Cost-Effectiveness of Optimizing Acute Stroke Care Services for Thrombolysis

Deciphering the contextual barriers to mainstreaming the implementation of stroke thrombolysis in a Ghanaian hospital: Findings from the activate mixed-methods study

BACKGROUND

Each year, stroke-related death and disability claim over 143 million years of healthy life globally. Despite accounting for much of the global stroke burden, acute stroke care in Low-and-Middle-Income Countries remains suboptimal. Thrombolysis, an effective treatment option for stroke, is only received by a minority of stroke patients in these settings.

AIM

To determine the context-specific barriers and facilitators for the implementation of mainstream stroke thrombolysis in a Ghanaian hospital.

METHODS

We employed a mixed-methods approach involving key stakeholders (recipients, providers, and leaders) in the acute stroke care continuum. Surveys were administered to acute stroke patients, and in-depth key informant interviews were conducted with experts in stroke care, including a neurologist, medical director, neurology residents, a stroke nurse, emergency physicians, a radiologist, and a pharmacist. The data collected from these interviews were transcribed and analysed using content analysis with the CFIR (Consolidated Framework for Implementation Research) model as a guiding template. Two independent coders were involved in the analysis process to ensure reliability and accuracy.

RESULTS

The stroke thrombolysis rate over a 6-month period was 0.83% (2 out of 242), with an average door-to-needle time among thrombolyzed patients being 2 hours, 37 minutes. Only 12.8% of patients (31 out of 242) presented within 4.5 hours of stroke symptom onset. The most significant obstacle to the implementation of acute stroke thrombolysis was related to the characteristics of the individuals involved, notably delays in presenting to the hospital among stroke patients due to a lack of knowledge about stroke symptoms and cultural beliefs. Additionally, a significant bottleneck that contributed to the discrepancy between the number of patients who presented within the 4.5-6 hour window and the number of patients who actually received thrombolysis was the inability to pay for the cost of thrombolytic agents. This was followed by challenges in the implementation processes.

CONCLUSIONS

Addressing challenges related to stroke awareness, and financial constraints via multi-level stakeholder engagement, and enactment of stroke protocols are crucial steps in ensuring a successful implementation of a stroke thrombolysis program in a resource-limited setting.

Cost-effectiveness of improvement strategies for reperfusion treatments in acute ischemic stroke: a systematic review

BACKGROUND

Reducing delays along the acute stroke pathway significantly improves clinical outcomes for acute ischemic stroke patients eligible for reperfusion treatments. The economic impact of different strategies reducing onset to treatment (OTT) is crucial information for stakeholders in acute stroke management. This systematic review aimed to provide an overview on the cost-effectiveness of several strategies to reduce OTT.

METHODS

A comprehensive literature search was conducted in EMBASE, PubMed, and Web of Science until January 2022. Studies were included if they reported 1/ stroke patients treated with intravenous thrombolysis and/or endovascular thrombectomy, 2/ full economic evaluation, and 3/ strategies to reduce OTT. The Consolidated Health Economic Evaluation Reporting Standards statement was applied to assess the reporting quality.

RESULTS

Twenty studies met the inclusion criteria, of which thirteen were based on cost-utility analysis with the incremental cost-effectiveness ratio per quality-adjusted life year gained as the primary outcome. Studies were performed in twelve countries focusing on four main strategies: educational interventions, organizational models, healthcare delivery infrastructure, and workflow improvements. Sixteen studies showed that the strategies concerning educational interventions, telemedicine between hospitals, mobile stroke units, and workflow improvements, were cost-effective in different settings. The healthcare perspective was predominantly used, and the most common types of models were decision trees, Markov models and simulation models. Overall, fourteen studies were rated as having high reporting quality (79%-94%).

CONCLUSIONS

A wide range of strategies aimed at reducing OTT is cost-effective in acute stroke care treatment. Existing pathways and local characteristics need to be taken along in assessing proposed improvements.

Cost-Consequence Analysis of Mobile Stroke Units vs. Standard Prehospital Care and Transport

Background: Mobile stroke units (MSUs) are the latest approach to improving time-sensitive stroke care delivery. Currently, there are no published studies looking at the expanded value of the MSU to diagnose and transport patients to the closest most appropriate facility. The purpose of this paper is to perform a cost consequence analysis of standard transport (ST) vs. MSU.

Methods and Results: A cost consequence analysis was undertaken within a decision framework to compare the incremental cost of care for patients with confirmed stroke that were served by the MSU vs. their simulated care had they been served by standard emergency medical services between July 2014 and October 2015. At baseline values, the incremental cost between MSU and ST was $70,613 ($856,482 vs. $785,869) for 355 patient transports. The MSU avoided 76 secondary interhospital transfers and 76 emergency department (ED) encounters. Sensitivity analysis identified six variables that had measurable impact on the model's variability and a threshold value at which MSU becomes the optimal strategy: number of stroke patients (>391), probability of requiring transfer to a comprehensive stroke center (CSC, >0.52), annual cost of MSU operations (<$696,053), cost of air transfer (>$8,841), probability initial receiving hospital is a CSC (<0.32), and probability of ischemic stroke with ST (<0.76).

Conclusions: MSUs can avert significant costs in the administration of stroke care once optimal thresholds are achieved. A comprehensive cost-effectiveness analysis is required to determine not just the operational value of an MSU but also its clinical value to patients and the society.

Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

A systematic review and meta-analysis of interventions to increase stroke thrombolysis

Background

Although the efficacy of tissue plasminogen activator (tPA) for acute ischemic stroke is well established, rates of tPA use remain low. For clinicians, advocates, and policy-makers seeking to increase tPA treatment rates, it is important to understand what interventions exist and their relative effectiveness.

Methods

We searched PubMed and EMBASE to identify all studies published between 1995 and January 8, 2015 documenting interventions to increase the use of tPA with broadly inclusive criteria. The principal summary measure was the percentage change in rate of tPA administration. Random effects meta-analytic models were built to summarize the effect of intervention compared to control overall and for intervention characteristics.

Results

The search yielded 1457 results of which 25 met eligibility criteria. We identified 14 pre-post studies, ten randomized controlled trials, and one quasi-experiment. Included studies targeted their interventions at emergency medical services (EMS) (n = 14), telemedicine (n = 6), and public education (n = 6). In a random effects model, tPA administration was significantly higher in the intervention arm across all studies limiting enrollment to ischemic stroke patients (n = 16) with a risk ratio (RR) of 1.80 (95% confidence interval [CI], 1.45–2.22). A trend towards increased tPA administration was observed for all intervention approaches: risk ratio of 1.73 (95% CI, 1.44–2.09) for EMS, 1.58 (95% CI, 0.72–3.47) for telemedicine, and 1.89 (95% CI, 0.77–4.65) for public education, the latter not restricted to ischemic stroke patients.

Conclusions

Interventions to increase tPA use appear to have considerable effectiveness. Our findings support the use of such interventions to improve stroke outcomes.

2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations for clinicians caring for adult patients with acute arterial ischemic stroke in a single document. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 guidelines and subsequent updates.

METHODS

Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. The members of the writing group unanimously approved all recommendations except when relations with industry precluded members voting. Prerelease review of the draft guideline was performed by 4 expert peer reviewers and by the members of the Stroke Council's Scientific Statements Oversight Committee and Stroke Council Leadership Committee. These guidelines use the American College of Cardiology/American Heart Association 2015 Class of Recommendations and Levels of Evidence and the new American Heart Association guidelines format.

RESULTS

These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings.

CONCLUSIONS

These guidelines are based on the best evidence currently available. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

Age-specific Cost Effectiveness of Using Intravenous Recombinant Tissue Plasminogen Activator for Treating Acute Ischemic Stroke

INTRODUCTION

Studies have demonstrated that intravenous recombinant tissue plasminogen activator (IV rtPA) is a cost-effective treatment for acute ischemic stroke. Age-specific cost effectiveness has not been well examined. This study estimated age-specific incremental cost-effectiveness ratios (ICERs) of IV rtPA treatment versus no IV rtPA.

METHODS

A Markov model was developed to examine the economic impact of IV rtPA over a 20-year time horizon on four age groups (18-44, 45-64, 65-80, and ≥81 years) from the U.S. healthcare sector perspective. The model used health outcomes from a national stroke registry adjusted by parameters from previous literature and current hospitalization costs in 2013 U.S. dollars. Long-term annual costs and quality-adjusted life years (QALYs) in the years after a stroke were discounted at 3% per year. Incremental costs, incremental QALYs, and ICERs were estimated and sensitivity analyses were conducted between 2015 and 2017.

RESULTS

Use of IV rtPA gained 0.55 QALYs and cost $3,941 more than no IV rtPA for stroke patients aged ≥18 years over a 20-year time horizon. IV rtPA was a dominant strategy compared to no IV rtPA for patients aged 18-44 and 45-64 years. For patients aged 65-80 years, IV rtPA gained 0.44 QALYs and cost $4,872 more than no IV rtPA (ICER=$11,132/QALY). For patients aged ≥81 years, ICER was estimated at $48,676/QALY.

CONCLUSIONS

IV rtPA saved costs and improved health outcomes for patients aged 18-64 years and was cost effective for those aged ≥65 years. These findings support the use of IV rtPA.

When has service provision for transient ischaemic attack improved enough? A discrete event simulation economic modelling study

OBJECTIVES

The aim of this study was to examine the impact of transient ischaemic attack (TIA) service modification in two hospitals on costs and clinical outcomes.

DESIGN

Discrete event simulation model using data from routine electronic health records from 2011.

PARTICIPANTS

Patients with suspected TIA were followed from symptom onset to presentation, referral to specialist clinics, treatment and subsequent stroke.

INTERVENTIONS

Included existing versus previous (less same day clinics) and hypothetical service reconfiguration (7-day service with less availability of clinics per day).

OUTCOME MEASURES

The primary outcome of the model was the prevalence of major stroke after TIA. Secondary outcomes included service costs (including those of treating subsequent stroke) and time to treatment and attainment of national targets for service provision (proportion of high-risk patients (according to ABCD² score) seen within 24 hours).

RESULTS

The estimated costs of previous service provision for 490 patients (aged 74±12 years, 48.9% female and 23.6% high risk) per year at each site were £340 000 and £368 000, respectively. This resulted in 31% of high-risk patients seen within 24 hours of referral (47/150) with a median time from referral to clinic attendance/treatment of 1.15 days (IQR 0.93-2.88). The costs associated with the existing and hypothetical services decreased by £5000 at one site and increased £21 000 at the other site. Target attainment was improved to 79% (118/150). However, the median time to clinic attendance was only reduced to 0.85 days (IQR 0.17-0.99) and thus no appreciable impact on the modelled incidence of major stroke was observed (10.7 per year, 99% CI 10.5 to 10.9 (previous service) vs 10.6 per year, 99% CI 10.4 to 10.8 (existing service)).

CONCLUSIONS

Reconfiguration of services for TIA is effective at increasing target attainment, but in services which are already working efficiently (treating patients within 1-2 days), it has little estimated impact on clinical outcomes and increased investment may not be worthwhile.

Relationship between functional disability and costs one and two years post stroke

BACKGROUND AND PURPOSE

Stroke affects mortality, functional ability, quality of life and incurs costs. The primary objective of this study was to estimate the costs of stroke care in Sweden by level of disability and stroke type (ischemic (IS) or hemorrhagic stroke (ICH)).

METHOD

Resource use during first and second year following a stroke was estimated based on a research database containing linked data from several registries. Costs were estimated for the acute and post-acute management of stroke, including direct (health care consumption and municipal services) and indirect (productivity losses) costs. Resources and costs were estimated per stroke type and functional disability categorised by Modified Rankin Scale (mRS).

RESULTS

The results indicated that the average costs per patient following a stroke were 350,000SEK/€37,000-480,000SEK/€50,000, dependent on stroke type and whether it was the first or second year post stroke. Large variations were identified between different subgroups of functional disability and stroke type, ranging from annual costs of 100,000SEK/€10,000-1,100,000SEK/€120,000 per patient, with higher costs for patients with ICH compared to IS and increasing costs with more severe functional disability.

CONCLUSION

Functional outcome is a major determinant on costs of stroke care. The stroke type associated with worse outcome (ICH) was also consistently associated to higher costs. Measures to improve function are not only important to individual patients and their family but may also decrease the societal burden of stroke.

Receptionist rECognition and rEferral of Patients with Stroke (RECEPTS): unannounced simulated patient telephone call study in primary care

Background

Stroke is a leading cause of morbidity and mortality. Timely recognition and referral are essential for treatment.

Aim

To examine the ability of receptionists in general practices to recognise symptoms of stroke and direct patients to emergency care.

Design and setting

Unannounced simulated patient telephone calls and prospective cross-sectional survey study in general practices in the Birmingham and Solihull area.

Method

A total of 52 general practices participated in a total of 520 simulated telephone calls, with 183 receptionists completing questionnaires. Logistic regression analyses were used to examine likelihood of referral for immediate care by ease of vignette recognition and number of common stroke symptoms present.

Results

General practice receptionists correctly referred 69% of simulated calls for immediate care. Calls classed as ‘difficult’ to recognise were less likely to be immediately referred. Compared with ‘easy’ calls: ‘difficult’ calls odds ratio (OR) 0.15, 95% confidence interval (CI) = 0.08 to 0.26; ‘moderate’ calls OR 0.55, 95% CI = 0.32 to 0.92. Similarly, calls including one or two ‘FAST’ symptoms were less likely to be referred immediately (compared with three FAST symptoms: one symptom OR 0.30, 95% CI = 0.13 to 0.72; two symptoms OR 0.35, 95% CI = 0.15 to 0.83).

Conclusion

General practice receptionists refer patients with stroke for immediate care when they present with several symptoms; however, they are less likely to refer patients presenting with only one symptom or less common symptoms of stroke. Optimum management of acute stroke in primary care requires interventions that improve receptionists’ knowledge of lesser-known stroke symptoms.

Service factors causing delay in specialist assessment for TIA and minor stroke: a qualitative study of GP and patient perspectives

OBJECTIVE

To understand how service factors contribute to delays to specialist assessment following transient ischaemic attack (TIA) or minor stroke.

DESIGN

Qualitative study using semistructured interviews, analysis by constant comparison.

SETTING

Leicester, UK.

PARTICIPANTS

Patients diagnosed with TIA or minor stroke, at hospital admission or in a rapid-access TIA clinic (n=42), general practitioners (GPs) of participating patients if they had been involved in the patients' care (n=18).

DATA

Accounts from patients and GPs of factors contributing to delay following action to seek help from a healthcare professional (HCP).

RESULTS

The following categories of delay were identified. First, delay in assessment in general practice following contact with the service; this related to availability of same day appointments, and the role of the receptionist in identifying urgent cases. Second, delays in diagnosis by the HCP first consulted, including GPs, optometrists, out-of-hours services, walk-in centres and the emergency department. Third, delays in referral after a suspected diagnosis; these included variable use of the ABCD(2) (Age, Blood pressure, Clinical features, Duration, Diabetes) risk stratification score and referral templates in general practice, and referral back to the patients' GP in cases where he/she was not the first HCP consulted.

CONCLUSIONS

Primary and emergency care providers need to review how they can best handle patients presenting with symptoms that could be due to stroke or TIA. In general practice, this may include receptionist training and/or triage by a nurse or doctor. Mechanisms need to be established to enable direct referral to the TIA clinic when patients whose symptoms have resolved present to other agencies. Further work is needed to improve diagnostic accuracy by non-specialists.

Burden of stroke in Italy: an economic model highlights savings arising from reduced disability following thrombolysis

BACKGROUND

The consequences of stroke must be assessed not only in terms of incidence and mortality rates, but also in terms of disability, which may persist long after the acute phase. Thrombolysis, if timely administered, can effectively reduce post-stroke disability.

AIMS

The economic model presented herein aims to evaluate, in eligible patients, the effects of alteplase on post-stroke disability and related costs over three-years.

METHODS

The economic analysis was developed on the basis of four key components: clinical outcomes from international trials, economic consequences extracted from cost of illness studies, regulatory data from national and international agencies, and national epidemiological data. A population-level model estimated the difference in disability costs between patients treated with standard care versus those receiving thrombolytic therapy within 4×5 h of acute ischemic stroke. The analysis covered 36 months from discharge.

RESULTS

Reduced costs related to post-stroke disability were observed in treated patients compared with those receiving standard care (control). The overall savings were €2330×15 per average patient: €1445×81 during the first 18 months, €362×25 between 18 and 24 months, and €522×09 in the 24-36 months period. The overall savings on 3174 Italian treated patients in 2013 were €7 395 907 over three-years.

CONCLUSION

Our study reveals that performing thrombolytic therapy in eligible patients improves economic outcomes compared with patients receiving standard care. This model is useful for decision makers, both within and outside of the Italian national context, as a tool to assess the cost-effectiveness of thrombolysis in both short- and long-term period.

Acute Ischemic Stroke (AIS) patient management in French stroke units and impact estimation of thrombolysis on care pathways and associated costs

BACKGROUND

Stroke is the second leading cause of death and a first leading cause of acquired disability in adults worldwide. This study aims to evaluate the current management and associated costs of acute ischemic stroke (AIS) for patients admitted in stroke units in France and over a one-year follow-up period as well as to assess the impact of improved thrombolytic management in terms of increasing the proportion of patients receiving thrombolysis and/or treated within 3 h from the onset of symptoms.

METHODS

A decision model was developed, which comprises two components: the first corresponding to the acute hospital management phase of patients with AIS up until hospital discharge, extracted from the national hospital discharge database (PMSI 2011), and the second corresponding to the post-acute (post-discharge) phase, based on national treatment guidelines and stroke experts' advice. Five post-acute clinical care pathways were defined. In-hospital mortality and mortality at 3 months post-discharge was taken into account into the model. Patient journeys and costs were determined for both phases. Improved thrombolytic management was modeled by increasing the proportion of patients receiving thrombolysis from the current estimated level of 16.7 to 25% as well as subsequently increasing the proportion of patients treated within 3 h of the onset of symptoms post-stroke from 50 to 100%. The impact on care pathways was derived from clinical data.

RESULTS

Among 202,078 hospitalizations for a stroke or a transient ischemic attack (TIA), 90,528 were for confirmed AIS, and 33% (29,999) of them managed within a stroke unit. After hospitalization, 60% of discharges were to home, 25% to rehabilitative care and then home, 2% to rehabilitative care and then a nursing home, 7% to long-term care, and 6% of stays ended with patient death. Of a total cost over 1 year of €610 million (mean cost per patient of €20,326), 70% concern the post-acute phase. By increasing the proportion of patients being thrombolyzed, costs are reduced primarily by a decrease in rehabilitative care, with savings per additional treated patient of €1,462. By adding improved timing, savings are more than doubled (€3,183 per additional treated patient).

CONCLUSIONS

This study confirms that the burden of AIS in France is heavy. By improving thrombolytic management in stroke units, patient journeys through care pathways can be modified, with increased discharges home, a change in post-acute resource consumption and net savings.

Use of Intravenous Thrombolytic Therapy in Acute Ischemic Stroke Patients: Evaluation of Clinical Outcomes

The use of intravenous thrombolytic therapy (ITT) in acute ischemic stroke (AIS) patients is still debated in China. We present the analysis of clinico-demographic retrospective data of 646 AIS patients that were treated by alteplase ITT at our hospital. The data collected included age, gender, education, income, drug use before disease onset, and awareness of stroke/ITT. The risk factors studied were hypertension, diabetes, hyperlipidemia, atrial fibrillation, coronary heart disease, cerebral infarction, transient ischemic attack, valvular heart disease, thyroid disease, migraine, asymptomatic carotid stenosis, family history of stroke, hyperhomocysteinemia, smoking, drinking, and gingivitis. Pre-ITT patient data included blood pressure and time from onset to hospital. Post-ITT patient data included National Institutes of Health Stroke Scale (NIHSS) scores, clinical outcome, revascularization, hemorrhage, healing rate, and 90-day mortality. Hospital management information included monthly ITT cases, discharges, bed turnaround times, length of hospital stay, bed utilization, drug ratio, massive cerebral infarction decompressive craniectomy, and social impact. Prognosis evaluation was based on post-ITT NIHSS and modified Rankin Scale (mRS) scores. We found that ITT success rate was 75.85 %, with a bleeding rate of 1.55 % and a 90-day mortality rate of 2.01 %. Overall, the data suggest that the ITT therapy was highly successful in AIS patients treated at our hospital.

Is prehospital treatment of acute stroke too expensive? An economic evaluation based on the first trial

BACKGROUND

Recently, a strategy for treating stroke directly at the emergency site was developed. It was based on the use of an ambulance equipped with a scanner, a point-of-care laboratory, and telemedicine capabilities (Mobile Stroke Unit). Despite demonstrating a marked reduction in the delay to thrombolysis, this strategy is criticized because of potentially unacceptable costs.

METHODS

We related the incremental direct costs of prehospital stroke treatment based on data of the first trial on this concept to one year direct cost savings taken from published research results. Key parameters were configuration of emergency medical service personnel, operating distance, and population density. Model parameters were varied to cover 5 different relevant emergency medical service scenarios. Additionally, the effects of operating distance and population density on benefit-cost ratios were analyzed.

RESULTS

Benefits of the concept of prehospital stroke treatment outweighed its costs with a benefit-cost ratio of 1.96 in the baseline experimental setting. The benefit-cost ratio markedly increased with the reduction of the staff and with higher population density. Maximum benefit-cost ratios between 2.16 and 6.85 were identified at optimum operating distances in a range between 43.01 and 64.88 km (26.88 and 40.55 miles). Our model implies that in different scenarios the Mobile Stroke Unit strategy is cost-efficient starting from an operating distance of 15.98 km (9.99 miles) or from a population density of 79 inhabitants per km2 (202 inhabitants per square mile).

CONCLUSION

This study indicates that based on a one-year benefit-cost analysis that prehospital treatment of acute stroke is highly cost-effective across a wide range of possible scenarios. It is the highest when the staff size of the Mobile Stroke Unit can be reduced, for example, by the use of telemedical support from hospital experts. Although efficiency is positively related to population density, benefit-cost ratios can be greater than 1 even in rural settings.

Rethinking capacity building for knowledge mobilisation: developing multilevel capabilities in healthcare organisations

Background

Knowledge mobilisation in healthcare organisations is often carried out through relatively short-term projects dependent on limited funding, which raises concerns about the long-term sustainability of implementation and improvement. It is becoming increasingly recognised that the translation of research evidence into practice has to be supported by developing the internal capacity of healthcare organisations to engage with and apply research. This process can be supported by external knowledge mobilisation initiatives represented, for instance, by professional associations, collaborative research partnerships and implementation networks. This conceptual paper uses empirical and theoretical literature on organisational learning and dynamic capabilities to enhance our understanding of intentional capacity building for knowledge mobilisation in healthcare organisations.

Discussion

The discussion is structured around the following three themes: (1) defining and classifying capacity building for knowledge mobilisation; (2) mechanisms of capability development in organisational context; and (3) individual, group and organisational levels of capability development. Capacity building is presented as a practice-based process of developing multiple skills, or capabilities, belonging to different knowledge domains and levels of complexity. It requires an integration of acquisitive learning, through which healthcare organisations acquire knowledge and skills from knowledge mobilisation experts, and experience-based learning, through which healthcare organisations adapt, absorb and modify their knowledge and capabilities through repeated practice. Although the starting point for capability development may be individual-, team- or organisation-centred, facilitation of the transitions between individual, group and organisational levels of learning within healthcare organisations will be needed.

Summary

Any initiative designed to build capacity for knowledge mobilisation should consider the subsequent trajectory of newly developed knowledge and skills within the recipient healthcare organisations. The analysis leads to four principles underpinning a practice-based approach to developing multilevel knowledge mobilisation capabilities: (1) moving from ‘building’ capacity from scratch towards ‘developing’ capacity of healthcare organisations; (2) moving from passive involvement in formal education and training towards active, continuous participation in knowledge mobilisation practices; (3) moving from lower-order, project-specific capabilities towards higher-order, generic capabilities allowing healthcare organisations to adapt to change, absorb new knowledge and innovate; and (4) moving from single-level to multilevel capability development involving transitions between individual, group and organisational learning.

Collaborations for leadership in applied health research and care: lessons from the theory of communities of practice

BACKGROUND

The paper combines the analytical and instrumental perspectives on communities of practice (CoPs) to reflect on potential challenges that may arise in the process of interprofessional and inter-organisational joint working within the Collaborations for Leaderships in Applied Health Research and Care (CLAHRCs)--partnerships between the universities and National Health Service (NHS) Trusts aimed at conducting applied health research and translating its findings into day-to-day clinical practice.

DISCUSSION

The paper discusses seminal theoretical literature on CoPs as well as previous empirical research on the role of these communities in healthcare collaboration, which is organised around the following three themes: knowledge sharing within and across CoPs, CoP formation and manageability, and identity building in CoPs. It argues that the multiprofessional and multi-agency nature of the CLAHRCs operating in the traditionally demarcated organisational landscape of the NHS may present formidable obstacles to knowledge sharing between various professional groupings, formation of a shared 'collaborative' identity, and the development of new communities within the CLAHRCs. To cross multiple boundaries between various professional and organisational communities and hence enable the flow of knowledge, the CLAHRCs will have to create an effective system of 'bridges' involving knowledge brokers, boundary objects, and cross-disciplinary interactions as well as address a number of issues related to professional and organisational identification.

SUMMARY

The CoP approach can complement traditional 'stage-of-change' theories used in the field of implementation research and provide a basis for designing theory-informed interventions and evaluations. It can help to illuminate multiple boundaries that exist between professional and organisational groups within the CLAHRCs and suggest ways of crossing those boundaries to enable knowledge transfer and organisational learning. Achieving the aims of the CLAHRCs and producing a sustainable change in the ways applied health research is conducted and implemented may be influenced by how effectively these organisations can navigate through the multiple CoPs involved and promote the development of new multiprofessional and multi-organisational communities united by shared practice and a shared sense of belonging--an assumption that needs to be explored by further empirical research.