Advances in Health Policy and Outcomes 2009
2010; Lippincott Williams & Wilkins; Volume: 41; Issue: 2 Linguagem: Inglês
10.1161/strokeaha.109.569939
ISSN1524-4628
AutoresLinda S. Williams, Anthony G. Rudd,
Tópico(s)Hospital Admissions and Outcomes
ResumoHomeStrokeVol. 41, No. 2Advances in Health Policy and Outcomes 2009 Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessReview ArticlePDF/EPUBAdvances in Health Policy and Outcomes 2009 Linda S. Williams, MD and Anthony G. Rudd, FRCP Linda S. WilliamsLinda S. Williams From the Veterans Affairs HSR&D Stroke Quality Enhancement Research Initiative, Roudebush Veterans Affairs Medical Center, and the Department of Neurology, Indiana University School of Medicine (L.S.W.), and the Clinical Standards Department (A.G.R.), Royal College of Physicians, London, England. and Anthony G. RuddAnthony G. Rudd From the Veterans Affairs HSR&D Stroke Quality Enhancement Research Initiative, Roudebush Veterans Affairs Medical Center, and the Department of Neurology, Indiana University School of Medicine (L.S.W.), and the Clinical Standards Department (A.G.R.), Royal College of Physicians, London, England. Originally published14 Jan 2010https://doi.org/10.1161/STROKEAHA.109.569939Stroke. 2010;41:e77–e80Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 14, 2010: Previous Version 1 A number of important studies have been published in 2009 providing further information about the most clinically and cost-effective ways of delivering care across the whole stroke pathway. From previous work in Oxford and elsewhere, it has been shown that patients with transient ischemic attack (TIA) can be prioritized into those at high risk and low risk of going on to develop stroke. Rothwell et al1 have also shown that urgent assessment and treatment reduce the 90-day risk of recurrent stroke by 80%. Further analysis of the data has been reported from the EXPRESS study on the effect of early intervention on hospital admission rate, hospital bed days, disability at 90 days, and hospital costs.2 Significant improvements in all of these outcomes were demonstrated, regardless of the characteristics of patients, resulting in savings of £624 per patient referred to the rapid-access service.Models for the delivery of hyperacute care vary considerably, and several articles have addressed how thrombolysis rates and outcomes can be improved. In the United Kingdom and many other countries, there is a move to the centralization of care in a small number of comprehensive stroke centers (CSCs). Despite a major restructuring of services, this is being developed without strong evidence to support it. A recent study has reported outcomes for 153 consecutive ischemic stroke patients treated with tissue plasminogen activator at a CSC, of whom 45 had been initially assessed and treated at a community hospital with secondary transfer to the CSC.3 Stroke to thrombolysis times were shorter when patients directly accessed the CSC and outcomes were better. No clinical factors could be identified by the authors to explain the differences; however, the sample size was small and the study was uncontrolled. An alternative model to direct admission to a CSC is the "drip and ship" model, whereby community hospitals initiate thrombolysis and then transfer the patient directly to a specialist center. Martin-Schild et al,4 in another small uncontrolled study, indicated that this approach does not compromise outcomes. The initial treatment in the community hospitals was conducted with telephone or videotelemedicine supervision by the specialists. For geographic areas where accessing a specialist unit without delay is impracticable, this protocol does seem to be a reasonable alternative that needs further evaluation.Once the patient has been admitted, the best model for acute care has been evaluated in a study from Germany, comparing semi-intensive stroke unit treatment (specialist stroke team and advanced monitoring systems) with conventional medical care (nonspecialist and basic physiologic monitoring).5 Again, this was an observational study, and it therefore needs to be interpreted with caution, but it showed evidence of improved outcomes at 1 year in those patients treated intensively. These findings applied to stroke patients but not to those being managed for TIA. Thrombolysis rates vary enormously between hospitals. Van Wijngaarden et al6 explored which aspects of organizational culture might explain the variation. A cohort study of 12 centers in the Netherlands looked at 10 characteristics, including learning culture, the presence of "uncompromising individual leadership," informal and formal feedback, and setting explicit goals. Several cultural characteristics of hospital organization were associated with thrombolysis rate. These are important findings and possibly are applicable to many aspects of delivering high-quality service, not just thrombolysis.After the hyperacute phase has passed, the evidence is very strong for care to be provided on a specialist stroke unit. Despite the large number of stroke unit trials, the evidence for them resulting in resource savings is limited. A retrospective analysis of 2 cohorts of patients admitted to hospital in Calgary, Canada, reported data for patients admitted to the general medical/neurology service before 2001 compared with a similar group admitted to the stroke unit after 2003.7 After case mix adjustment, the average length of stay on the stroke unit was 4 days shorter than in the general ward, with a 9% reduction in the proportion of patients staying >7 days. In-hospital case fatality was reduced by 4.5%. These data provide important evidence to support the argument for universal stroke unit care on the basis not just of clinical effectiveness but also of cost-effectiveness. Several studies have previously shown that the benefits of stroke units shown in research trials can be replicated in routine practice. An additional analysis, this time from Australia of >17 000 admissions, reinforced the message.8 Both improvements in mortality and reductions in institutionalization rate were demonstrated in patients, regardless of age and case severity.The need to ensure that specialist stroke services run effectively 7 days a week has been shown by Crowley et al.9 It has already been demonstrated that access to scanning and other acute stroke services is less likely to be achieved in a timely fashion on weekends, but this is 1 of the first times that an impact has been shown on outcomes. Admission during the weekend was associated with increased mortality after intracerebral hemorrhage compared with admission during the remainder of the week. In a separate article, however, no differences were found in outcomes after subarachnoid hemorrhage between weekend and weekday admissions.10Management of patients after discharge from hospital receives much less attention in the research literature than does acute stroke. Two articles have provided rather contradictory results. The first was a randomized, controlled trial involving 265 patients of a structured reassessment system at 6 months after stroke compared with conventional care.11 No differences were found in independence or emotional distress in carers at 12 months. Health and social care resource use and mean cost per patient were also similar. This was a fairly low-intensity intervention, and it may be that patients require more to demonstrate benefit; however, current recommendations in the National Clinical Guidelines for Stroke (2008) in England that all patients should have a specialist reassessment at 6 months after stroke has not been supported by any trial evidence. A study from Canada12 looked at nearly 4000 patients discharged from hospital in Quebec after stroke and, by using a Markov chain model, analyzed the impact of various facilitated care interventions. Planned access to a primary care provider appears to improve outcomes and reduce the need for Emergency Department visits and is a less expensive way of providing care. That study does appear to support a structured plan for postdischarge care and was based on a very large patient sample; however, it was based on observational data and was therefore subject to all sorts of issues in interpretation. There is a need for different models to be tested in randomized trials. Even though the Forster trial failed to show benefit, the status quo is inadequate. One of the most frequent complaints that patients make is the lack of support they receive after discharge from hospital.Cost of Stroke CareRobust cost-effectiveness studies are essential for development of services and interventions. A literature review13 identified a total of 120 cost studies. Huge variations in the cost of stroke were found, with average costs ranging from $468 to $146 149. Differences in cost were evident not just between countries but also within countries. For example, estimates in the United States varied 20-fold. The authors were justifiably concerned that with such variable results, there was a potential for selection bias in secondary economic analyses, with the authors including those costs that were more likely to produce the desired results. Cost-effectiveness modeling was conducted in the United Kingdom with data from the South London Stroke Register of stroke unit care followed by early supported discharge (ESD), compared with stroke unit care without ESD and general medical care without ESD.14 Using the cost-effectiveness threshold of £30 000 that has been adopted by the National Institute of Health Clinical Excellence in the United Kingdom, stroke unit care followed by ESD is the cost-effective strategy compared with the other 2 options. The clinical benefit of using anticoagulation to prevent stroke in patients with atrial fibrillation has been accepted after several positive, randomized, controlled trials. The cost-effectiveness of using warfarin in the "real world" has not, however, been demonstrated, given that it is a difficult drug to give. Dosage needs to be individualized according to the patient's international normalized ratio, requiring regular blood tests. Failure to achieve the target international normalized ratio results in either an increase risk of bleeding or ineffective prevention. Concordance with treatment is often poor. Sorenson et al15 modeled 4 different scenarios for warfarin treatment, ranging from perfect control to real world prescription and control of warfarin, aspirin, or neither for warfarin-eligible patients. The results were striking, with perfect control producing very substantial reductions in stroke rate and cost compared with the real world situation. The need to improve the quality of anticoagulation and decrease the rate of warfarin discontinuation are highlighted.Quality of Care StudiesSeveral studies published in the past year have provided insight into successful programs to improve the quality of inpatient stroke care, as well as to identify patient and hospital factors associated with the quality of stroke care. Data from 790 hospitals voluntarily participating from 2003 to 2007 in the American Stroke Association Get With the Guidelines Stroke program demonstrated that this comprehensive inpatient stroke quality improvement program was associated with significant improvements over time (baseline to year 5) in all 7 indicators and a composite quality indicator.16 These improvements were independent of facility size, geographic location, and teaching status. Another publication from this dataset found that off-hours presentation was associated with a small increase in risk of in-hospital death (0.6% absolute increase) in patients with ischemic stroke and a slightly higher risk for patients with hemorrhagic stroke (3.1% absolute increase), although quality of care did not differ by time of presentation.17 A Canadian study found that adjusted in-hospital mortality risk in patients admitted with stroke was greatest in low-income patients, who were also more likely to be admitted to low-volume hospitals.18 The authors suggested that further exploring the links between socioeconomic status and hospital characteristics may yield important understanding about targets for stroke quality improvement efforts. Another pre/post-designed study demonstrated that a system redesign initiative in 15 hospitals in Australia was associated not only with improvements in process indicators but also with improvements in adjusted patient outcomes at discharge.19 This study is an important demonstration of the expected but infrequently demonstrated process-outcome link in quality improvement research. Finally, in addition to the traditional inpatient stroke quality indicators, a single-site study demonstrated improvements in influenza vaccination for patients hospitalized with stroke, illustrating the importance of focusing on aspects of care not specifically related to stroke itself to deliver optimal care to the hospitalized stroke patient.20 As more data from large national quality improvement studies become available, data describing organizational factors at the hospital or team level and more detailed information about specific strategies associated with the greatest improvements will hopefully be published to fuel ongoing efforts for continuous quality improvement in inpatient stroke care.The postdischarge period after stroke may present an important opportunity for improvements in poststroke risk factor management. Two studies identified important evidence-practice gaps in poststroke care for patients in different poststroke settings. A US study of dually enrolled Medicare and Medicaid beneficiaries living in nursing homes demonstrated that of the quality indicators measured by the minimum data set, fewer than a quarter of the recommended quality indicators for poststroke care were delivered.21 Specific stroke-related indicators included in this study were head computed tomography or magnetic resonance imaging for suspected hemispheric stroke symptoms in residents without a prior history of stroke, provision of warfarin for residents with atrial fibrillation, and cholesterol-lowering medication for residents <70 years of age with hypercholesterolemia and stroke or TIA. A Canadian study found that, compared with patients with coronary artery disease, those with cerebrovascular disease had greater gaps in poststroke risk factor care (achievement of blood pressure and cholesterol targets).22 Importantly, among those with cerebrovascular disease only, women were less likely than men to achieve risk factor targets, suggesting that these may be important subgroups for ongoing quality improvement strategies aimed at risk factor management.Age-Related Stroke Outcome StudiesA series of reports from the Stroke Outcomes Research Canada Working Group provide important insight into the relation between age and stroke care. Although the oldest elderly in Canada are more likely to be admitted on the weekend, are less likely to be admitted to an intensive care unit, and have higher risk-adjusted in-hospital mortality,23 data suggest that the benefits of organized stroke care are of equal magnitude in all age groups.24 Furthermore, data from the province of Ontario suggest that stroke care delivery in a coordinated system does not differ by age, including use of thrombolytics, dysphagia screening, provision of antithrombotic therapy, and warfarin for patients with atrial fibrillation, although slightly fewer diagnostic investigations were performed in the very elderly.25 A single-site study in the United Kingdom also demonstrated fewer diagnostic evaluations and lifestyle modification recommendations in older stroke survivors.26The social consequences of stroke are an area that deserves further investigation. A systematic review of return to work among younger stroke survivors and other aspects of social participation after stroke suggested strategies to improve the assessment of these important outcomes among all stroke survivors.27 Stroke caregiving research in 2009 further highlighted the importance of assessment of patient and caregiver changes over time rather than at stroke discharge only as a key driver of caregiver burden,28 as well as the potential impact of strategies that actively involve patients and caregivers in information exchange after stroke on patient knowledge, satisfaction, and mental health outcomes.29DisclosuresNone.FootnotesCorrespondence to Linda S. Williams, MD, Veterans Affairs HSR&D Stroke Quality Enhancement Research Initiative, Roudebush Veterans Affairs Medical Center, Indianapolis, IN. 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Thrift A and Vickrey B (2012) Advances in Health Policy and Outcome 2010–2011, Stroke, 43:2, (300-301), Online publication date: 1-Feb-2012.McKevitt C, Fudge N, Redfern J, Sheldenkar A, Crichton S, Rudd A, Forster A, Young J, Nazareth I, Silver L, Rothwell P and Wolfe C (2011) Self-Reported Long-Term Needs After Stroke, Stroke, 42:5, (1398-1403), Online publication date: 1-May-2011. February 2010Vol 41, Issue 2 Advertisement Article InformationMetrics https://doi.org/10.1161/STROKEAHA.109.569939PMID: 20075353 Manuscript receivedOctober 6, 2009Manuscript acceptedOctober 14, 2009Originally publishedJanuary 14, 2010 Keywordsadvanceshealth policyoutcomesPDF download Advertisement SubjectsTreatment
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