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1.
Stroke ; 54(4): 1148-1159, 2023 04.
Artículo en Inglés | MEDLINE | ID: mdl-36715006

RESUMEN

To our knowledge, the adoption of Learning Health System (LHS) concepts or approaches for improving stroke care, patient outcomes, and value have not previously been summarized. This topical review provides a summary of the published evidence about LHSs applied to stroke, and case examples applied to different aspects of stroke care from high and low-to-middle income countries. Our attempt to systematically identify the relevant literature and obtain real-world examples demonstrated the dissemination gaps, the lack of learning and action for many of the related LHS concepts across the continuum of care but also elucidated the opportunity for continued dialogue on how to study and scale LHS advances. In the field of stroke, we found only a few published examples of LHSs and health systems globally implementing some selected LHS concepts, but the term is not common. A major barrier to identifying relevant LHS examples in stroke may be the lack of an agreed taxonomy or terminology for classification. We acknowledge that health service delivery settings that leverage many of the LHS concepts do so operationally and the lessons learned are not shared in peer-reviewed literature. It is likely that this topical review will further stimulate the stroke community to disseminate related activities and use keywords such as learning health system so that the evidence base can be more readily identified.


Asunto(s)
Aprendizaje del Sistema de Salud , Accidente Cerebrovascular , Humanos
2.
Stroke ; 54(1): 151-158, 2023 01.
Artículo en Inglés | MEDLINE | ID: mdl-36416128

RESUMEN

BACKGROUND: Endovascular thrombectomy (EVT) access in remote areas is limited. Preliminary data suggest that long distance transfers for EVT may be beneficial; however, the magnitude and best imaging strategy at the referring center remains uncertain. We hypothesized that patients transferred >300 miles would benefit from EVT, achieving rates of functional independence (modified Rankin Scale [mRS] score of 0-2) at 3 months similar to those patients treated at the comprehensive stroke center in the randomized EVT extended window trials and that the selection of patients with computed tomography perfusion (CTP) at the referring site would be associated with ordinal shift toward better outcomes on the mRS. METHODS: This is a retrospective analysis of patients transferred from 31 referring hospitals >300 miles (measured by the most direct road distance) to 9 comprehensive stroke centers in Australia and New Zealand for EVT consideration (April 2016 through May 2021). RESULTS: There were 131 patients; the median age was 64 [53-74] years and the median baseline National Institutes of Health Stroke Scale score was 16 [12-22]. At baseline, 79 patients (60.3%) had noncontrast CT+CT angiography, 52 (39.7%) also had CTP. At the comprehensive stroke center, 114 (87%) patients underwent cerebral angiography, and 96 (73.3%) proceeded to EVT. At 3 months, 62 patients (48.4%) had an mRS score of 0 to 2 and 81 (63.3%) mRS score of 0 to 3. CTP selection at the referring site was not associated with better ordinal scores on the mRS at 3 months (mRS median of 2 [1-3] versus 3 [1-6] in the patients selected with noncontrast CT+CT angiography, P=0.1). Nevertheless, patients selected with CTP were less likely to have an mRS score of 5 to 6 (odds ratio 0.03 [0.01-0.19]; P<0.01). CONCLUSIONS: In selected patients transferred >300 miles, there was a benefit for EVT, with outcomes similar to those treated in the comprehensive stroke center in the EVT extended window trials. Remote hospital CTP selection was not associated with ordinal mRS improvement, but was associated with fewer very poor 3-month outcomes.


Asunto(s)
Isquemia Encefálica , Procedimientos Endovasculares , Accidente Cerebrovascular , Humanos , Persona de Mediana Edad , Isquemia Encefálica/terapia , Estudios Retrospectivos , Nueva Zelanda , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/cirugía , Trombectomía/métodos , Procedimientos Endovasculares/métodos , Resultado del Tratamiento
3.
Stroke ; 53(1): 268-278, 2022 01.
Artículo en Inglés | MEDLINE | ID: mdl-34727742

RESUMEN

Stroke contributes an estimated $28 billion to US health care costs annually, and alternative payment models aim to improve outcomes and lower spending over fee-for-service by aligning economic incentives with high value care. This systematic review evaluates historical and current evidence regarding the impacts of alternative payment models on stroke outcomes, spending, and utilization. Included studies evaluated alternative payment models in 4 categories: pay-for-performance (n=3), prospective payments (n=14), shared savings (n=5), and capitated payments (n=14). Pay-for-performance models were not consistently associated with improvements in clinical quality indicators of stroke prevention. Studies of prospective payments suggested that poststroke spending was shifted between care settings without consistent reductions in total spending. Shared savings programs, such as US Medicare accountable care organizations and bundled payments, were generally associated with null or decreased spending and service utilization and with no differences in clinical outcomes following stroke hospitalizations. Capitated payment models were associated with inconsistent effects on poststroke spending and utilization and some worsened clinical outcomes. Shared savings models that incentivize coordination of care across care settings show potential for lowering spending with no evidence for worsened clinical outcomes; however, few studies evaluated clinical or patient-reported outcomes, and the evidence, largely US-based, may not generalize to other settings.


Asunto(s)
Planes de Aranceles por Servicios/economía , Costos de la Atención en Salud/estadística & datos numéricos , Gastos en Salud/estadística & datos numéricos , Reembolso de Incentivo/economía , Accidente Cerebrovascular/terapia , Ahorro de Costo , Hospitalización/economía , Humanos , Medicare/economía , Mecanismo de Reembolso/economía , Estados Unidos
4.
Qual Life Res ; 31(6): 1657-1666, 2022 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-34837601

RESUMEN

OBJECTIVES: To determine the impact of genetic muscle disorders and identify the sociodemographic, illness, and symptom factors influencing quality of life. METHODS: Adults (aged 16-90 years) with a confirmed clinical or molecular diagnosis of a genetic muscle disorder identified as part of a nationwide prevalence study were invited to complete an assessment of the impact of their condition. Quality of life was measured using the World Health Organization Quality of Life questionnaire. Impact was measured via the prevalence of symptoms and comparisons of quality of life against New Zealand norms. Multivariate regression models were used to identify the most significant predictors of quality of life domains. RESULTS: 490/596 participants completed the assessment (82.2% consent rate). Quality of life was lower than the general population on physical (t = 9.37 p < 0.0001, d = 0.54) social (t = 2.27 p = 0.02, d = 0.13) and environmental domains (t = 2.28 p = 0.02, d = 0.13), although effect sizes were small. No difference was found on the psychological domain (t = - 1.17 p = 0.24, d = 0.07). Multivariate regression models (predicting 42%-64% of the variance) revealed personal factors (younger age, being in employment and in a relationship), symptoms (lower pain, fatigue, and sleep difficulties), physical health (no need for ventilation support, fewer activity limitations and no comorbidities), and psychosocial factors (lower depression, anxiety, behavioural dyscontrol and higher self-efficacy, satisfaction with health care and social support) contributed to improved quality of life. CONCLUSIONS: A range of factors influence the quality of life in adults diagnosed with a genetic muscle disorder and some may serve as targets for multi-faceted intervention.


Asunto(s)
Enfermedades Musculares , Calidad de Vida , Adulto , Ansiedad/psicología , Trastornos de Ansiedad , Depresión/psicología , Humanos , Calidad de Vida/psicología , Encuestas y Cuestionarios
5.
Clin Rehabil ; 36(2): 240-250, 2022 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-34414801

RESUMEN

OBJECTIVE: To undertake an economic analysis of the Take Charge intervention as part of the Taking Charge after Stroke (TaCAS) study. DESIGN: An open, parallel-group, randomised trial comparing active and control interventions with blinded outcome assessment. SETTING: Community. PARTICIPANTS: Adults (n = 400) discharged to community, non-institutional living following acute stroke. INTERVENTIONS: The Take Charge intervention, a strengths based, self-directed rehabilitation intervention, in two doses (one or two sessions), and a control intervention (no Take Charge sessions). MEASURES: The cost per quality-adjusted life year (QALY) saved for the period between randomisation (always post hospital discharge) and 12 months following acute stroke. QALYs were calculated from the EuroQol-5D-5L. Costs of stroke-related and non-health care were obtained by questionnaire, hospital records and the New Zealand Ministry of Health. RESULTS: One-year post hospital discharge cost of care was mean (95% CI) $US4706 (3758-6014) for the Take Charge intervention group and $6118 (4350-8005) for control, mean (95% CI) difference $ -1412 (-3553 to +729). Health utility scores were mean (95% CI) 0.75 (0.73-0.77) for Take Charge and 0.71 (0.67-0.75) for control, mean (95% CI) difference 0.04 (0.0-0.08). Cost per QALY gained for the Take Charge intervention was $US -35,296 (=£ -25,524, € -30,019). Sensitivity analyses confirm Take Charge is cost-effective, even at a very low willingness-to-pay threshold. With a threshold of $US5000 per QALY, the probability that Take Charge is cost-effective is 99%. CONCLUSION: Take Charge is cost-effective and probably cost saving.


Asunto(s)
Calidad de Vida , Accidente Cerebrovascular , Adulto , Análisis Costo-Beneficio , Humanos , Años de Vida Ajustados por Calidad de Vida , Encuestas y Cuestionarios
6.
Stroke ; 52(10): e590-e593, 2021 10.
Artículo en Inglés | MEDLINE | ID: mdl-34465202

RESUMEN

Background and Purpose: Due to practical advantages, increasing trial safety data, recent Australian Guideline endorsement and local population needs we switched to tenecteplase for stroke thrombolysis from alteplase. We describe our change process and real-world outcome data. Methods: Mixed-methods including stakeholder engagement, preimplementation and postimplementation surveys, and assessment of patient treatment rates, metrics, and clinical outcomes preimplementation and postimplementation adjusting regression analyses for age, sex, National Institutes of Health Stroke Scale, premorbid modified Rankin Scale score, and thrombectomy using New Zealand National Stroke Registry data. Results: Preswitch consultation involved stroke and emergency clinicians, pharmacists, national regulatory bodies, and hospital legal teams. All survey responders (90% response rate) supported the proposed change and remained satisfied 12 months postimplementation. Between January 2018 and February 2021, we treated 555 patients with alteplase and 283 with tenecteplase. Patients treated with tenecteplase had greater odds of a favorable modified Rankin Scale using both shift (adjusted odds ratio, 1.60 [95% CI, 1.15­2.22]) and dichotomous analyses (modified Rankin Scale score, 0­2; adjusted odds ratio, 2.17 [95% CI, 1.31­3.59]) and shorter median (interquartile range) door-to-needle time (median, 53 [38­73.5] versus 61 minutes [45­85], P=0.0002). Symptomatic intracranial hemorrhage rates (tenecteplase 1.8% versus 3.4%; adjusted odds ratio, 0.46 [95% CI, 0.13­1.64]), death by day 7 (tenecteplase 7.5% versus 11.8%; adjusted odds ratio, 0.46 [95% CI, 0.21­0.99]), and median (interquartile range) needle to groin time for the 42 transferred regional patients (tenecteplase 155 [113­248] versus 200 [158­266]; P=0.27) did not significantly differ. Conclusions: Following stakeholder endorsement, a region-wide switch from alteplase to tenecteplase was successfully implemented. We found evidence of benefit and no evidence of harm.


Asunto(s)
Fibrinolíticos/uso terapéutico , Accidente Cerebrovascular/tratamiento farmacológico , Tenecteplasa/uso terapéutico , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Fibrinolíticos/efectos adversos , Humanos , Hemorragias Intracraneales/complicaciones , Hemorragias Intracraneales/mortalidad , Masculino , Persona de Mediana Edad , Nueva Zelanda , Oportunidad Relativa , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/cirugía , Tenecteplasa/efectos adversos , Trombectomía , Terapia Trombolítica/métodos , Tiempo de Tratamiento , Activador de Tejido Plasminógeno/uso terapéutico , Resultado del Tratamiento
7.
Stroke ; 52(3): 1087-1090, 2021 03.
Artículo en Inglés | MEDLINE | ID: mdl-33588597

RESUMEN

BACKGROUND AND PURPOSE: In ischemic stroke, intravenous tenecteplase is noninferior to alteplase in selected patients and has some practical advantages. Several stroke centers in New Zealand changed to routine off-label intravenous tenecteplase due to improved early recanalization in large vessel occlusion, inconsistent access to thrombectomy within stroke networks, and for consistency in treatment protocols between patients with and without large vessel occlusion. We report the feasibility and safety outcomes in tenecteplase-treated patients. METHODS: We performed a retrospective analysis of consecutive patients thrombolyzed with intravenous tenecteplase at 1 comprehensive and 2 regional stroke centers from July 14, 2018, to February 29, 2020. We report the baseline clinical characteristics, rates of symptomatic intracranial hemorrhage, and angioedema. These were then compared with patient outcomes with those treated with intravenous alteplase at 2 other comprehensive stroke centers. Multivariable mixed-effects logistic regression models were performed assessing the association of tenecteplase with symptomatic intracranial hemorrhage and independent outcome (modified Rankin Scale score, 0-2) at day 90. RESULTS: There were 165 patients treated with tenecteplase and 254 with alteplase. Age (75 versus 74 years), sex (56% versus 60% male), National Institutes of Health Stroke Scale scores (8 versus 10), median door-to-needle times (47 versus 48 minutes), or onset-to-needle time (129 versus 130 minutes) were similar between the groups. Symptomatic intracranial hemorrhage occurred in 3 (1.8% [95% CI, 0.4-5.3]) tenecteplase patients compared with 7 (2.7% [95% CI, 1.1-5.7]) alteplase patients (P=0.75). There were no differences between tenecteplase and alteplase in the rates of angioedema (4 [2.4%; 95% CI, 0.7-6.2] versus 1 [0.4%; 95% CI, 0.01-2.2], P=0.08) or 90-day functional independence (100 [61%] versus 140 [57%], P=0.47), respectively. In mixed-effects logistic regression models, there was no significant association between thrombolytic choice and symptomatic intracranial hemorrhage (odds ratio tenecteplase, 0.62 [95% CI, 0.14-2.80], P=0.53) or functional independence (odds ratio tenecteplase, 1.20 [95% CI, 0.74-1.95], P=0.46). CONCLUSIONS: Routine use of tenecteplase for stroke thrombolysis was feasible and had comparable safety profile and outcome to alteplase.


Asunto(s)
Fibrinolíticos/uso terapéutico , Accidente Cerebrovascular Isquémico/tratamiento farmacológico , Tenecteplasa/uso terapéutico , Terapia Trombolítica/efectos adversos , Administración Intravenosa , Anciano , Anciano de 80 o más Años , Angioedema/epidemiología , Angioedema/etiología , Estudios de Factibilidad , Femenino , Fibrinolíticos/efectos adversos , Humanos , Hemorragias Intracraneales/epidemiología , Hemorragias Intracraneales/etiología , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tenecteplasa/efectos adversos , Tiempo de Tratamiento , Activador de Tejido Plasminógeno/efectos adversos , Activador de Tejido Plasminógeno/uso terapéutico , Resultado del Tratamiento
8.
Stroke ; 52(5): e117-e130, 2021 05.
Artículo en Inglés | MEDLINE | ID: mdl-33878892
9.
Intern Med J ; 51(8): 1251-1254, 2021 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-33196138

RESUMEN

BACKGROUND: Headache is a common problem in primary care and one of the main reasons general practitioners (GP) consult the neurology service. We developed an online adult headache guideline (Supporting Information Appendix S1) for the greater Wellington Region as a resource for GP to guide identification of concerning headaches, initiation of prophylactic medications for migraine and management of analgesic overuse headache. AIMS: To examine the effectiveness of this adult headache guideline in reducing demand on the neurology outpatient service for headache patients that could readily be managed in primary care. METHODS: We reviewed electronic referrals to Wellington Hospital's neurology department before and after the implementation of the online headache guideline. The primary outcome was the proportion of referrals for headache. Secondary outcomes included proportion of referrals requiring clinic review, rate of pre-referral trial of headache prophylactic medication and medication overuse headache diagnosed at neurological consultation. RESULTS: Nine hundred neurology referrals before and 801 referrals after the publication of the online headache guideline were included. There was a statistically significant reduction in proportion of referrals for headache (15.4% vs 11.7%; P = 0.026). There was neither an increased rate of pre-referral adequate prophylactic medication trial (33.8% vs 27.7%; P = 0.320) nor fewer medication overuse headaches diagnosed during the neurology assessment (21.9% vs 25.0%; P = 0.674). CONCLUSION: The launch of an online headache guideline was associated with a reduction in demand on neurology service. Further education could improve the utilisation of this guideline, to avoid delays in prophylactic treatment and reduce the harm of medication overuse.


Asunto(s)
Cefaleas Secundarias , Neurología , Adulto , Instituciones de Atención Ambulatoria , Cefalea/diagnóstico , Cefalea/epidemiología , Cefalea/terapia , Cefaleas Secundarias/diagnóstico , Cefaleas Secundarias/epidemiología , Cefaleas Secundarias/terapia , Humanos , Derivación y Consulta
10.
Clin Rehabil ; 35(7): 1021-1031, 2021 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-33586474

RESUMEN

OBJECTIVE: To use secondary data from the Taking Charge after Stroke study to explore mechanisms for the positive effect of the Take Charge intervention on physical health, advanced activities of daily living and independence for people after acute stroke. DESIGN: An open, parallel-group, randomised trial with two active and one control intervention and blinded outcome assessment. SETTING: Community. PARTICIPANTS: Adults (n = 400) discharged to community, non-institutional living following acute stroke. INTERVENTIONS: One, two, or zero sessions of the Take Charge intervention, a self-directed rehabilitation intervention which helps a person with stroke take charge of their own recovery. MEASURES: Twelve months after stroke: Mood (Patient Health Questionnaire-2, Mental Component Summary of the Short Form 36); 'ability to Take Charge' using a novel measure, the Autonomy-Mastery-Purpose-Connectedness (AMP-C) score; activation (Patient Activation Measure); body mass index (BMI), blood pressure (BP) and medication adherence (Medication Adherence Questionnaire). RESULTS: Follow-up was near-complete (388/390 (99.5%)) of survivors at 12 months. Mean age (SD) was 72.0 (12.5) years. There were no significant differences in mood, activation, 'ability to Take Charge', medication adherence, BMI or BP by randomised group at 12 months. There was a significant positive association between baseline AMP-C scores and 12-month outcome for control participants (1.73 (95%CI 0.90 to 2.56)) but not for the Take Charge groups combined (0.34 (95%CI -0.17 to 0.85)). CONCLUSION: The mechanism by which Take Charge is effective remains uncertain. However, our findings support a hypothesis that baseline variability in motivation, mastery and connectedness may be modified by the Take Charge intervention.


Asunto(s)
Afecto , Motivación , Rehabilitación de Accidente Cerebrovascular , Accidente Cerebrovascular/psicología , Actividades Cotidianas , Anciano , Presión Sanguínea , Índice de Masa Corporal , Femenino , Humanos , Masculino , Cumplimiento de la Medicación , Calidad de Vida
11.
J Stroke Cerebrovasc Dis ; 30(12): 106121, 2021 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-34601242

RESUMEN

BACKGROUND: There is little information regarding the safety of intravenous tissue plasminogen activator (IV-tPA) in patients with stroke and COVID-19. METHODS: This multicenter study included consecutive stroke patients with and without COVID-19 treated with IV-tPA between February 18, 2019, to December 31, 2020, at 9 centers participating in the CASCADE initiative. Clinical outcomes included modified Rankin Scale (mRS) at hospital discharge, in-hospital mortality, the rate of hemorrhagic transformation. Using Bayesian multiple regression and after adjusting for variables with significant value in univariable analysis, we reported the posterior adjusted odds ratio (OR, with 95% Credible Intervals [CrI]) of the main outcomes. RESULTS: A total of 545 stroke patients, including 101 patients with COVID-19 were evaluated. Patients with COVID-19 had a more severe stroke at admission. In the study cohort, 85 (15.9%) patients had a hemorrhagic transformation, and 72 (13.1%) died in the hospital. After adjustment for confounding variables, discharge mRS score ≥2 (OR: 0.73, 95% CrI: 0.16, 3.05), in-hospital mortality (OR: 2.06, 95% CrI: 0.76, 5.53), and hemorrhagic transformation (OR: 1.514, 95% CrI: 0.66, 3.31) were similar in COVID-19 and non COVID-19 patients. High-sensitivity C reactive protein level was a predictor of hemorrhagic transformation in all cases (OR:1.01, 95%CI: 1.0026, 1.018), including those with COVID-19 (OR:1.024, 95%CI:1.002, 1.054). CONCLUSION: IV-tPA treatment in patients with acute ischemic stroke and COVID-19 was not associated with an increased risk of disability, mortality, and hemorrhagic transformation compared to those without COVID-19. IV-tPA should continue to be considered as the standard of care in patients with hyper acute stroke and COVID-19.


Asunto(s)
COVID-19/complicaciones , Fibrinolíticos/administración & dosificación , Accidente Cerebrovascular Isquémico/tratamiento farmacológico , Terapia Trombolítica , Anciano , Anciano de 80 o más Años , COVID-19/diagnóstico , COVID-19/mortalidad , Evaluación de la Discapacidad , Europa (Continente) , Femenino , Fibrinolíticos/efectos adversos , Mortalidad Hospitalaria , Humanos , Infusiones Intravenosas , Hemorragias Intracraneales/inducido químicamente , Irán , Accidente Cerebrovascular Isquémico/complicaciones , Accidente Cerebrovascular Isquémico/diagnóstico , Accidente Cerebrovascular Isquémico/mortalidad , Masculino , Persona de Mediana Edad , Medición de Riesgo , Factores de Riesgo , Terapia Trombolítica/efectos adversos , Terapia Trombolítica/mortalidad , Factores de Tiempo , Resultado del Tratamiento
12.
Neuroepidemiology ; 54(5): 427-432, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32957111

RESUMEN

BACKGROUND: In New Zealand, Maori and Pacific people have higher age-adjusted stroke incidence rates, younger age at first stroke, and higher mortality at 12 months than other ethnic groups. We aimed to determine if access to acute stroke reperfusion therapy with intravenous thrombolysis (IVT) or endovascular thrombectomy (EVT) is equitable among ethnic groups. METHODS: Data were obtained from the Northern Region component of the New Zealand Stroke Registry over the 21 months between January 1, 2018 and September 30, 2019. Data recorded included demographic details, self-identified ethnicity, treatment times, and clinical outcomes. National hospital discharge coding of patients admitted with ischemic stroke and stroke unspecified was used to determine the proportion of patients treated by ethnic group. RESULTS: There were 537 patients normally resident in the Northern Region who received reperfusion therapy: 281 received IVT alone, 123 received EVT after bridging IVT, and 133 received EVT alone. Of the 537 patients treated with IVT or EVT, there were 81 (15.1%) Maori, 78 (14.5%) Pacific, 57 (10.6%) Asian, and 341 (63.5%) NZ European/other ethnicity patients. There were no ethnic differences in treatment process times. When compared with NZ European/others, Maori and Pacific people were younger, and Maori had worse neurological impairment at admission. A higher proportion of Maori were treated with EVT with a trend to higher proportion treated with IVT. Day 90 modified Rankin Scale (mRS) for EVT-treated patients was similar apart from Asian patients who had worse outcome when compared with NZ European/others (mRS 3 vs. 2; p = 0.03). CONCLUSIONS: This study has shown equitable access to acute stroke reperfusion therapies and largely similar outcomes in different ethnic groups in northern New Zealand.


Asunto(s)
Accesibilidad a los Servicios de Salud , Disparidades en Atención de Salud/etnología , Accidente Cerebrovascular Isquémico/etnología , Reperfusión , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Pueblos Indígenas , Accidente Cerebrovascular Isquémico/tratamiento farmacológico , Accidente Cerebrovascular Isquémico/cirugía , Masculino , Persona de Mediana Edad , Nueva Zelanda , Trombectomía , Terapia Trombolítica
13.
Intern Med J ; 50(10): 1202-1207, 2020 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31762157

RESUMEN

BACKGROUND: Post-discharge stroke follow-up clinics intend to improve care and may reduce readmission. Pre-2013, there was no consistent post-stroke specialist follow up offered at Wellington Hospital. We tested whether the establishment of a clinical nurse specialist follow-up clinic reduced the 12-month readmission rate. METHODS: This is a sequential comparison of stroke patients admitted 1 year prior and 1 year after clinic establishment in 2013. The primary outcome was 12-month hospital readmission rate; main secondary outcomes were guideline adherence and recurrent vascular events. Patients were identified from hospital discharge records and underwent chart review. We adjusted results for differences in baseline characteristics. RESULTS: We identified 603 eligible patients; 288 pre- and 315 post-nurse clinic implementations. There was no difference based on study cohort in the 1-year readmission rate (adjusted odds ratio (aOR) = 1.14; 95% CI, 0.7-1.89; P = 0.583), or recurrent composite vascular events at 1 year (aOR = 1.56; 95% CI, 0.89-2.9; P = 0.159). When looking at clinic attendance as the main variable of interest, a pre-specified sub-group analysis, there was a significant difference in implementation of best medical therapy (aOR 2.66 (1.19-5.94); P = 0.017), and a trend towards reduction of vascular events and/or death at 1 year post discharge (aOR 0.53 (0.28-1.02); P = 0.056). CONCLUSIONS: There was no reduction in the 1-year hospital readmission or vascular event recurrence rate for patients admitted with stroke following the establishment of a specialist nurse-led stroke follow-up clinic. Actual clinic attendance, however, did appear to confer some benefit. This study suggests that more consistent and potentially earlier timed follow up is probably desirable.


Asunto(s)
Enfermeras Clínicas , Accidente Cerebrovascular , Cuidados Posteriores , Estudios de Seguimiento , Humanos , Recurrencia Local de Neoplasia , Alta del Paciente , Readmisión del Paciente , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/terapia
14.
Intern Med J ; 50(11): 1367-1372, 2020 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-31707750

RESUMEN

BACKGROUND: Intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) can help reverse stroke symptoms in selected patients but are both time sensitive interventions. AIMS: To report current stroke reperfusion rates and quality measures as well as trends over time in New Zealand. METHOD: Since 2015 New Zealand treatment centres have been mandated to enter prospectively all IVT and EVT patients into a low-cost National Stroke Register. Data were cleaned, and missing data added where possible through contact with individual hospitals. Main outcomes include treatment delays, vital status at day 7 and complications. RESULTS: In 2018, there were 719 of 7173 (10.0%) patients with ischaemic stroke or stroke unspecified treated with IVT, up from 389 of 5963 (6.5%) patients in 2015 (P < 0.001), with no change in day 7 mortality (P = 0.63) or sICH rate (P = 0.22). Median (interquartile range (IQR)) door-to-needle times decreased from 65 (47-89) min in 2017 to 59 (40-84) min in 2018 (P = 0.022), and patients treated within 60 min increased from 40 to 51% (P < 0.001). In 2018, there were 243 (3.4%) patients treated with EVT up from 134/6859 (1.9%) in 2017 (P < 0.0001), with no change in 7-day mortality (P = 0.39) or intracerebral haemorrhage (sICH) (P = 0.78). There was no significant change in onset-to-needle (P = 0.21), arrival-to-groin (P = 0.28) or onset-to-reperfusion time (P = 0.32). CONCLUSION: Stroke reperfusion rates in New Zealand are continuously rising with no associated increase in complications. More patients are being treated faster upon hospital arrival but there remains room for further improvement in reducing onset to treatment delays.


Asunto(s)
Isquemia Encefálica , Procedimientos Endovasculares , Accidente Cerebrovascular , Isquemia Encefálica/epidemiología , Isquemia Encefálica/terapia , Humanos , Nueva Zelanda/epidemiología , Reperfusión , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/terapia , Trombectomía , Terapia Trombolítica , Resultado del Tratamiento
15.
J Stroke Cerebrovasc Dis ; 29(11): 105228, 2020 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-33066882

RESUMEN

BACKGROUND: This report aims to describe changes that centres providing transient ischaemic attack (TIA) pathway services have made to stay operational in response to the SARS-CoV-2 pandemic. METHODS: An international cross-sectional description of the adaptions of TIA pathways between 30th March and 6th May 2020. Experience was reported from 18 centres with rapid TIA pathways in seven countries (Australia, France, UK, Canada, USA, New Zealand, Italy, Canada) from three continents. RESULTS: All pathways remained active (n = 18). Sixteen (89%) had TIA clinics. Six of these clinics (38%) continued to provide in-person assessment while the majority (63%) used telehealth exclusively. Of these, three reported PPE use and three did not. Five centres with clinics (31%) had adopted a different vascular imaging strategy. CONCLUSION: The COVID pandemic has led TIA clinics around the world to adapt and move to the use of telemedicine for outpatient clinic review and modified investigation pathways. Despite the pandemic, all have remained operational.


Asunto(s)
Infecciones por Coronavirus/terapia , Vías Clínicas/tendencias , Prestación Integrada de Atención de Salud/tendencias , Equipo Hospitalario de Respuesta Rápida/tendencias , Ataque Isquémico Transitorio/terapia , Neumonía Viral/terapia , Pautas de la Práctica en Medicina/tendencias , Telemedicina/tendencias , Australia , COVID-19 , Infecciones por Coronavirus/diagnóstico , Infecciones por Coronavirus/virología , Estudios Transversales , Diagnóstico por Imagen/tendencias , Europa (Continente) , Humanos , Ataque Isquémico Transitorio/diagnóstico , Nueva Zelanda , América del Norte , Pandemias , Equipo de Protección Personal/tendencias , Neumonía Viral/diagnóstico , Neumonía Viral/virología , Factores de Tiempo
16.
J Stroke Cerebrovasc Dis ; 29(12): 105321, 2020 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-33069086

RESUMEN

BACKGROUND: The emergence of the COVID-19 pandemic has significantly impacted global healthcare systems and this may affect stroke care and outcomes. This study examines the changes in stroke epidemiology and care during the COVID-19 pandemic in Zanjan Province, Iran. METHODS: This study is part of the CASCADE international initiative. From February 18, 2019, to July 18, 2020, we followed ischemic and hemorrhagic stroke hospitalization rates and outcomes in Valiasr Hospital, Zanjan, Iran. We used a Bayesian hierarchical model and an interrupted time series analysis (ITS) to identify changes in stroke hospitalization rate, baseline stroke severity [measured by the National Institutes of Health Stroke Scale (NIHSS)], disability [measured by the modified Rankin Scale (mRS)], presentation time (last seen normal to hospital presentation), thrombolytic therapy rate, median door-to-needle time, length of hospital stay, and in-hospital mortality. We compared in-hospital mortality between study periods using Cox-regression model. RESULTS: During the study period, 1,026 stroke patients were hospitalized. Stroke hospitalization rates per 100,000 population decreased from 68.09 before the pandemic to 44.50 during the pandemic, with a significant decline in both Bayesian [Beta: -1.034; Standard Error (SE): 0.22, 95% CrI: -1.48, -0.59] and ITS analysis (estimate: -1.03, SE = 0.24, p < 0.0001). Furthermore, we observed lower admission rates for patients with mild (NIHSS < 5) ischemic stroke (p < 0.0001). Although, the presentation time and door-to-needle time did not change during the pandemic, a lower proportion of patients received thrombolysis (-10.1%; p = 0.004). We did not see significant changes in admission rate to the stroke unit and in-hospital mortality rate; however, disability at discharge increased (p < 0.0001). CONCLUSION: In Zanjan, Iran, the COVID-19 pandemic has significantly impacted stroke outcomes and altered the delivery of stroke care. Observed lower admission rates for milder stroke may possibly be due to fear of exposure related to COVID-19. The decrease in patients treated with thrombolysis and the increased disability at discharge may indicate changes in the delivery of stroke care and increased pressure on existing stroke acute and subacute services. The results of this research will contribute to a similar analysis of the larger CASCADE dataset in order to confirm findings at a global scale and improve measures to ensure the best quality of care for stroke patients during the COVID-19 pandemic.


Asunto(s)
Isquemia Encefálica/terapia , COVID-19 , Hospitalización/tendencias , Hemorragias Intracraneales/terapia , Evaluación de Procesos y Resultados en Atención de Salud/tendencias , Accidente Cerebrovascular/terapia , Terapia Trombolítica/tendencias , Tiempo de Tratamiento/tendencias , Anciano , Anciano de 80 o más Años , Teorema de Bayes , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidad , COVID-19/epidemiología , Femenino , Mortalidad Hospitalaria/tendencias , Humanos , Análisis de Series de Tiempo Interrumpido , Hemorragias Intracraneales/diagnóstico , Hemorragias Intracraneales/mortalidad , Irán/epidemiología , Tiempo de Internación/tendencias , Masculino , Persona de Mediana Edad , Recuperación de la Función , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/mortalidad , Factores de Tiempo , Resultado del Tratamiento
17.
Lancet ; 391(10123): 850-859, 2018 03 03.
Artículo en Inglés | MEDLINE | ID: mdl-29274727

RESUMEN

BACKGROUND: Intensive antiplatelet therapy with three agents might be more effective than guideline treatment for preventing recurrent events in patients with acute cerebral ischaemia. We aimed to compare the safety and efficacy of intensive antiplatelet therapy (combined aspirin, clopidogrel, and dipyridamole) with that of guideline-based antiplatelet therapy. METHODS: We did an international, prospective, randomised, open-label, blinded-endpoint trial in adult participants with ischaemic stroke or transient ischaemic attack (TIA) within 48 h of onset. Participants were assigned in a 1:1 ratio using computer randomisation to receive loading doses and then 30 days of intensive antiplatelet therapy (combined aspirin 75 mg, clopidogrel 75 mg, and dipyridamole 200 mg twice daily) or guideline-based therapy (comprising either clopidogrel alone or combined aspirin and dipyridamole). Randomisation was stratified by country and index event, and minimised with prognostic baseline factors, medication use, time to randomisation, stroke-related factors, and thrombolysis. The ordinal primary outcome was the combined incidence and severity of any recurrent stroke (ischaemic or haemorrhagic; assessed using the modified Rankin Scale) or TIA within 90 days, as assessed by central telephone follow-up with masking to treatment assignment, and analysed by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN47823388. FINDINGS: 3096 participants (1556 in the intensive antiplatelet therapy group, 1540 in the guideline antiplatelet therapy group) were recruited from 106 hospitals in four countries between April 7, 2009, and March 18, 2016. The trial was stopped early on the recommendation of the data monitoring committee. The incidence and severity of recurrent stroke or TIA did not differ between intensive and guideline therapy (93 [6%] participants vs 105 [7%]; adjusted common odds ratio [cOR] 0·90, 95% CI 0·67-1·20, p=0·47). By contrast, intensive antiplatelet therapy was associated with more, and more severe, bleeding (adjusted cOR 2·54, 95% CI 2·05-3·16, p<0·0001). INTERPRETATION: Among patients with recent cerebral ischaemia, intensive antiplatelet therapy did not reduce the incidence and severity of recurrent stroke or TIA, but did significantly increase the risk of major bleeding. Triple antiplatelet therapy should not be used in routine clinical practice. FUNDING: National Institutes of Health Research Health Technology Assessment Programme, British Heart Foundation.


Asunto(s)
Aspirina/farmacología , Isquemia Encefálica/tratamiento farmacológico , Dipiridamol/farmacología , Ticlopidina/análogos & derivados , Enfermedad Aguda , Anciano , Aspirina/administración & dosificación , Aspirina/efectos adversos , Clopidogrel , Dinamarca/epidemiología , Dipiridamol/administración & dosificación , Dipiridamol/efectos adversos , Quimioterapia Combinada , Femenino , Georgia/epidemiología , Hemorragia/inducido químicamente , Humanos , Isquemia/tratamiento farmacológico , Isquemia/patología , Ataque Isquémico Transitorio/inducido químicamente , Ataque Isquémico Transitorio/epidemiología , Masculino , Persona de Mediana Edad , Nueva Zelanda/epidemiología , Inhibidores de Agregación Plaquetaria , Estudios Prospectivos , Recurrencia , Proyectos de Investigación/normas , Medición de Riesgo , Accidente Cerebrovascular/tratamiento farmacológico , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Terapia Trombolítica/métodos , Ticlopidina/administración & dosificación , Ticlopidina/efectos adversos , Ticlopidina/farmacología , Resultado del Tratamiento , Reino Unido/epidemiología
18.
Clin Rehabil ; 32(8): 1086-1097, 2018 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-29843517

RESUMEN

OBJECTIVE: To assess the feasibility of conducting a randomized controlled trial of an instructional and educational stroke DVD and determine the feasibility and preliminary efficacy of this intervention in a multinational context. DESIGN: Non-funded, pilot randomized controlled trial of intervention versus usual care. SETTING: International, multicentre, community-based. PARTICIPANTS: Community-living adults up to three years post stroke with moderate to severe disability and their nominated informal caregivers. INTERVENTIONS: Intervention patients viewed and practised rehabilitation techniques demonstrated in the DVD over six weeks. MAIN MEASURES: Trial feasibility by number of active recruitment sites, recruitment efficiency, randomization and follow-up. Intervention feasibility by patient and caregiver impressions. Preliminary efficacy by the quality of life - 5-level EuroQol-5D (EQ-5D) health status measure, General Health Questionnaire and Centre for Epidemiological Studies-Depression at two months. RESULTS: In total, 14 recruitment sites were established across eight countries. Recruitment was achieved at nine (64%) sites. Over 16 months, 66 participants were recruited (mean (SD) age = 63.5 (12.47) years) and randomized to intervention ( n = 34) and control ( n = 32) groups. In total, 54 (82%) completed a follow-up assessment. Patient and/or caregiver comments about the benefits and barriers to accessing the intervention were mixed. There were no significant between-group differences in outcomes at two months ( P > 0.05). CONCLUSION: Conducting a multinational trial of a stroke DVD requires full funding. The intervention was acceptable to some patients and their caregivers, yet a generalized education approach did not fully meet their needs and/or expectations. A more individualized method may be required to meet peoples' changing needs during stroke recovery.


Asunto(s)
Educación del Paciente como Asunto , Rehabilitación de Accidente Cerebrovascular/métodos , Terapia Asistida por Computador/métodos , Cuidadores , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Estudios Prospectivos
19.
J Stroke Cerebrovasc Dis ; 27(7): 2014-2018, 2018 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-29610038

RESUMEN

GOALS: Many patients with transient ischemic attack (TIA) receive initial assessments by general practitioners (GPs) who may lack TIA management experience. In a randomized controlled trial (RCT), we showed that electronic decision support for GPs improves patient outcomes and guideline adherence. Some stroke services prefer to improve referrer expertise through TIA/stroke education sessions instead of promoting TIA decision aids or triaging tools. This is a secondary analysis of whether a GP education session influenced TIA management and outcomes. MATERIALS AND METHODS: Post hoc analysis of a multicenter, single blind, parallel group, cluster RCT comparing TIA/stroke electronic decision support guided GP management with usual care to assess whether a pretrial TIA/stroke education session also affected RCT outcomes. FINDINGS: Of 181 participating GPs, 79 (43.7%) attended an education session and 140 of 291 (48.1%) trial patients were managed by these GPs. There were fewer 90-day stroke events and 90-day vascular events or deaths in patients treated by GPs who attended education; 2 of 140 (1.4%) and 10 of 140 (7.1%) respectively, compared with those who did not; 5 of 151 (3.3%), and 14 of 151 (9.3%), respectively. Logistic regression for association between 90-day stroke and 90-day vascular events or death and education, however, was nonsignificant (odds ratio [OR] .42 (.08 to 2.22), P = .29 and .59 (95% confidence interval [CI] .27 to 1.29), P = .18 respectively. Guideline adherence was not improved by the education session: OR .84 (95% CI .49 to 1.45), P = .54. CONCLUSION: In the described setting, a GP TIA/stroke education session did not significantly enhance guideline adherence or reduce 90-day stroke or vascular events following TIA.


Asunto(s)
Sistemas de Apoyo a Decisiones Clínicas , Médicos Generales/educación , Ataque Isquémico Transitorio/terapia , Accidente Cerebrovascular/prevención & control , Anciano , Femenino , Adhesión a Directriz , Humanos , Ataque Isquémico Transitorio/mortalidad , Masculino , Guías de Práctica Clínica como Asunto , Método Simple Ciego , Accidente Cerebrovascular/mortalidad , Resultado del Tratamiento
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