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Bager JE, Jood K, Nordanstig A, Andersson T, Nåtman J, Hjerpe P, Rosengren A, Mourtzinis G. Long-term risk-factor control and secondary prevention are insufficient after first TIA: Results from QregPV. Eur Stroke J 2024; 9:154-161. [PMID: 38032016 PMCID: PMC10916821 DOI: 10.1177/23969873231215629] [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: 09/02/2023] [Accepted: 11/04/2023] [Indexed: 12/01/2023] Open
Abstract
INTRODUCTION Long-term risk-factor control and secondary prevention are not well characterized in patients with a first transient ischemic attack (TIA). With baseline levels as reference, we compared primary-care data on blood pressure (BP), low-density lipoprotein cholesterol (LDL-C), smoking, and use of antihypertensives, statins and antiplatelet treatment/oral anticoagulation (APT/OAC) during 5 years after a first TIA. PATIENTS AND METHODS Patients in QregPV, a Swedish primary-care register for the Region of Västra Götaland, with a first TIA discharge diagnosis from wards proficient in stroke care 2010 to 2012 were identified and followed up to 5 years. BP, LDL-C, smoking, use of antihypertensives, statins, APT/OAC, and achievement of target levels were calculated. We used logistic mixed-effect models to analyze the effect of follow-up over time on risk-factor control and secondary prevention treatment. RESULTS We identified 942 patients without prior cerebrovascular disease who had a first TIA. Compared to baseline, the first year of follow-up was associated with improvements in concomitant attainment of BP <140/90 mmHg, LDL-C < 2.6 mmol/L and non-smoking, which rose from 20% to 33% (OR 2.08, 95% CI 1.38-3.13), but then stagnated in years 2-5. In the first year of follow-up, 47% of patients had complete secondary prevention treatment (antihypertensives, APT/OAC and statin), but continued follow-up was associated with a yearly decrease in secondary prevention treatment (OR 0.94, 95% CI 0.94-0.98). CONCLUSION Risk-factor control was inadequate, leaving considerable potential for improved secondary prevention treatment after a first TIA in Swedish patients followed up to 5 years.
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Affiliation(s)
- Johan-Emil Bager
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Emergency Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Katarina Jood
- Department of Clinical Neuroscience, Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Annika Nordanstig
- Department of Clinical Neuroscience, Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Tobias Andersson
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Regionhälsan R&D Centre, Skaraborg Primary Care, Skövde, Sweden
| | | | - Per Hjerpe
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Regionhälsan R&D Centre, Skaraborg Primary Care, Skövde, Sweden
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Georgios Mourtzinis
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine and Emergency Mölndal, Sahlgrenska University Hospital, Gothenburg, Sweden
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Pedersen RA, Petursson H, Hetlevik I, Thune H. Stroke follow-up in primary care: a discourse study on the discharge summary as a tool for knowledge transfer and collaboration. BMC Health Serv Res 2021; 21:41. [PMID: 33413305 PMCID: PMC7792345 DOI: 10.1186/s12913-020-06021-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 12/16/2020] [Indexed: 12/02/2022] Open
Abstract
Background The acute treatment for stroke takes place in hospitals and in Norway follow-up of stroke survivors residing in the communities largely takes place in general practice. In order to provide continuous post stroke care, these two levels of care must collaborate, and information and knowledge must be transferred between them. The discharge summary, a written report from the hospital, is central to this communication. Norwegian national guidelines for treatment of stroke, issued in 2010, therefore give recommendations on the content of the discharge summaries. One ambition is to achieve collaboration and knowledge transfer, contributing to integration of the health care services. However, studies suggest that adherence to guidelines in general practice is weak, that collaboration within the health care services does not work the way the authorities intend, and that health care services are fragmented. This study aims to assess to what degree the discharge summaries adhere to the guideline recommendations on content and to what degree they are used as tools for knowledge transfer and collaboration between secondary and primary care. Methods The study was an analysis of 54 discharge summaries for home-dwelling stroke patients. The patients had been discharged from two Norwegian local hospitals in 2011 and 2012 and followed up in primary care. We examined whether content was according to guidelines’ recommendations and performed a descriptive and interpretative discourse analysis, using tools adapted from an established integrated approach to discourse analysis. Results We found a varying degree of adherence to the different advice for the contents of the discharge summaries. One tendency was clear: topics relevant here and now, i.e. at the hospital, were included, while topics most relevant for the later follow-up in primary care were to a larger degree omitted. In most discharge summaries, we did not find anything indicating that the doctors at the hospital made themselves available for collaboration with primary care after dischargeof the patient. Conclusions The discharge summaries did not fulfill their potential to serve as tools for collaboration, knowledge transfer, and guideline implementation. Instead, they may contribute to sustain the gap between hospital medicine and general practice.
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Affiliation(s)
- Rune Aakvik Pedersen
- Department of Public Health and Nursing, General Practice Research Unit, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Halfdan Petursson
- Department of Public Health and Nursing, General Practice Research Unit, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Irene Hetlevik
- Department of Public Health and Nursing, General Practice Research Unit, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Henriette Thune
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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Bacellar A, Pedreira BB, Costa G, Assis T, Lobo C, Nascimento O. Predictors of readmission and long length of stay in elders admitted with neurological disorders in a tertiary center: a real-world investigation. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:321-329. [DOI: 10.1590/0004-282x20190041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 02/01/2019] [Indexed: 01/27/2023]
Abstract
ABSTRACT Hospital readmission and long length of stay (LOS) increase morbidity and hospital mortality and are associated with excessive costs to health systems. Objective: This study aimed to identify predictors of hospital readmission and long LOS among elders with neurological disorders (NDs). Methods: Patients ≥ 60 years of age admitted to the hospital between January 1, 2009, and December 31, 2010, with acute NDs, chronic NDs as underpinnings of acute clinical disorders, and neurological complications of other diseases were studied. We analyzed demographic factors, NDs, and comorbidities as independent predictors of readmission and long LOS (≥ 9 days). Logistic regression was performed for multivariate analysis. Results: Overall, 1,154 NDs and 2,679 comorbidities were identified among 798 inpatients aged ≥ 60 years (mean 75.8 ± 9.1). Of the patients, 54.5% were female. Patient readmissions were 251(31%) and 409 patients (51%) had an LOS ≥ 9 days (95% confidence interval 48%–55%). We found no predictors for readmission. Low socioeconomic class (p = 0.001), respiratory disorder (p < 0.001), infection (p < 0.001), genitourinary disorder (p < 0.033), and arterial hypertension (p = 0.002) were predictors of long LOS. Identified risks of long LOS explained 22% of predictors. Conclusions: Identifying risk factors for patient readmission are challenges for neurology teams and health system stakeholders. As low socioeconomic class and four comorbidities, but no NDs, were identified as predictors for long LOS, we recommend studying patient multimorbidity as well as functional and cognitive scores to determine whether they improve the risk model of long LOS in this population.
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Affiliation(s)
- Aroldo Bacellar
- D’Or Institute for Research and Education, Brasil; Universidade Federal Fluminense, Brasil
| | | | | | - Telma Assis
- D’Or Institute for Research and Education, Brasil
| | - Camila Lobo
- D’Or Institute for Research and Education, Brasil
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Rea F, Micieli G, Musicco M, Cavallini A, Santucci C, Merlino L, Ieva F, Ferrarese C, Corrao G. Adherence to recommendations and clinical outcomes of patients hospitalized for stroke: the role of the admission ward-a real-life investigation from Italy. Neurol Sci 2019; 40:1433-1442. [PMID: 30941626 DOI: 10.1007/s10072-019-03867-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 03/23/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To determine whether out-of-hospital healthcare and adverse outcomes are better in stroke patients admitted to a neurology ward compared with those admitted to general wards. METHODS Beneficiaries of the National Health Service from the Italian Lombardy Region who were discharged alive after hospital admission during the year 2009 for ischemic stroke (9776 patients) or intracerebral or subarachnoid hemorrhage (1102 patients) entered into the cohort and were followed until 2012. Exposure of interest was the ward type where inpatients were admitted (neuro vs. general wards). Outcomes were out-of-hospital healthcare (i.e., drug prescriptions, diagnostic procedures, and laboratory clinical evaluations) and adverse clinical outcomes (i.e., all-cause death and hospital readmission). Exposure-outcome associations were investigated. High-dimensional propensity score methodology was used for taking into account confounders. Mediation analysis was used to verify whether the association between ward type and clinical outcomes is mediated by out-of-hospital adherence to healthcare. RESULTS Better adherence to out-of-hospital healthcare received from patients discharged from neuro, rather than general, wards was observed being the proportions of adherent patients 42.4% and 39.5%, respectively. Compared with general wards, discharge from neuro was associated with reduced 3-year emergency admissions (from 50.1 to 47.5% among ischemic stroke patients) and reduced 3-year mortality (from 37.5 to 27.0% among hemorrhagic stroke patients). From 10 to 15% of outcome risk, reductions were mediated by better adherence to out-of-hospital healthcare. CONCLUSIONS For patients with acute ischemic and hemorrhagic stroke, admission to neuro vs. general wards is associated with better out-of-hospital healthcare and long-term adverse outcomes.
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Affiliation(s)
- Federico Rea
- National Centre for Healthcare Research & Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy. .,Laboratory of Healthcare Research & Pharmacoepidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.
| | - Giuseppe Micieli
- Department of Emergency Neurology, IRCCS Mondino Foundation, Pavia, Italy
| | | | - Anna Cavallini
- San Matteo Hospital Stroke Unit and Mondino Institute Cerebrovascular Disease and Stroke Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Claudia Santucci
- Department of Oncology, IRCCS - Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - Luca Merlino
- Epidemiologic Observatory, Lombardy Regional Health Service, Milan, Italy
| | - Francesca Ieva
- MOX-Modelling and Scientific Computing, Department of Mathematics, Politecnico di Milano, Milan, Italy
| | - Carlo Ferrarese
- Department of Neurology, San Gerardo Hospital, Monza, Italy.,School of Medicine and Surgery and Milan Center for Neuroscience (NeuroMi), University of Milano-Bicocca, Monza, Italy
| | - Giovanni Corrao
- National Centre for Healthcare Research & Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.,Laboratory of Healthcare Research & Pharmacoepidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
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Pedersen RA, Petursson H, Hetlevik I. Stroke follow-up in primary care: a prospective cohort study on guideline adherence. BMC FAMILY PRACTICE 2018; 19:179. [PMID: 30486788 PMCID: PMC6263549 DOI: 10.1186/s12875-018-0872-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 11/16/2018] [Indexed: 11/30/2022]
Abstract
Background After a stroke, a person has an increased risk of recurrent strokes. Effective secondary prevention can provide significant gains in the form of reduced disability and mortality. While considerable efforts have been made to provide high quality acute treatment of stroke, there has been less focus on the follow-up in general practice after the stroke. One strategy for the implementation of high quality, evidence-based treatment is the development and distribution of clinical guidelines. However, from similar fields of practice, we know that guidelines are often not adhered to. The purpose of this study was to investigate to what degree patients who have suffered a stroke are followed up in general practice, if recommendations in the national guidelines are followed, and if patients achieve the treatment goals recommended in the guidelines. Methods The study included patients with cerebral infarction identified by the ICD-10 discharge diagnoses I63.0 trough I63.9 in two Norwegian local hospitals. In total 51 patients participated. They were listed with general practitioners in 18 different clinics. The material consists of the general practitioners’ (GPs’) medical records for these patients in the first year of follow-up; in total 381 consultations. Results Of the 381 consultations during the first year of follow-up, 71 (19%) had stroke as the main topic. The blood pressure (BP) target value < 140/90 mmHg was reached by 24 patients (47%). The low density lipoprotein (LDL) cholesterol target value < 2.0 mmol/L was reached by 14 (27%) of the 51 patients. In total six patients (12%) got advice on physical activity and three (6%) received dietary advice. No advice about alcohol consumption was recorded. Conclusions The findings support earlier claims that the development and distribution of guidelines alone is not enough to implement a certain practice. Despite being a serious condition, stroke gets limited attention in the first year of follow-up in general practice. This can be explained by the complexity of general practice, where even a serious condition loses the competition for attention to other apparently equally important issues. Electronic supplementary material The online version of this article (10.1186/s12875-018-0872-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rune Aakvik Pedersen
- General Practice Research Unit, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, PO Box 8905 MTFS, N-7491, Trondheim, Norway.
| | - Halfdan Petursson
- General Practice Research Unit, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, PO Box 8905 MTFS, N-7491, Trondheim, Norway
| | - Irene Hetlevik
- General Practice Research Unit, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, PO Box 8905 MTFS, N-7491, Trondheim, Norway
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