Portal de Periódicos da CAPES

Health Services Research

2019; Lippincott Williams & Wilkins; Volume: 50; Issue: 5 Linguagem: Inglês

10.1161/strokeaha.118.024093

1524-4628

Brystana G. Kaufman, Anna Kucharska‐Newton, Janet Prvu Bettger,

Global Public Health Policies and Epidemiology

HomeStrokeVol. 50, No. 5Health Services Research Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBHealth Services ResearchA Critical Need in Stroke Care Brystana G. Kaufman, PhD, Anna Kucharska-Newton, PhD, MPH and Janet Prvu Bettger, ScD Brystana G. KaufmanBrystana G. Kaufman Correspondence to Brystana G. Kaufman, PhD, Duke Margolis Center for Health Policy, 230 Science Dr, Durham, NC 27705. Email E-mail Address: [email protected] From the Duke University, Margolis Center for Health Policy; Durham, NC (B.G.K., J.P.B.) , Anna Kucharska-NewtonAnna Kucharska-Newton University of Kentucky, College of Public Health, Lexington (A.K.-N.) Department of Epidemiology, The Gillings School of Global Public Health, University of North Carolina at Chapel Hill (A.K.-N.) and Janet Prvu BettgerJanet Prvu Bettger From the Duke University, Margolis Center for Health Policy; Durham, NC (B.G.K., J.P.B.) Duke Clinical Research Institute, Durham, NC (J.P.B.). Originally published20 Mar 2019https://doi.org/10.1161/STROKEAHA.118.024093Stroke. 2019;50:e121–e124Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: March 20, 2019: Ahead of Print Evidence defining high-quality stroke care has improved dramatically in the past 20 years; however, the gap between evidence and practice persists in stroke prevention, treatment, and rehabilitation.1 Although clinical trials have been instrumental in advancing the science supporting evidence-based guidelines, research is needed to identify gaps and factors contributing to gaps in care and outcomes and to develop strategies that promote uptake of evidence-based treatment and services for stroke patients. This article discusses health services research (HSR) as a multidisciplinary field encompassing outcomes research, implementation science, and financial evaluations that can address critical evidence, practice and policy gaps in stroke care.Introduction to HSRThe objective of HSR is to identify strategies for improving population health, which must balance access and quality of care against cost. Although greater use and quality of care generally increase cost, the triple aim of improvements in health care refers to the potential for health systems to improve population outcomes and patient experience at reduced cost by reducing waste and low-value care and increasing use of high-value preventive and evidence-based care. The push toward publicly reporting healthcare quality and value-based payment models has boosted the relevance of HSR across the care continuum, particularly for high service use, high cost, and high morbidity events, such as stroke. As a result, HSR has broad application across multiple disciplines and all components of stroke care.The suboptimal uptake of effective preventive and therapeutic treatments for stroke presents several opportunities for HSR to contribute to improvements in care and outcomes for patients. Developing strategies to improve use of evidence-based care requires knowledge of the multifactorial pathways which govern health behaviors, systems, and processes of care. Conceptual frameworks can be used to depict the complex pathways contributing to the gaps between evidence and practice. Donabedian framework for evaluating the quality of health care draws on characteristics of the structure and process of care delivery influencing patient and health system outcomes.2 Commonly used to evaluate health services utilization, Andersen Behavioral Model of Health Services Use suggests that patients' use of health care depends on clinical and nonclinical factors, including patient demographics and local resources.2 Similarly, the social-ecological framework posits that the individual is nested within family and social networks, further influenced by interactions with health care, that are shaped by their local communities and the broader system of policies and regulations. Finally, organizational theories are used to understand how the characteristics of patients, caregivers, providers, and settings can impact the dissemination of interventions.3Investigators collaborating across disciplines can use theory-driven HSR to develop impactful research questions and to identify areas critical for intervention for improving access, quality and outcomes. Many federal agencies, professional associations, and foundations are funding research and care innovation targeting health disparities, health systems delivery reform, and population cost and outcomes. Examples of specific opportunities for early career investigators to explore fellowship opportunities, research funding, and networking in HSR are listed in Table.Table. Examples of Health Services Research Resources for Early Career InvestigatorsNetworkingFellowshipsResearch FundingPrivate Foundations John A. Hartford Foundation (eg, Health and Aging Policy Fellows Program)X Robert Wood Johnson Foundation (eg, Clinical Scholars Program; Culture of Health Leaders)X Commonwealth Fund (eg, Minority Health and Margaret E. Mahoney Fellowships)X West Health Institute (eg, Telehealth Research symposium)XProfessional Associations American Heart AssociationXX Quality of Care and Outcomes Research (eg, Young Investigator award)XX Council on Lifestyle and Cardiometabolic HealthX Council on Epidemiology and PreventionX Get With The Guidelines (eg, Young Investigator Seed Grant)X American Geriatrics SocietyX Gerontological Society of America (eg, early career networking group)X NorthEast Cerebrovascular Consortium (eg, mini-grant initiative)XX American Federation for Aging Research (eg, Medical Student Training in Aging Research)XX AcademyHealth (eg, Real-World Evidence Fellowship; directory of 400+ policy fellowships)XX Disparities Research Interest GroupX Quality and Value Interest GroupX Behavioral Health Services ResearchXPublic Institutions National Institutes of Health (eg, T32 National Research Service Award)X Agency for Healthcare Research and Quality (eg, Mentored Clinical Scientist Development)X Patient-Centered Outcomes Research Institute (eg, K12 Institutional Mentored Career Development Program for Learning Health Systems Research)X National Center for Health Statistics (eg, Health Policy Scholars Program)XCritical HSR Needs in Stroke CareAccessExamining the evolution and causes of cardiovascular disease and health disparities is a key function of HSR. Increased understanding of the factors that improve primary prevention could substantially reduce the burden of stroke in the population. Increasingly, community-based and behavioral interventions are being evaluated and utilized for stroke prevention and health promotion.4 Although care provision contributes to health outcomes, up to 80% of health outcomes are determined by factors external to treatment decisions.5 Social determinants of health, such as living conditions, food availability, educational opportunities, economic stability, the physical environment and transportation, health care and social systems of support, and community engagement may explain some of the disproportionate stroke burden.The magnitude of stroke disparities has increased over time, with racial and geographic variation in prevention, treatment, and rehabilitation strategies.6 Community factors driving geographic variation in health outcomes are shaped by the distribution of resources and range from availability of healthcare services, including certified stroke centers and postacute care facilities, to societal supports, such as the quality of public education and affordability of health insurance. Studying these factors can identify opportunities to narrow the care delivery gap contributing to differential outcomes for subpopulations.Because randomization of access to care and social determinants is not possible or ethical, secondary data sources are commonly used to retrospectively evaluate use and outcomes. For example, in the United States, the Centers for Medicare and Medicaid Services allow administrative data to be used for research with institutional review board oversight. Healthcare claims data and facility data can be used to examine geographic variation and associations with patient demographics. Additional sources of data for healthcare use and outcomes include national surveys (eg, Medical Expenditures Panel Survey, American Community Survey, and National Health Interview Survey) and state-level data on hospitalizations available through the Health Care Cost and Utilization Program. The National Center for Health Statistics provides public use files and death information. Finally, Census data provide publicly available information on community sociodemographic characteristics and resources. Despite the limitations of retrospective data, secondary data repositories can be used alone or linked with 1 clinical data to reveal rich perspectives on opportunities for improvement in stroke prevention and care.QualityNew evidence for stroke care is slow to be implemented; effective therapeutic interventions, for example, receiving intravenous tissue-type plasminogen activator treatment, are inconsistently used in practice, even when recommended in clinical guidelines.7 Historically, clinical care relies on diffusion of new evidence to reach front-line providers through continuing education activities and local guideline updates. HSR has been instrumental in improving practice and policy through active examination of barriers and facilitators of guideline implementation and adapting care models to fit the organizational context. Mobile stroke units, for example, innovatively address access and quality. Interventions that affect factors driving stroke care evidence uptake are critically needed in future research.Health service researchers work with clinicians, healthcare administrators, and other stakeholders to integrate evidence-based interventions into the existing operational culture. A pragmatic randomized trial in China tested whether a multifaceted quality improvement intervention improves hospital adherence to evidence-based acute stroke care.8 In postacute care, clinical trials, such as the COMPASS Study (Comprehensive Post-Acute Stroke Services) funded by the Patient-Centered Outcomes Research Institute test the effectiveness of a transitional care model on patient-centered outcomes.9 Both of these interventions are examples of HSR used to help providers navigate practical barriers to optimal care. Specifically, these examples address clinical pathways, care protocols, and regulatory requirements to improve care delivery and billing for posthospital medical follow-up care.Quality improvement research has become an important component of HSR, providing an opportunity for iterative data-driven improvements. In contrast with patient-level, disease-specific quality improvement initiatives, HSR contributes a population-based systems perspective that ideally creates synergy with quality improvement projects at local or regional levels. Both providers and patients behave differently in a trial setting than in the clinic resulting in differences in protocol, adherence, and outcomes; consequently, health services researchers frequently use quasiexperimental study designs to better understand real-world outcomes in the actual patient population. Electronic health records can be used to provide real-time data on patient health status and quality of care. Organized efforts, such as the PCORnet (National Patient-Centered Clinical Research Network), engage clinical and patient partner networks to harmonize electronic health record data across multiple healthcare systems and collectively address barriers and scientific capacity for use. Electronic health record data are also the backbone of US national stroke registries, such as the American Heart Association's Get With The Guidelines–Stroke, the Centers for Disease Control and Prevention-funded Paul Coverdell National Acute Stroke, and the Florida Puerto Rico Stroke Registries. HSR using pragmatic trials, quality improvement, and implementation research show great potential in accelerating translation of evidence into everyday practice and policy.CostThe price of health care in the United States escalated to 18% of gross domestic product as of 2016, and total stroke costs are forecasted to increase by 238% from 2010 to 2030.10 Policy makers are hopeful that alternative payment models will curb costs; however, the impact of new payment models and pricing on acute and postacute stroke care is unclear. The fee-for-service payment design still dominates reimbursement for stroke care in the United States, incentivizing health systems to provide more, not necessarily better, care. Financial incentives for cost containment may spur uptake of innovative care models. Alternatively, value-based payment and managed care models may cause tension if better stroke care increases costs. Health economists are key contributors to HSR to evaluate the impact of alternative payment models, such as bundled payments, accountable care organizations, and managed care, on stroke outcomes.Opportunities to compare long term costs of care and effectiveness of preventive and therapeutic therapies are abundant. Comparative clinical and cost-effectiveness research of different therapeutic modalities helps payers, providers, and patients in decision-making. Cost-effectiveness models simulate real-world population outcomes and estimate the incremental cost relative to the net gain in quality-adjusted life years. For example, data from the Interventional Management of Stroke III Trial, funded by the United States National Institutes of Health, were used to evaluate variations in outcomes and cost observed over 12 months for subjects receiving endovascular therapy compared with intravenous tissue-type plasminogen activator alone. Financial evaluations can demonstrate the economic incentive for investment in improvements in the care process for acute and postacute stroke.SummaryHSR is an important type of research to improve stroke outcomes through reduction in stroke disparities, improvements in the implementation and dissemination of evidence-based practices, and alignment of payment models with optimal patient-centered outcomes. Stroke care is complex. Health services methods and models can inform multilevel interventions that can be used to improve the provision and implementation of stroke care across care settings. Collaborations between healthcare professionals, administrators, and HSR methodologists are critical to designing HSR studies and interventions that will improve stroke care and outcomes.DisclosuresJ. Prvu Bettger receives Research funding from the Patient-Centered Outcomes Research Institute, National Institutes of Health, and the Medical Research Council. The other authors report no conflicts.FootnotesCorrespondence to Brystana G. Kaufman, PhD, Duke Margolis Center for Health Policy, 230 Science Dr, Durham, NC 27705. Email brystana.[email protected]eduReferences1. Donnellan C, Sweetman S, Shelley E. Health professionals' adherence to stroke clinical guidelines: a review of the literature.Health Policy. 2013; 111:245–263. doi: 10.1016/j.healthpol.2013.05.002Google Scholar2. McDonald KM, Sundaram V, Bravata DM, Lewis R, Lin N, Kraft SA, et al. Closing the quality gap: a critical analysis of quality improvement strategies (Vol. 7: care coordination). Shojania KG, McDonald KM, Wachter RM, Owens DK, eds. In: Conceptual Frameworks and Their Application to Evaluating Care Coordination Interventions. Rockville, MD: Agency for Healthcare Research and Quality; 2007:109–130.Google Scholar3. Milat AJ, Li B. Narrative review of frameworks for translating research evidence into policy and practice.Public Health Res Pract. 2017; 27:2711704.Google Scholar4. Salinas J, Schwamm LH. Behavioral interventions for stroke prevention: the need for a new conceptual model.Stroke. 2017; 48:1706–1714. doi: 10.1161/STROKEAHA.117.015909LinkGoogle Scholar5. McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion.Health Aff (Millwood). 2002; 21:78–93. doi: 10.1377/hlthaff.21.2.78CrossrefMedlineGoogle Scholar6. Cruz-Flores S, Rabinstein A, Biller J, Elkind MS, Griffith P, Gorelick PB, et al; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Epidemiology and Prevention; Council on Quality of Care and Outcomes Research. Racial-ethnic disparities in stroke care: the American experience: a statement for healthcare professionals from the American Heart Association/American Stroke Association.Stroke. 2011; 42:2091–2116. doi: 10.1161/STR.0b013e3182213e24LinkGoogle Scholar7. Messé SR, Khatri P, Reeves MJ, Smith EE, Saver JL, Bhatt DL, et al. Why are acute ischemic stroke patients not receiving IV tPA? Results from a national registry.Neurology. 2016; 87:1565–1574. doi: 10.1212/WNL.0000000000003198CrossrefMedlineGoogle Scholar8. Wang Y, Li Z, Zhao X, Wang C, Wang X, Wang D, et al; GOLDEN BRIDGE—AIS Investigators. Effect of a multifaceted quality improvement intervention on hospital personnel adherence to performance measures in patients with acute ischemic stroke in China: a randomized clinical trial.JAMA. 2018; 320:245–254. doi: 10.1001/jama.2018.8802CrossrefMedlineGoogle Scholar9. Duncan PW, Bushnell CD, Rosamond WD, Jones Berkeley SB, Gesell SB, D'Agostino RB, et al. The Comprehensive Post-Acute Stroke Services (COMPASS) study: design and methods for a cluster-randomized pragmatic trial.BMC Neurol. 2017; 17:133. doi: 10.1186/s12883-017-0907-1CrossrefMedlineGoogle Scholar10. Heidenreich PA, Trogdon JG, Khavjou OA, Butler J, Dracup K, Ezekowitz MD, et al; American Heart Association Advocacy Coordinating Committee; Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Clinical Cardiology; Council on Epidemiology and Prevention; Council on Arteriosclerosis; Thrombosis and Vascular Biology; Council on Cardiopulmonary; Critical Care; Perioperative and Resuscitation; Council on Cardiovascular Nursing; Council on the Kidney in Cardiovascular Disease; Council on Cardiovascular Surgery and Anesthesia, and Interdisciplinary Council on Quality of Care and Outcomes Research. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association.Circulation. 2011; 123:933–944. doi: 10.1161/CIR.0b013e31820a55f5LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Brom H, Brooks Carthon J, Sloane D, McHugh M and Aiken L (2021) Better nurse work environments associated with fewer readmissions and shorter length of stay among adults with ischemic stroke: A cross‐sectional analysis of United States hospitals, Research in Nursing & Health, 10.1002/nur.22121, 44:3, (525-533), Online publication date: 1-Jun-2021. Park E, Gil Y, Kim C, Kim B and Hwang S (2021) Presence of Thrombectomy-capable Stroke Centers Within Hospital Service Areas Explains Regional Variation in the Case Fatality Rate of Acute Ischemic Stroke in Korea, Journal of Preventive Medicine and Public Health, 10.3961/jpmph.21.329, 54:6, (385-394), Online publication date: 30-Nov-2021. Littlewood R, Canfell O and Tracey F (2020) Building a Children's Health Service and System Research Strategy: development and integration in an Australian paediatric healthcare setting, BMC Health Services Research, 10.1186/s12913-020-05267-6, 20:1, Online publication date: 1-Dec-2020. May 2019Vol 50, Issue 5 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.118.024093PMID: 30890107 Originally publishedMarch 20, 2019 Keywordspopulation healthcaregivershealth services researchhealth behaviorpatientsPDF download Advertisement SubjectsEpidemiologyEthics and PolicyHealth ServicesQuality and OutcomesRisk Factors