared incrementally, BioMonitor 2-AF dominates Reveal LINQ and Confirm RX.

LIMITATIONS

The cost-effectiveness analysis for implantable cardiac monitors is based on a strong assumption of clinical equivalence and should be interpreted with caution.

CONCLUSIONS

All three implantable cardiac monitors could be considered cost-effective at a £20,000-30,000 threshold, compared with standard of care monitoring, for cryptogenic stroke patients with no atrial fibrillation detected after 24 hours of external electrocardiographic monitoring; however, further clinical studies are required to confirm their efficacy in cryptogenic stroke patients.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018109216.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 5. See the NIHR Journals Library website for further project information.

Early Supported Discharge for Neurorehabilitation Following Acquired Brain Injury

Introduction: Early Supported Discharge (ESD) is a clinical flow management service offering interdisciplinary rehabilitation, wherein patients are provided supported in-home rehabilitation treatment; in comparison to conventional hospital-based rehabilitation model of service delivery. There has been little research into the functional outcomes for other types of acquired brain injury (ABI).

Methods: In this prospective cohort study, ABI patients presenting at a level I trauma center in Calgary, Canada were placed in either an ESD program or conventional inpatient rehabilitation (IPR) program based on their medical history and presentation. A small number of patients completed both programs (ESD+IPR group). ESD therapies were designed to emulate IPR. Participants completed professionally-rated Mayo-Portland Adaptability Index-4 (MPAI), Quality of Life after Brain Injury (QOLIBRI), Generalized Anxiety Questionnaire-7 (GAD7), Montreal Cognitive Assessment (MoCA), and Patient Health Questionnaire-9 (PHQ9) surveys at 1, 3, and 6 months following initial assessment pre-rehabilitation. Caregivers completed the Zarit Burden Interview (ZBI) at the same time points. The Supervision Rating Scale (SRS) and Disability Rating Scale (DRS) were completed at admission to rehabilitation and all follow-ups. Generalized estimate equations models were used to describe the three groups over time, including age as a covariate.

Results: Significant effects of time were reported in the MPAI participant sub-score in the ESD and IPR groups (χ(2)2 = 42.429, p < 0.000; χ(2)2 = 9.773, p = 0.008), showing significantly higher scores between 1 and 3 month timepoints for both groups. ZBI scores were significantly lower in the ESD group at 1 month compared to 3 and 6 months (χ(2)2 = 31.252, p < 0.001). The proportion of patients with medical complications during rehabilitation was 25.3% in ESD compared to 74.7% patients in IPR.

Conclusions: Improvements in functional outcomes were evident in patients participating in ESD and IPR, with more medical complications reported in the IPR group. Caregiver burden lessened over time in the ESD group but not in the IPR group. Both ESD and ESD+IPR groups can be considered viable alternatives to traditional inpatient rehabilitation. A randomized control trial would be required to properly compare rehabilitation streams. Further investigation into affective and lifestyle elements of ABI recovery would also improve our understanding of targeted neurorehabilitation in this population.

Reduction in Stroke After Transient Ischemic Attack in a Province-Wide Cohort Between 2003 and 2015

BACKGROUND

Improvements in management of transient ischemic attack (TIA) have decreased stroke and mortality post-TIA. Studies examining trends over time on a provincial level are limited. We analyzed whether efforts to improve management have decreased the rate of stroke and mortality after TIA from 2003 to 2015 across an entire province.

METHODS

Using administrative data from the Canadian Institute for Health Information's (CIHI) databases from 2003 to 2015, we identified a cohort of patients with a diagnosis of TIA upon discharge from the emergency department (ED). We examined stroke rates at Day 1, 2, 7, 30, 90, 180, and 365 post-TIA and 1-year mortality rates and compared trends over time between 2003 and 2015.

RESULTS

From 2003 to 2015 in Ontario, there were 61,710 patients with an ED diagnosis of TIA. Linear regressions of stroke after the index TIA showed a significant decline between 2003 and 2015, decreasing by 25% at Day 180 and 32% at 1 year (p < 0.01). The 1-year stroke rate decreased from 6.0% in 2003 to 3.4% in 2015. Early (within 48 h) stroke after TIA continued to represent approximately half of the 1-year event rates. The 1-year mortality rate after ED discharge following a TIA decreased from 1.3% in 2003 to 0.3% in 2015 (p < 0.001).

INTERPRETATION

At a province-wide level, 1-year rates of stroke and mortality after TIA have declined significantly between 2003 and 2015, suggesting that efforts to improve management may have contributed toward the decline in long-term risk of stroke and mortality. Continued efforts are needed to further reduce the immediate risk of stroke following a TIA.

Configuration-Dependent Optimal Impedance Control of an Upper Extremity Stroke Rehabilitation Manipulandum

Robots are becoming a popular means of rehabilitation since they can decrease the laborious work of a therapist, and associated costs, and provide well-controlled repeatable tasks. Many researchers have postulated that human motor control can be mathematically represented using optimal control theories, whereby some cost function is effectively maximized or minimized. However, such abilities are compromised in stroke patients. In this study, to promote rehabilitation of the stroke patient, a rehabilitation robot has been developed using optimal control theory. Despite numerous studies of control strategies for rehabilitation, there is a limited number of rehabilitation robots using optimal control theory. The main idea of this work is to show that impedance control gains cannot be kept constant for optimal performance of the robot using a feedback linearization approach. Hence, a general method for the real-time and optimal impedance control of an end-effector-based rehabilitation robot is proposed. The controller is developed for a 2 degree-of-freedom upper extremity stroke rehabilitation robot, and compared to a feedback linearization approach that uses the standard optimal impedance derived from covariance propagation equations. The new method will assign optimal impedance gains at each configuration of the robot while performing a rehabilitation task. The proposed controller is a linear quadratic regulator mapped from the operational space to the joint space. Parameters of the two controllers have been tuned using a unified biomechatronic model of the human and robot. The performances of the controllers were compared while operating the robot under four conditions of human movements (impaired, healthy, delayed, and time-advanced) along a reference trajectory, both in simulations and experiments. Despite the idealized and approximate nature of the human-robot model, the proposed controller worked well in experiments. Simulation and experimental results with the two controllers showed that, compared to the standard optimal controller, the rehabilitation system with the proposed optimal controller is assisting more in the active-assist therapy while resisting in active-constrained case. Furthermore, in passive therapy, the proposed optimal controller maintains the position error and interaction forces in safer regions. This is the result of updating the impedance in the operational space using a linear time-variant impedance model.

Model for Medical Student Introductory Telemedicine Education

Background: Several medical specialty organizations and the American Telemedicine Association have developed specialty-specific guidelines and tips for optimal telemedicine use. Formal introductory education for medical students appears to lag behind these other developments. Introduction: Leaders at the University of Iowa Hospitals and Clinics recognized that students would benefit from an introductory educational program pertinent across all specialties to prepare them for future telemedicine use. The program objective was to introduce a short educational intervention highlighting basic principles to improve knowledge and help students gain confidence with telemedicine technology. Materials and Methods: The program consists of three modules, a video, and a simulation session. The first module presents telemedicine history, current uses, terminology, Medicare-Medicaid rules, and legal issues. The second addresses efficacy, ethical concerns, and best practices. The third reviews steps for success, including environment (sound, lighting, color, and camera placement), communication tips, documentation, and follow-up. The video demonstrates an ideal telemedicine visit. A short quiz follows each module. A 1-h simulation session utilizes case scenarios, telemedicine software, and peripheral equipment. A retrospective pretest and posttest were used to gauge success. Results: One hundred fifty-three second year medical students completed the program during 2017. Ninety-three (60%) completed the questionnaire. Posttest results showed higher (positive) mean scores for all questions addressed in the program regarding basic telemedicine knowledge and confidence issues. Conclusion: This program model was effective in improving basic knowledge and confidence in telemedicine among second-year medical students. We speculate that they are more informed and prepared for future telemedicine rotations and practices.

Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018

The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider’s recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.

Secondary stroke prevention services in Canada: a cross-sectional survey and geospatial analysis of resources, capacity and geographic access

BACKGROUND

Rapid assessment and management of transient ischemic attacks and nondisabling strokes by specialized stroke prevention services reduces the risk of recurrent stroke and improves outcomes. In Canada, with its vast geography and with 16.8% of the population living in rural areas, access to these services is challenging, and considerable variation in access to care exists. The purpose of this multiphase study was to identify sites across Canada providing stroke prevention services, evaluate resource capacity and determine geographic access for Canadians.

METHODS

We developed a Stroke Prevention Services Resource Inventory that contained 22 questions on the organization and delivery of stroke prevention services and quality monitoring. The inventory ran from November 2015 to January 2016 and was administered online. We conducted a geospatial analysis to estimate access by drive times. Considerations were made for hours of operation and access within and across provincial borders.

RESULTS

A total of 123 stroke prevention sites were identified, of which 119 (96.7%) completed the inventory. Most (95) are designated stroke prevention or rapid assessment clinics. Of the 119 sites, 68 operate full time, and 39 operate less than 2.5 days per week. A total of 87.3% of the Canadian population has access to a stroke prevention service within a 1-hour drive; however, only 69.2% has access to a service that operates 5-7 days a week. Allowing provincial border crossing improves access (< 6-h drive) for those who are beyond a 6-hour drive within their home province (3.4%).

INTERPRETATION

Most Canadians have reasonable geographic access to stroke prevention services. Allowing patients to cross borders improves the existing access for many, particularly some remote communities along the Ontario-Quebec and British Columbia-Alberta borders.

Rural versus urban academic hospital mortality following stroke in Canada

Introduction

Stroke is one of the leading causes of death in Canada. While stroke care has improved dramatically over the last decade, outcomes following stroke among patients treated in rural hospitals have not yet been reported in Canada.

Objectives

To describe variation in 30-day post-stroke in-hospital mortality rates between rural and urban academic hospitals in Canada. We also examined 24/7 in-hospital access to CT scanners and selected services in rural hospitals.

Materials and methods

We included Canadian Institute for Health Information (CIHI) data on adjusted 30-day in-hospital mortality following stroke from 2007 to 2011 for all acute care hospitals in Canada excluding Quebec and the Territories. We categorized rural hospitals as those located in rural small towns providing 24/7 emergency physician coverage with inpatient beds. Urban hospitals were academic centres designated as Level 1 or 2 trauma centres. We computed descriptive data on local access to a CT scanner and other services and compared mean 30-day adjusted post-stroke mortality rates for rural and urban hospitals to the overall Canadian rate.

Results

A total of 286 rural hospitals (3.4 million emergency department (ED) visits/year) and 24 urban hospitals (1.5 million ED visits/year) met inclusion criteria. From 2007 to 2011, 30-day in-hospital mortality rates following stroke were significantly higher in rural than in urban hospitals and higher than the Canadian average for every year except 2008 (rural average range = 18.26 to 21.04 and urban average range = 14.11 to 16.78). Only 11% of rural hospitals had a CT-scanner, 1% had MRI, 21% had in-hospital ICU, 94% had laboratory and 92% had basic x-ray facilities.

Conclusion

Rural hospitals in Canada had higher 30-day in-hospital mortality rates following stroke than urban academic hospitals and the Canadian average. Rural hospitals also have very limited local access to CT scanners and ICUs. These rural/urban discrepancies are cause for concern in the context of Canada’s universal health care system.

Cost-effectiveness of stroke care in Aboriginal and non-Aboriginal patients: an observational cohort study in the Northern Territory of Australia

OBJECTIVE

To assess cost-effectiveness of stroke care for Aboriginal compared with non-Aboriginal patients in the Northern Territory (NT), Australia.

DESIGN

Cost-effectiveness analysis using data from a cohort-based follow-up study of stroke incidents.

SETTING

Public hospitals in the NT from 1992 to 2013.

PARTICIPANTS

Individual patient data were extracted and linked from the hospital inpatient and primary care information systems.

OUTCOME MEASURES

Incremental cost-effectiveness ratios were calculated and assessed graphically. Survival time was used to measure effectiveness of stroke care, in comparison with the net costs per life-year gained, from a healthcare perspective, by applying multivariable models to account for time-dependent confounding.

RESULTS

2158 patients with incident stroke were included (1171 males, 1178 aged <65 years and 966 from remote areas). 992 patients were of Aboriginal origin (46.0%, disproportionately higher than the population proportion of 27%). Of all cases, 42.6% were ischaemic and 29.8% haemorrhagic stroke. Average age of stroke onset was 51 years in Aboriginal, compared with 65 years in non-Aboriginal patients (p<0.001). Aboriginal patients had 71.4% more hospital bed-days, and 7.4% fewer procedures than non-Aboriginal patients. Observed health costs averaged $A50 400 per Aboriginal compared with $A33 700 per non-Aboriginal patient (p<0.001). The differential costs and effects for each population were distributed evenly across the incremental cost-effectiveness plane threshold line, indicating no difference in cost-effectiveness between populations. After further adjustment for confounding and censoring, cost-effectiveness appeared greater for Aboriginal than non-Aboriginal patients, but this was not statistically significant (p=0.25).

CONCLUSIONS

Stroke care for the NT Aboriginal population is at least as cost-effective as the non-Aboriginal population. Stroke care presents worthwhile and equitable survival benefits for Aboriginal patients in remote communities, notwithstanding their higher level burden of disease. These findings are relevant for healthcare planning and policy development regarding equal access to stroke care for Aboriginal patients.

Patient with stroke: hospital discharge planning, functionality and quality of life

ABSTRACT Stroke still causes high levels of human inability and suffering, and it is one of the main causes of death in developed countries, including Portugal. Objective: analyze the strategies of hospital discharge planning for these patients, increasing the knowledge related to hospitalhome transition, discharge planning processes and the main impact on the quality of life and functionality. Method: integrative literature review using the PICOD criteria, with database research. Results: 19 articles were obtained, using several approaches and contexts. For quality of life, the factors related to the patient satisfaction with care and the psychoemotional aspects linked with functionality are the most significant. Conclusion: during the hospitalization period, a careful hospital discharge planning and comprehensive care to patients and caregivers - in particular the functional and psychoemotional aspects - tend to have an impact on the quality of life of patients.

The potential health and economic impact of improving stroke care standards for Australia

Background

Evidence of the burden of suboptimal stroke care should expedite quality improvement. We aimed to estimate the health and economic impact of improving acute stroke management to best practice standards using Australia as a case study.

Methods

Hospital performance in Australia was estimated using data from the National Stroke Audit of Acute Services 2013. The percentage of patients provided evidence-based therapies in all hospitals was compared to that achieved in the aggregate of top performing benchmark hospitals (that included between them, a minimum contribution of 15% of all cases audited). The number of additional patients who would receive therapies if this performance gap was rectified was applied to a standardized economic simulation model that comprised stroke rates and resource-use estimates from the North East Melbourne Stroke Incidence Study applied to the 2013 Australian population.

Results

In 2013, 41,398 patients were estimated to have been hospitalized with stroke. If acute care was improved to that of Australian benchmarks, there would be an additional 15,317 patients accessing stroke units; 1960 receiving thrombolysis; and 4007 being treated with antihypertensive medication, 3082 with antiplatelet medication, 2179 with anticoagulant medication, and 3514 with lipid-lowering therapy. Approximately 9329 disability-adjusted life years could be avoided. This additional care provided would be cost effective at AUD 3304 per disability adjusted life year avoided.

Conclusion

The benefits of reducing evidence–practice gaps in Australia are considerable. Further investment in initiatives to optimize hospital care is justified.

Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines, update 2015

Stroke rehabilitation is a progressive, dynamic, goal-orientated process aimed at enabling a person with impairment to reach their optimal physical, cognitive, emotional, communicative, social and/or functional activity level. After a stroke, patients often continue to require rehabilitation for persistent deficits related to spasticity, upper and lower extremity dysfunction, shoulder and central pain, mobility/gait, dysphagia, vision, and communication. Each year in Canada 62,000 people experience a stroke. Among stroke survivors, over 6500 individuals access in-patient stroke rehabilitation and stay a median of 30 days (inter-quartile range 19 to 45 days). The 2015 update of the Canadian Stroke Best Practice Recommendations: Stroke Rehabilitation Practice Guidelines is a comprehensive summary of current evidence-based recommendations for all members of multidisciplinary teams working in a range of settings, who provide care to patients following stroke. These recommendations have been developed to address both the organization of stroke rehabilitation within a system of care (i.e., Initial Rehabilitation Assessment; Stroke Rehabilitation Units; Stroke Rehabilitation Teams; Delivery; Outpatient and Community-Based Rehabilitation), and specific interventions and management in stroke recovery and direct clinical care (i.e., Upper Extremity Dysfunction; Lower Extremity Dysfunction; Dysphagia and Malnutrition; Visual-Perceptual Deficits; Central Pain; Communication; Life Roles). In addition, stroke happens at any age, and therefore a new section has been added to the 2015 update to highlight components of stroke rehabilitation for children who have experienced a stroke, either prenatally, as a newborn, or during childhood. All recommendations have been assigned a level of evidence which reflects the strength and quality of current research evidence available to support the recommendation. The updated Rehabilitation Clinical Practice Guidelines feature several additions that reflect new research areas and stronger evidence for already existing recommendations. It is anticipated that these guidelines will provide direction and standardization for patients, families/caregiver(s), and clinicians within Canada and internationally.

Beneficial Effects of Implementing Stroke Protocols Require Establishment of a Geographically Distinct Unit

BACKGROUND AND PURPOSE

Usefulness of multidisciplinary stroke units in acute stroke patients is well established. There is extensive western literature on usefulness of stroke units in outcome, but limited evidence from the rest of the world. We aim to evaluate the impact of establishing a stroke unit on outcome in patients presenting to a tertiary care facility.

METHODS

This is a retrospective study of 1003 patients with acute stroke admitted to Hamad General Hospital, Qatar, between January 2014 and February 2015. Patients directly admitted to intensive care unit (132) were excluded. We compared outcomes of pre- and poststroke ward (SW) establishment and in SW patients versus those of general medical wards.

RESULTS

Before the establishment of the SW, 175 patients were admitted to the hospital. From April 2014 to February 2015, 696 patients were admitted (SW, 545; medical ward, 151). There was a significant reduction in length of stay from 14.7±27.7 to 6.2±20.2 days (P=0.0001) and incidence of complications (23.6% versus 6.4%, P=0.0001) after implementation of stroke-specific protocols. Prognosis at discharge (modified Rankin Scale 0-2 in 56.0% versus 70.4%, P=0.001) and at 90 days (modified Rankin Scale 0-2 in 70.6% versus 95.0%, P=0.001) also significantly improved. Compared with medical ward patients, outcome was significantly better in SW patients with fewer complications (10.9% versus 5.0%, P=0.013) and shorter length of stay (8.9±30.7 versus 5.4±16.1 days, P=0.05).

CONCLUSIONS

Establishing a distinct SW is essential for achieving full benefits of stroke protocols implementation. SW patients have significantly fewer complications and better prognosis when compared with patients in medical wards.

Canadian Stroke Best Practice Recommendations: Mood, Cognition and Fatigue following Stroke Practice Guidelines, Update 2015

Every year, approximately 62 000 people with stroke and transient ischemic attack are treated in Canadian hospitals, and the evidence suggests one-third or more will experience vascular-cognitive impairment, and/or intractable fatigue, either alone or in combination. The 2015 update of the Canadian Stroke Best Practice Recommendations: Mood, Cognition and Fatigue Module guideline is a comprehensive summary of current evidence-based recommendations for clinicians in a range of settings, who provide care to patients following stroke. The three consequences of stroke that are the focus of the this guideline (poststroke depression, vascular cognitive impairment, and fatigue) have high incidence rates and significant impact on the lives of people who have had a stroke, impede recovery, and result in worse long-term outcomes. Significant practice variations and gaps in the research evidence have been reported for initial screening and in-depth assessment of stroke patients for these conditions. Also of concern, an increased number of family members and informal caregivers may also experience depressive symptoms in the poststroke recovery phase which further impact patient recovery. These factors emphasize the need for a system of care that ensures screening occurs as a standard and consistent component of clinical practice across settings as stroke patients transition from acute care to active rehabilitation and reintegration into their community. Additionally, building system capacity to ensure access to appropriate specialists for treatment and ongoing management of stroke survivors with these conditions is another great challenge.

Stroke rehabilitation: clinical picture, assessment, and therapeutic challenge

This chapter reviews the evolution of stroke rehabilitation in the last 20 years. It begins by describing the different types of stroke that can occur in adults, their potential consequences on a person's capacity to function in daily life and statistics on the number of strokes and their burden on families and the economy. The assessment of stroke severity, recovery of function over time, and the impact of initial stroke severity and age on potential recovery are then addressed as well as the concept of rehabilitation to enhance recovery. Fueled by the synthesis of an ever-increasing research knowledge base and the creation of stroke rehabilitation recommendations for optimal delivery of rehabilitation services and of therapeutic interventions, stroke rehabilitation has changed dramatically. Examples of improvements in stroke rehabilitation in Canada are given with emphasis on the "best practices" inspired stroke rehabilitation continuum recently recommended for the Province of Quebec. The need for an improved community-based rehabilitation approach that includes regular follow-ups and community-based programs promoting reintegration is emphasized. The importance of knowledge translation strategies to promote the uptake of best-practice recommendations is illustrated by describing the activities of the Sensorimotor Rehabilitation Research Team. Over the past 3 years, the researchers of this team and clinicians in three rehabilitation centers, two in Montreal and one in Quebec City, have collaborated to adopt standardized assessment tools, create a common stroke registry, a best-practice recommended approach to interventions and the participation of clinicians in the research process.

Canadian Stroke Best Practice Recommendations: Secondary Prevention of Stroke Guidelines, Update 2014

Every year, approximately 62 000 people with stroke and transient ischemic attack are treated in Canadian hospitals. The 2014 update of the Canadian Secondary Prevention of Stroke guideline is a comprehensive summary of current evidence-based recommendations for clinicians in a range of settings, who provide care to patients following stroke. Notable changes in this 5th edition include an emphasis on treating the highest risk patients who present within 48 h of symptom onset with transient or persistent motor or speech symptoms, who need to be transported to the closest emergency department with capacity for advanced stroke care; a recommendation for brain and vascular imaging (of the intra- and extracranial vessels) to be completed urgently using computed tomography/computed tomography angiography; prolonged cardiac monitoring for patients with suspective cardioembolic stroke but without evidence for atrial fibrillation on electrocardiogram or holter monitoring; and de-emphasizing the need for routine echocardiogram. The Canadian Stroke Best Practice Recommendations include a range of supporting materials such as implementation resources to facilitate the adoption of evidence to practice, and related performance measures to enable monitoring of uptake and effectiveness of the recommendations using a standardized approach. The guidelines further emphasize the need for a systems approach to stroke care, involving an interprofessional team, with access to specialists regardless of patient location, and the need to overcome geographical barriers to ensure equity in access within a universal health-care system.

Drivers of costs associated with reperfusion therapy in acute stroke: the Interventional Management of Stroke III Trial

BACKGROUND AND PURPOSE

The Interventional Management of Stroke (IMS) III study tested the effect of intravenous tissue-type plasminogen activator (tPA) alone when compared with intravenous tPA followed by endovascular therapy and collected cost data to assess the economic implications of the 2 therapies. This report describes the factors affecting the costs of the initial hospitalization for acute stroke subjects from the United States.

METHODS

Prospective cost analysis of the US subjects was treated with intravenous tPA alone or with intravenous tPA followed by endovascular therapy in the IMS III trial. Results were compared with expected Medicare payments.

RESULTS

The adjusted cost of a stroke admission in the study was $35 130 for subjects treated with endovascular therapy after intravenous tPA treatment and $25 630 for subjects treated with intravenous tPA alone (P<0.0001). Significant factors related to costs included treatment group, baseline National Institutes of Health Stroke Scale, time from stroke onset to intravenous tPA, age, stroke location, and comorbid diabetes mellitus. The mean cost for subjects who had routine use of general anesthesia as part of endovascular therapy was $46 444 when compared with $30 350 for those who did not have general anesthesia. The costs of embolectomy for IMS III subjects and patients from the National Inpatient Sample cohort exceeded the Medicare diagnosis-related group payment in ≥75% of patients.

CONCLUSIONS

Minimizing the time to start of intravenous tPA and decreasing the use of routine general anesthesia may improve the cost-effectiveness of medical and endovascular therapy for acute stroke.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT00359424.

Effect of a provincial system of stroke care delivery on stroke care and outcomes

BACKGROUND

Systems of stroke care delivery have been promoted as a means of improving the quality of stroke care, but little is known about their effectiveness. We assessed the effect of the Ontario Stroke System, a province-wide strategy of regionalized stroke care delivery, on stroke care and outcomes in Ontario, Canada.

METHODS

We used population-based provincial administrative databases to identify all emergency department visits and hospital admissions for acute stroke and transient ischemic attack from Jan. 1, 2001, to Dec. 31, 2010. Using piecewise regression analyses, we assessed the effect of the full implementation of the Ontario Stroke System in 2005 on the proportion of patients who received care at stroke centres, and on rates of discharge to long-term care facilities and 30-day mortality after stroke.

RESULTS

We included 243 287 visits by patients with acute stroke or transient ischemic attack. The full implementation of the Ontario Stroke System in 2005 was associated with an increase in rates of care at stroke centres (before implementation: 40.0%; after implementation: 46.5%), decreased rates of discharge to long-term care facilities (before implementation: 16.9%; after implementation: 14.8%) and decreased 30-day mortality for hemorrhagic (before implementation: 38.3%; after implementation: 34.4%) and ischemic stroke (before implementation: 16.3%; after implementation: 15.7%). The system's implementation was also associated with marked increases in the proportion of patients who received neuroimaging, thrombolytic therapy, care in a stroke unit and antithrombotic therapy.

INTERPRETATION

The implementation of an organized system of stroke care delivery was associated with improved processes of care and outcomes after stroke.

Analysis of the costs and payments of a coordinated stroke center and regional stroke network

BACKGROUND AND PURPOSE

An earlier study demonstrated significantly improved access, treatment, and outcomes after the implementation of a progressive, comprehensive stroke program at a tertiary care community hospital, Saint Luke's Neuroscience Institute (SLNI). This study evaluated the costs associated with implementing such a program.

METHODS

Retrospective analysis of total hospital costs and payments for treating patients with ischemic stroke at SLNI (n=1570) as program enhancement evolved over time (2005, 2007, and 2010) and compared with published national estimates. Analyses were stratified by patient demographic characteristics, patient outcomes, treatments, time, and comorbidities.

RESULTS

Controlling for inflation, there was no difference in SLNI total costs between 2005 and either 2007 or 2010, suggesting that while SLNI provided an increased level of services, any additional expenditures were offset by efficiencies. SLNI total costs were slightly lower than published benchmarks. Consistent with previous stroke care cost estimates, the median overall differential between total hospital costs and payments for all ischemic stroke cases was negative.

CONCLUSIONS

SLNI total costs remained consistent over time and were slightly lower than previously published estimates, suggesting that a focused, streamlined stroke program can be implemented without a significant economic impact. This finding further demonstrates that providing comprehensive stroke care with improved access and treatment may be financially feasible for other hospitals.