Does implementation of a standardized pathway of stroke care affect functional outcome after stroke?

BACKGROUND: A stroke care pathway (SCP) was introduced in Norway in 2018. The goal of the pathway was to avoid delay in treatment and diagnostics of acute stroke and to secure treatment according to national guidelines. In this study, we aimed to evaluate how the implementation of the SCP affects outcome after stroke. METHODS: We performed a register-based study using data from the Norwegian Stroke Register that covers 87% of acute stroke patients in Norway. Patients included 1 year before and 1 year after the introduction of the care pathway were compared (2017 vs 2019). Change in functional outcome, the proportion of independent patients 90 days post-stroke, discharge destination, proportions admitted to stroke units and 90 days mortality were compared. Functional outcome was measured using modified Rankin Scale (mRS) and functional independence was defined as mRS 0-2. RESULTS: In total, 11,009 patients with 90 days follow-up data were analyzed. Comparing the cohorts from 2017 and 2019, there was no change in demographics or stroke characteristics. No statistically significant differences in mRS, admission to thrombolysis time, or 90 days mortality were found. However, the proportion of patients discharged directly home and treated in a stroke unit increased from 2017 to 2019. CONCLUSION: The implementation of a standardized pathway of stroke care in Norway did not lead to improvement in functional outcome or a reduction in 90 days mortality. However, the proportion of patients discharged directly home increased, and more patients were treated in stroke units in 2019 compared with 2017.

ABCD3-I and ABCD2 Scores in a TIA Population with Low Stroke Risk.

OBJECTIVES: We aimed to evaluate the ABCD3-I score and compare it with the ABCD2 score in short- (1 week) and long-term (3 months; 1 year) stroke risk prediction in our post-TIA stroke risk study, MIDNOR TIA. MATERIALS AND METHODS: We performed a prospective, multicenter study in Central Norway from 2012 to 2015, enrolling 577 patients with TIA. In a subset of patients with complete data for both scores (n = 305), we calculated the AUC statistics of the ABCD3-I score and compared this with the ABCD2 score. A telephone follow-up and registry data were used for assessing stroke occurrence. RESULTS: Within 1 week, 3 months, and 1 year, 1.0% (n = 3), 3.3% (n = 10), and 5.2% (n = 16) experienced a stroke, respectively. The AUCs for the ABCD3-I score were 0.72 (95% CI, 0.54 to 0.89) at 1 week, 0.66 (95% CI, 0.53 to 0.80) at 3 months, and 0.68 (0.95% CI, 0.56 to 0.79) at 1 year. The corresponding AUCs for the ABCD2 score were 0.55 (95% CI, 0.24 to 0.86), 0.55 (95% CI, 0.42 to 0.68), and 0.63 (95% CI, 0.50 to 0.76). CONCLUSIONS: The ABCD3-I score had limited value in a short-term prediction of subsequent stroke after TIA and did not reliably discriminate between low- and high-risk patients in a long-term follow-up. The ABCD2 score did not predict subsequent stroke accurately at any time point. Since there is a generally lower stroke risk after TIA during the last years, the benefit of these clinical risk scores and their role in TIA management seems limited. Clinical Trial Registration. This trial is registered with NCT02038725 (retrospectively registered, January 16, 2014).

Stroke in Norway 2015­16 ­ treatment and outcomes. / Hjerneslag i Norge 2015­16 ­ behandling og resultater.

BACKGROUND: Treatment of stroke in Norway is decentralised; patients with stroke are treated at 50 different hospitals. We have surveyed the treatment of stroke in these hospitals and collated this with data from the Norwegian Stroke Registry. We wished to investigate whether there was any variation in treatment interventions and treatment outcomes between university hospitals and local hospitals. MATERIAL AND METHOD: A questionnaire survey among all Norwegian hospitals examined treatment interventions and resource availability. Data from the Norwegian Stroke Registry in 2015-2016 (n = 17 183) were used to compare patient characteristics and treatment outcomes for patients in university hospitals (n = 5 312) and local hospitals (n = 11 871). Treatment quality was measured using the quality indicators in the Norwegian Stroke Registry. RESULTS: The median age in the university hospitals was 75 years (interquartile range 65-83), and 44.1% of the patients were women. The median age in the local hospitals was 76 years (interquartile range 67-85); 46.7% women. Goal achievement on five out of ten quality indicators was high; for example, more than 90% of the patients were treated in a stroke unit, irrespective of the type of hospital. At the university hospitals, 1 038 (19.0%) of patients received thrombolytic therapy, compared to 1 612 (17.2%) in the local hospitals. Adjusted for age and level of consciousness, the probability of being self-reliant three months after the stroke was higher in local hospitals (OR 1.15, CI 1.04-1.27). INTERPRETATION: The decentralised stroke treatment in Norway accomplishes high and moderate goal achievement on the Norwegian Stroke Registry's quality indicators. The quality of treatment in local hospitals appears to be equally good or better than that provided in university hospitals.

Stroke risk after transient ischemic attack in a Norwegian prospective cohort.

BACKGROUND: Transient ischemic attack (TIA) is a risk factor of stroke. Modern treatment regimens and changing risk factors in the population justify new estimates of stroke risk after TIA, and evaluation of the recommended ABCD2 stroke risk score. METHODS: From October, 2012, to July, 2014, we performed a prospective, multicenter study in Central Norway, enrolling patients with a TIA within the previous 2 weeks. Our aim was to assess stroke risk at 1 week, 3 months and 1 year after TIA, and to determine the predictive value of the dichotomized ABCD2 score (0-3 vs 4-7) at each time point. We used data obtained by telephone follow-up and registry data from the Norwegian Stroke Register. RESULTS: Five hundred and seventy-seven patients with TIA were enrolled of which 85% were examined by a stroke specialist within 24 h after symptom onset. The cumulative incidence of stroke within 1 week, 3 months and 1 year of TIA was 0.9% (95% CI, 0.37-2.0), 3.3% (95% CI, 2.1-5.1) and 5.4% (95% CI, 3.9-7.6), respectively. The accuracy of the ABCD2 score provided by c-statistics at 7 days, 3 months and 1 year was 0.62 (95% CI, 0.39-0.85), 0.62 (95% CI, 0.51-0.74) and 0.64 (95% CI, 0.54-0.75), respectively. CONCLUSIONS: We found a lower stroke risk after TIA than reported in earlier studies. The ABCD2 score did not reliably discriminate between low and high risk patients, suggesting that it may be less useful in populations with a low risk of stroke after TIA. TRIAL REGISTRATION: Unique identifier: NCT02038725 (retrospectively registered, January 16, 2014).

Percutaneous Coronary Intervention as a Trigger for Stroke.

Percutaneous coronary intervention (PCI) is a plausible triggering factor for stroke, yet the magnitude of this excess risk remains unclear. This study aimed to quantify the transient change in risk of stroke for up to 12 weeks after PCI. We applied the case-crossover method, using data from the Norwegian Patient Register on all hospitalizations in Norway in the period of 2008 to 2014. The relative risk (RR) of ischemic stroke was highest during the first 2 days after PCI (RR 17.5, 95% confidence interval [CI] 4.2 to 72.8) and decreased gradually during the following weeks. The corresponding RR was 2.0 (95% CI 1.2 to 3.3) 4 to 8 weeks after PCI. The RR for women was more than twice as high as for men during the first 4 postprocedural weeks, RR 10.5 (95% CI 3.8 to 29.3) and 4.4 (95% CI 2.7 to 7.2), respectively. Our results were compatible with an increased RR of hemorrhagic stroke 4 to 8 weeks after PCI, but the events were few and the estimates were very imprecise, RR 3.0 (95% CI 0.8 to 11.1). The present study offers new knowledge about PCI as a trigger for stroke. Our estimates indicated a substantially increased risk of ischemic stroke during the first 2 days after PCI. The RR then decreased gradually but stayed elevated for 8 weeks. Increased awareness of this vulnerable period after PCI in clinicians and patients could contribute to earlier detection and treatment for patients suffering a postprocedural stroke.

Complications in the first week after stroke: a 10-year comparison.

BACKGROUND: Complications after stroke have been associated with poor outcome. Modern stroke treatment might reduce the occurrence of complications. The aim of this study was to investigate whether the frequency and type of complications during the first week after stroke has changed in patients treated in a stroke unit in 2013 compared to 2003. METHODS: In total 489 patients in 2003 and 185 patients in 2013 with acute stroke were included and followed prospectively for 1 week, examining the frequency of 12 predefined complications adjusted for severity of stroke. Informed consent was given by all patients or their next of kin. RESULTS: Mean (SD) age was 77.2 (10.2) and 76.9 (8.5) in 2003 and 2013 respectively, P = 0.455. Severity of stroke, measured by the Scandinavian Stroke Scale, was 39.5 (16.8) versus 37.0 (16.4), P = 0.011. After adjustment for stroke severity the results showed an odds ratio of 0.64 for experiencing one or more complications in the 2013 cohort versus the 2003 cohort, P = 0.035. The subgroup analysis showed that the reduction was only significant in the group with moderate stroke, with 74 % experiencing one or more complications in 2003 compared to 45 % in 2013, P < 0.001. Progressing stroke and myocardial infarction occurred significantly less frequent in 2013 than in 2003; the frequency of other complications remained unchanged. CONCLUSIONS: The risk of experiencing one or more complications has decreased from 2003 to 2013. The reduction was most pronounced in patents with moderate stroke with a significant reduction in progressing stroke and myocardial infarction.

Comparison of the validity of stroke diagnoses in a medical quality register and an administrative health register.

AIMS: Health registers are essential sources of data used in a wide range of stroke research, including epidemiological, clinical and healthcare studies. Regardless of the type of register, the data must be of high quality to be useful. In this study, we investigated and compared the correctness and completeness of the Norwegian Patient Register (an administrative health register) and the Norwegian Stroke Register (a medical quality register for acute stroke). METHODS: We reviewed the medical records for 5192 admissions to hospital in 2012 and defined cases of stroke in the two registers as true positive, false positive, true negative or false negative. We calculated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value with 95% confidence intervals assuming a normal approximation of the binomial distribution. RESULTS: The Norwegian Stroke Register was highly correct and relatively complete (sensitivity 88.1%, specificity 100% and PPV 98.6%). The Norwegian Patient Register was more complete, but less correct, when we included both the main and secondary diagnoses of stroke (sensitivity 96.8%, specificity 99.6% and PPV 79.7%); restricting the analyses to the main diagnoses of stroke resulted in less complete and more correct registrations (sensitivity 86.1%, specificity 99.9% and PPV 93.5%). CONCLUSIONS: The Norwegian Stroke Register and the Norwegian Patient Register are adequately complete and correct to serve as valuable sources of data for epidemiological, clinical and healthcare studies, as well as for administrative purposes.

Inter-rater reliability of a national acute stroke register.

BACKGROUND: Medical quality registers are useful sources of knowledge about diseases and the health services. However, there are challenges in obtaining valid and reliable data. This study aims to assess the reliability in a national medical quality register. METHODS: We randomly selected 111 patients having had a stroke in 2012. An experienced stroke nurse completed the Norwegian Stroke Register paper forms for all 111 patients by review of the medical records. We then extracted all registered data on the same patients from the Norwegian Stroke Register and calculated Cohen's kappa and Gwet's AC(1) with 95 % confidence intervals for 51 nominal variables and Cohen's quadratic weighted kappa and Gwet's AC(2) for three ordinal variables. For two time variables, we calculated the Intraclass Correlation Coefficient. RESULTS: Substantial to excellent reliability (kappa > 0.60/AC(1)> 0.80) was observed for most variables related to past medical history, functional status, stroke subtype and discharge destination. Although excellent reliability was observed for time of stroke onset (ICC 0.93), this variable was hampered with a substantial amount of missing values. Some variables related to treatment and examinations in hospital displayed low levels of agreement. This applies to heart rate monitoring (kappa 0.17/AC(1) 0.46), swallowing test performed (kappa 0.19/AC(1) 0.27) and mobilized out of bed within 24 h after admission (kappa 0.04/AC(1) -0.11). CONCLUSION: A majority of the variables in The Norwegian Stroke Register have substantial to excellent reliability. The problem areas seem to be the lack of completeness in the time variable indicating stroke onset and poor reliability in some variables concerning examinations and treatment received in hospital.

Stroke unit care combined with early supported discharge improves 5-year outcome: a randomized controlled trial.

BACKGROUND AND PURPOSE: Early supported discharge (ESD) seems to be a promising alternative to conventional follow-up care after acute stroke. We have previously shown that stroke unit care combined with ESD has beneficial effects on functional outcome and the use of resources for up to 1 year. The aim of this trial was to evaluate outcome after 5 years. METHODS: We performed a randomized controlled trial with 320 acute stroke patients allocated to ordinary stroke unit care (160 patients) or stroke unit care with ESD (160 patients). The ESD service consisted of a mobile team that co-coordinated hospital discharge and further rehabilitation during 1 month of follow-up in cooperation with the primary health care. Mortality, residence, and functional outcome including modified Rankin scale were registered after 5 years. All assessments were blinded. RESULTS: There was no difference between the groups with modified Rankin scale score ≤2 (P=0.213), but there was a trend toward greater improvement in modified Rankin scale score in the ESD group from onset of stroke (38% versus 30%; P=0.106). More patients were dead or institutionalized in the ordinary stroke unit care group (P=0.032); 158 patients were alive, 84 were in ESD, and 74 were in ordinary stroke unit care. Of the 158 patients alive, a greater proportion were living at home in ESD (86%/70%; P=0.019). CONCLUSIONS: Stroke unit care combined with ESD seems to reduce death and institutional care and to improve patients' chances of living at home 5 years after stroke compared to traditional stroke care. There is a trend toward improved functional outcome in the ESD group.

[Cost-estimates for stroke]. / Kostnadsvurderinger ved hjerneslag.

BACKGROUND: The annual incidence of stroke in Norway is 15,000. The disease has tremendous health-related and economic consequences. The aim of this article is to give an overview of the cost implications of stroke. MATERIAL AND METHODS: The article is based on literature identified through searching the Medline and Cochrane databases, and analysis of our own stroke data at St. Olavs Hospital. Costs are presented in Norwegian kroner (NOK). RESULTS: The average cost during the first year after a stroke is 150,000-170,000 NOK, according to economic analyses of stroke trials in Trondheim and Swedish studies. The average lifetime cost is estimated to be NOK 600,000. Stroke-related total annual public costs are approximately 7 - 8 billion NOK. Acute stroke unit care, extended stroke unit service with early supported discharge and cooperation with the primary health care system seem to be the most effective methods of reducing costs and improving functional outcome after a stroke. INTERPRETATION: The cost of stroke is significant. Economic analyses of treatment strategies and care plans for stroke patients will help us to make the most of the resources at our disposal for the benefit of our patients.

[Rehabilitation of patients with stroke]. / Rehabilitering av pasienter med hjerneslag.

Stroke is one of the most frequent causes of death and disability. 14,000 to 15,000 individuals are hit by stroke in Norway annually, and the incidence is expected to rise. Optimal organization of rehabilitation for stroke patients has been extensively documented during the last 10 years. It is established that a larger reduction of disability and mortality for stroke patients is obtained by treatment and rehabilitation in stroke units than in general medical wards. WHO Region Europe recommends that all stroke patients are treated in stroke units in the acute phase. Additional reduction in mortality and disability is achieved through home-based rehabilitation, coordination by a multidisciplinary ambulatory team and by emphasizing cooperation between different levels of healthcare. Strategies for organising rehabilitation for different stroke patients must be based on scientific evidence; more knowledge is needed and much research is currently ongoing. The field of neuroscience has developed quickly during the last years, and evidence of brain plasticity gives reason to believe that an increase in the amount and intensity of training is important for an optimal effect. There is a need for more systematized knowledge, and further research will hopefully define a more specific and optimal strategy for stroke rehabilitation within a few years.

Early supported discharge for stroke patients improves clinical outcome. Does it also reduce use of health services and costs? One-year follow-up of a randomized controlled trial.

BACKGROUND: An early supported discharge service (ESD) appears to be a promising alternative to conventional care. The aim of this trial was to compare the use of health services and costs with traditional stroke care during a one-year follow-up. METHODS: Three hundred and twenty patients were randomly allocated either to ordinary stroke unit care or stroke unit care combined with ESD which was coordinated by a mobile team. The use of all health services was recorded prospectively; its costs were measured as service costs and represent a combination of calculated average costs and tariffs. Hospital expenses were measured as costs per inpatient day and adjusted for the DRG. RESULTS: There was a reduction in average number of inpatient days at 52 weeks in favour of the ESD group (p = 0.012), and a non-significant reduction in total mean service costs in the ESD group (EUR 18,937/EUR 21,824). ESD service seems to be most cost-effective for patients with a moderate stroke. CONCLUSION: Acute stroke unit care combined with an ESD programme may reduce the length of institutional stay without increasing the costs of outpatient rehabilitation compared with traditional stroke care.

Acute stroke unit care combined with early supported discharge. Long-term effects on quality of life. A randomized controlled trial.

OBJECTIVES: The aim of the present trial was to compare the effects of an extended stroke unit service (ESUS) with the effects of an ordinary stroke unit service (OSUS) on long-term quality of life (QoL). DESIGN: One year follow-up of a randomized controlled trial with 320 acute stroke patients allocated either to OSUS (160 patients) or ESUS (160 patients) with early supported discharge and follow-up by a mobile team. The intervention was a mobile team and close co-operation with the primary health care service. All assessments were blinded. MAIN OUTCOME MEASURE: Primary outcome of QoL in this paper was measured by the Nottingham Health Profile (NHP) at 52 weeks. Secondary outcomes measured at 52 weeks were differences between the groups measured by the Frenchay Activity Index, Montgomery-Asberg Depression Scale, Mini-Mental State Score and the Caregivers Strain Index. RESULTS: The ESUS group had a significantly better QoL (mean score 78.9) assessed by global NHP after one year than the OSUS group (mean score 75.2) (p =0.048). There were no significant differences between the groups in the secondary outcomes, but a trend in favour of ESUS. Caregivers Strain Index showed a mean score of 23.3 in the ESUS group and 22.6 in the OSUS group (p=0.089). CONCLUSION: It seems that stroke unit treatment combined with early supported discharge in addition to reducing the length of hospital stay can improve long-term QoL. However, similar trials are necessary to confirm the benefit of this type of service.

Stroke unit care combined with early supported discharge: long-term follow-up of a randomized controlled trial.

BACKGROUND AND PURPOSE: Early supported discharge from a stroke unit reduces the length of hospital stay. Evidence of a benefit for the patients is still unknown. The aim of this trial was to evaluate the long-term effects of an extended stroke unit service (ESUS), characterized by early supported discharge. The short-term effects were published previously. METHODS: We performed a randomized controlled trial in which 320 acute stroke patients were allocated to either ordinary stroke unit service (OSUS) (160 patients) or stroke unit care with early supported discharge (160 patients). The ESUS consists of a mobile team that coordinates early supported discharge and further rehabilitation. Primary outcome was the proportion of patients who were independent as assessed by modified Rankin Scale (RS) (RS < or =2=global independence). Secondary outcomes measured at 52 weeks were performance on the Barthel Index (BI) (BI > or =95=independent in activities of daily living), differences in final residence, and analyses to identify patients who benefited most from an early supported discharge service. All assessments were blinded. RESULTS: We found that 56.3% of the patients in the ESUS versus 45.0% in the OSUS were independent (RS < or =2) (P=0.045). The number needed to treat to achieve 1 independent patient in ESUS versus OSUS was 9. The odds ratio for independence was 1.56 (95% CI, 1.01 to 2.44). There were no significant differences in BI score and final residence. Patients with moderate to severe stroke benefited most from the ESUS. CONCLUSIONS: Stroke service based on treatment in a stroke unit combined with early supported discharge appears to improve the long-term clinical outcome compared with ordinary stroke unit care. Patients with moderate to severe stroke benefit most.