Administrative challenges to regionalization.

The ideal emergency care system delivers the right care to the right patient at the right time and yields appropriate patient outcomes at a sustainable overall cost. Transforming the current system of emergency care into the Institute of Medicine's vision of a coordinated, regionalized, and accountable emergency care system requires careful consideration of administrative challenges and barriers. Left unaddressed, certain processes, systems, and structures may prevent integration efforts or threaten long-term viability.

An approach to coordinate efforts to reduce the public health burden of stroke: the Delta States Stroke Consortium.

Stroke is the third leading cause of death and a leading cause of disability in the United States, with a particularly high burden on the residents of the southeastern states, a region dubbed the "Stroke Belt." These five states - Alabama, Arkansas, Louisiana, Mississippi, and Tennessee - have formed the Delta States Stroke Consortium to direct efforts to reduce this burden. The consortium is proposing an approach to identify domains where interventions may be instituted and an array of activities that can be implemented in each of the domains. Specific domains include 1) risk factor prevention and control; 2) identification of stroke signs and symptoms and encouragement of appropriate responses; 3) transportation, Emergency Medical Services care, and acute care; 4) secondary prevention; and 5) recovery and rehabilitation management. The array of activities includes 1) education of lay public; 2) education of health professionals; 3) general advocacy and legislative actions; 4) modification of the general environment; and 5) modification of the health care environment. The Delta States Stroke Consortium members propose that together these domains and activities define a structure to guide interventions to reduce the public health burden of stroke in this region.

Impact of a voluntary trauma system on mortality, length of stay, and cost at a level I trauma center.

Trauma systems have been shown to decrease injury-related mortality; however, their development has been slow often requiring legislative codification. The purpose of this study was to evaluate the impact of a voluntary regional trauma system on outcomes at a Level I trauma center. We conducted a retrospective cohort study in an American College of Surgeons-verified Level I trauma center including all patients admitted to a Level I trauma center during the periods April 1995 through March 1996 (T-1) and April 1997 through March 1998 (T-2). Our main outcome measures were in-hospital mortality, hospital length of stay, cost of care Compared with T-1 patients T-2 patients had lower mortality (odds ratio 0.48, 95% confidence interval 0.32-0.71). A similar decline in mortality was observed for the entire six-county region compared with the remainder of the state. Among the most severely injured patients (Injury Severity Score > or = 16) T-2 patients had a shorter length of stay (16.5 vs 19.5 days; P < 0.05) and lower mean cost of care ($29,795 vs $34,983; P < 0.05). A voluntary trauma system can be implemented without the need for legislative mandate. After system implementation patient and financial outcomes were improved at an individual Level I trauma center.

Recommendations for improving the quality of care through stroke centers and systems: an examination of stroke center identification options: multidisciplinary consensus recommendations from the Advisory Working Group on Stroke Center Identification Options of the American Stroke Association.

BACKGROUND AND PURPOSE: The American Stroke Association (ASA) assembled a multidisciplinary group of experts to develop recommendations regarding the potential effectiveness of establishing an identification program for stroke centers and systems. "Identification" refers to the full spectrum of models for assessing and recognizing standards of quality care (self-assessment, verification, certification, and accreditation). A primary consideration is whether stroke center identification might improve patient outcomes. METHODS: In February 2001, ASA, with the support of the Stroke Council's Executive Committee, decided to embark on an evaluation of the potential impact of stroke center identification. HealthPolicy R&D was selected to prepare a comprehensive report. The investigators reported on models outside the area of stroke, ongoing initiatives within the stroke community (such as Operation Stroke), and state and federal activities designed to improve care for stroke patients. The investigators also conducted interviews with thought leaders in the stroke community, representing a diverse sampling of specialties and affiliations. In October 2001, the Advisory Working Group on Stroke Center Identification developed its consensus recommendations. This group included recognized experts in neurology, emergency medicine, emergency medical services, neurological surgery, neurointensive care, vascular disease, and stroke program planning. RESULTS: There are a variety of existing identification programs, generally falling within 1 of 4 categories (self-assessment, verification, certification, and accreditation) along a continuum with respect to intensity and scope of review and consumption of resources. Ten programs were evaluated, including Peer Review Organizations, trauma centers, and new efforts by the National Committee on Quality Assurance and the Joint Commission on the Accreditation of Healthcare Organizations to identify providers and disease management programs. The largest body of literature on clinical outcomes associated with identification programs involves trauma centers. Most studies support that trauma centers and systems lead to improved mortality rates and patient outcomes. The Advisory Working Group felt that comparison to the trauma model was most relevant given the need for urgent evaluation and treatment of stroke. The literature in other areas generally supports the positive impact of identification programs, although patient outcomes data have less often been published. In the leadership interviews, participants generally expressed strong support for pursuing some form of voluntary identification program, although concerns were raised that this effort could meet with some resistance. CONCLUSIONS: Identification of stroke centers and stroke systems competencies is in the best interest of stroke patients in the United States, and ASA should support the development and implementation of such processes. The purpose of a stroke center/systems identification program is to increase the capacity for all hospitals to treat stroke patients according to standards of care, recognizing that levels of involvement will vary according to the resources of hospitals and systems.