Abstract WP354: The Rural Health Care Penalty: Urban-rural Disparities in Stroke Center Performance

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Toby I Gropen ◽  
Mark Beasley ◽  
Charles Wira ◽  
Abigail Egan ◽  
Tracy E Madsen ◽  
...  
Keyword(s):  
Rapid Improvement ◽  
Performance Achievement ◽  
Urban Location ◽  
Time Interaction ◽  
National Quality ◽  
Health Initiatives ◽  
Urban Rural ◽  
Discharge Volume ◽  
Stroke Center ◽  
System Variables

Goal: To determine hospital and stroke system characteristics associated with higher levels of stroke center performance. Methods: We included all Centers for Medicare and Medicaid Services designated Acute Care Hospitals and Critical Access Centers (ACH/CAC) from January 1, 2005 to December 31, 2014. Higher stroke center performance was defined as earning a performance achievement award (PAA) on a predefined set of 7 evidence-based measures in a national quality program, Get-With-The-Guidelines-Stroke (GWTG-S). Generalized Estimating Equations were used to model characteristics associated with attaining a PAA over nine years of data. Hospital variables included total, ischemic and hemorrhagic stroke discharge volumes; medicaid discharge volume; patient race/ethnicity; ownership; rurality (Truven Health MarketScan); and state and/or national stroke center certification. Stroke system variables included emergency medical service (EMS) stroke routing protocol; stroke center directives (legislation, regulation, or department of health initiatives); and location in a region with a stroke consortium. Results: As a percentage of all ACH/CACs, GWTG-S hospitals with PAA increased significantly over time from 0.001% (5/4530) in 2005 to 24% (1086/4526) in 2014 (linear and nonlinear p’s<0.0001). Variables associated with PAA status at the p<0.05 level were included in the combined analysis. Significant independent predictors of PAA status included urban location (p<0.0001); total (p=0.0016) and ischemic stroke (p<0.0048) discharge volumes; national stroke center designation (p<0.0001); and presence of state stroke center directives (p=0.0012). EMS routing was not statistically significant but there was an EMS-by-time interaction; hospitals with EMS routing had a significantly increased rate of earning PAA (p = 0.0463). Conclusions: There has been rapid improvement in stroke center performance from 2005 to 2014. Urban location, higher hospital discharge volume, national stroke center designation, and state stroke directives are independently associated with better stroke center performance. After controlling for hospital and stroke system factors, there are significant urban-rural disparities in stroke center performance.

Abstract TP414: Support from a Comprehensive Stroke Center Improves Door to tPA Times at Primary Stroke Centers

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Julie M Fussner ◽  
Kelly Montgomery ◽  
Tinatin Gumberidze ◽  
Erin Supan
Keyword(s):  
Gap Analysis ◽  
Heart Association ◽  
Measure Data ◽  
Quality Improvement Initiative ◽  
University Hospitals ◽  
Stroke Registry ◽  
National Quality ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
System Average

Target Stroke, a national quality improvement initiative of the American Heart Association /American Stroke Association (AHA/ASA) to improve the timeliness of administration of intravenous (IV) tissue plasminogen activator (tPA) to eligible stroke patients, was launched in 2010. The door-to-needle time goal is 60 minutes (mins) from hospital arrival. Earlier administration of IV t-PA is associated with greater functional recovery. Since 2009 University Hospitals Comprehensive Stroke and Cerebrovascular Center (UHCSCC) has meet quarterly with its 7 system community hospitals to share stroke core measure data, review clinical practice guidelines and address new system initiatives for the care of the stroke patient. The purpose of this project is to demonstrate how a comprehensive stroke center (CSC) can assist a primary stroke center (PSC) to improve their door to tPA treatment times. In 2010 to support the primary stroke centers, the UHCSCC developed standardized stroke education for nurses including an online course for tPA. In 2014 an additional online interactive module was created to assist nurses in programing the Alaris IV pump to improve their speed. In 2013 the quarterly system meetings started to include door to CT and door to tPA data with discussions about best practices and challenges. The AHA Target Stroke campaign recommendations and evidenced-based strategies were reviewed and a gap analysis at each hospital was completed to identify opportunities. Throughout 2012-2013 the stroke coordinator at UHCSCC led monthly conference calls with the community stroke coordinators. Since 2014 the stroke operations manager visits each community hospital monthly to work with the stroke coordinator and their teams reviewing TPA cases. Finally, a formal feedback took was developed and is sent to the PSC to provide patient outcomes and opportunities on all TPA cases that are transferred to the CSC. The AHA Get With The Guidelines stroke registry is used to monitor compliance. In 2012 the University Hospitals Health System average door to tPA in 60 mins was only 41%. January - June 2015, the system average has improved 86%. Community primary stroke centers benefit from the comprehensive stroke center interventions and support to improve door to tPA in 60 mins.

The Study on Public Motivation Policies Concerning Construction of Urban Ecological Environmental Infrastructure

2012 ◽  
Vol 178-181 ◽  
pp. 322-327
Author(s):  
Jing Hua Cui ◽  
Hao Yan Li
Keyword(s):  
Effective Treatment ◽  
Capital Investment ◽  
Urban Pollution ◽  
Financial Policy ◽  
Rapid Improvement ◽  
Taxation Policy ◽  
Slow Pace ◽  
Urban Rural ◽  
The Government ◽  
Environmental Infrastructure

With the rapid improvement of urbanization and the acceleration of urban-rural integration, environmental problems in China call for urgent actions. One of the important factors of non-effective treatment of Chinese urban pollution is due to the lagging of construction of urban environmental infrastructure. By analysis, this paper concludes that the limited number of investment entities, rare amount of capital investment and poor investment effectiveness account for the slow pace of construction of urban environmental infrastructure in China. Considering this, the government should allocate a larger share of fiscal capital investment, adopt preferential taxation policy and green financial policy, and perform public-private cooperation to smoothen the construction of urban environmental infrastructure.

Abstract TP357: Top Reasons Why IV r-TPA Not Given in Wisconsin Rural and Primary Stroke Center Hospitals

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Sue Fuhrman ◽  
Jeannie Pittenger ◽  
Anne Hansen ◽  
Kathy Polum ◽  
Kathryn Miller ◽  
...  
Keyword(s):  
Community Education ◽  
Treatment Options ◽  
Rapid Improvement ◽  
Time Period ◽  
Improved Outcomes ◽  
Primary Stroke Center ◽  
Stroke Center ◽  
Get With The Guidelines ◽  
Hospital Group ◽  
Iv Tpa

Background and Issues— Stroke continues to be a significant cause of morbidity and mortality. Research has shown improved outcomes when IV tPA is started as close as possible to the time the patient was last known well. Although the use of IV tPA has increased over time, there still an opportunity to increase the use of IV tPA so more patients may benefit from this acute intervention. Purpose— To explore the top reasons documented for not giving IV tPA in WI Rural and WI PSC Hospitals. Methods— Two groups (Rural and WI PSC) were established in Wisconsin through the Get With The Guidelines-Stroke database. The Rural hospital group includes an average of 13 hospitals with 282 total documented reasons for no IV tPA being given. The WI PSC Hospital group includes 26 hospitals with 2552 documented reasons for not giving IV tPA. The time period in which these reasons were tracked was January 1, 2008 through December 31, 2011. Reasons were ranked as a percentage of the whole for each group, and the top five are listed in the Results section. Results— Conclusions— Advanced age and rapid improvement of symptoms are commonly documented reasons for not giving IV tPA in both Rural and PSC Hospitals in WI. Rural hospitals also note some facility reasons; whereas the PSC hospitals noted delay in presentation to their facility or that tPA was started elsewhere as common reasons for not administering this acute intervention. Of all the reasons listed above, the patient that already received tPA at another institution is the only absolute contraindication for more tPA. An opportunity exists to increase education to providers on weighing the relative risk for tPA criteria versus the potential benefit of the patient, as well as community education of early treatment necessity. Further research is also needed to determine other factors (i.e. salvageable penumbra) in deciding on treatment options.

Abstract WP284: Regional Disparities in the Quality of Stroke Care

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Seth Seabury ◽  
Katalin Bognar ◽  
Yaping Xu ◽  
Caroline Huber ◽  
S. R Commerford ◽  
...  
Keyword(s):  
Regression Analysis ◽  
Stroke Care ◽  
Performance Measure ◽  
Care Quality ◽  
Measure Data ◽  
Quality Reporting ◽  
Urban Rural ◽  
Stroke Center ◽  
Hospital Compare

Background: Geographic variation in healthcare quality, including an urban-rural difference, is well recognized. For stroke care, we were interested in the relationship with stroke center certification and access to neurological services. Hypothesis: We assessed the hypothesis that the use of thrombolytic therapy (t-PA) is associated with stroke certification level and access to neurological services. Methods: Performance measure data in the 2015 Hospital Compare, a CMS quality reporting system, were used to document the gap in care quality among hospitals according to large, medium, small-metro, and non-metro areas and Joint Commission (JC) certification. Regression analysis was used to estimate the association between t-PA use and certification level or access to neurological services. Results: On average, non-metro hospitals performed worse than metro hospitals on JC-endorsed stroke quality measures; the biggest disparity was in the use of t-PA for eligible patients arriving within 2 hours (STK-4). Certified stroke centers in every geographic designation provided higher quality of care; however, a large variation was observed among non-certified hospitals (Figure). Regression analysis suggested that improvements in certification or access were associated with 45% and 21% absolute improvements, respectively, in the percent of patients receiving t-PA (Table). Conclusion: The large quality gap in stroke care between metro and non-metro areas can, in part, be addressed by approaches to achieve stroke center certification or to adopt decision support systems such as telemedicine.

Abstract WP359: Achieving Target: Stroke Honor Roll Status through the Utilization of 9 Best Practice Strategies

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Jennifer Garland
Keyword(s):  
Brain Imaging ◽  
Best Practice ◽  
Rapid Acquisition ◽  
Rapid Access ◽  
Honor Roll ◽  
Stroke Team ◽  
Data Feedback ◽  
National Quality ◽  
Primary Stroke Center ◽  
Stroke Center

Background: Target: Stroke is a national quality initiative of the American Heart Association/American Stroke Association with the goal of improving <60 minute door-to-needle times (DTN) for at least 50% of patients receiving IV rt-PA. (AHA/ASA, 2012) Purpose: To improve DTN times <60 minutes at an urban Primary Stroke Center in South California through the utilization of the Target: Stroke national quality initiative. Methods: Retrospective data analysis for 11 IV rt-PA receiving patients in the Get With The Guidelines-Stroke (GWTG-Stroke) database from 11/01/2011 to 01/31/2012. Employment of 9 Target: Stroke Best Practice Strategies: Advance Hospital Notification by EMS (Emergency Medical Services), Rapid Triage Protocol and Stroke Team Notification, Single Call Activation System, Stroke Tools, Rapid Acquisition and Interpretation of Brain Imaging, Rapid Laboratory Testing, Rapid Access to Intravenous IV rt-PA, Team-Based Approach, and Prompt Data Feedback. Results: The hospital received advanced hospital notification by EMS for 10 out of 11 (90.9%) IV rt-PA receiving patients. 100% of the patients were rapidly triaged, the stroke team was notified via single call activation & overhead page (stroke alert), and the appropriate thrombolytic stroke order sets were implemented (Stroke Tools). Rapid acquisition and interpretation of brain imaging were measured. CT Scan order to CT complete turn-around-time (TAT) averaged 12 minutes. CT Complete to CT Read TAT averaged 11.33 minutes.Average PT/INR and PTT TATs were 26.1 minutes. Rapid access to intravenous IV rt-PA was mixed by the Emergency Department pharmacist at the bedside for 100% of patients. The Team-Based Approach and prompt Data Feedback were practiced by holding monthly Stroke Steering Committee meetings that included interdisciplinary team members and disseminating data. Eight out of eleven (72.7%) acute ischemic stroke patients treated with IV rt-PA received the medication <60 minutes. Median door-to-needle (DTN) time for patients treated with IV rt-PA: 42 minutes. Conclusion: By employing 9 Target: Stroke Best Practice Strategies at an urban Primary Stroke Center in South California, the hospital was able to achieve Target: Stroke Honor Roll status from 11/01/2011 to 01/31/2012.

Abstract TP400: Examining Five Year Trends of Documented Tissue Plasminogen Activator Contraindications in Wisconsin

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Michelle Scharnott ◽  
Kathryn Miller ◽  
Dot Bluma ◽  
Lynn Serdynski
Keyword(s):  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Systems Of Care ◽  
Advanced Age ◽  
Rapid Improvement ◽  
Quality Improvement Effort ◽  
National Quality ◽  
Tissue Plasminogen ◽  
Referral Hospitals ◽  
Get With The Guidelines

Background: Target: Stroke was initiated in 2010 as a national quality improvement effort. This American Stroke Association campaign gave tools, consulting and data analysis to hospitals to improve door to needle time with tissue plasminogen activator (tPA). Along with this effort, the state of Wisconsin continued to work on a stroke system of care as well as education on tPA warnings versus absolute contraindications. Methods: This study looked at an average of 40 Wisconsin hospitals and 26,185 ischemic stroke patients in Get With The Guidelines- Stroke over a five year period to determine if there were trends in how hospitals documented contraindications for tPA. Results: From 2010 to 2014 Advanced Age and Age >80 decreased as a tPA contraindication by 7.3% and 4.6% respectively. Rapid Improvement decreased from 38% of the tPA contraindications to 35.1% over this time period. Hospitals also listed a 2.5% increase in the amount of patients receiving tPA in an outside hospital before transfer. Conclusions: Through efforts such as Target: Stroke, statewide education and systems of care work, Wisconsin hospitals have improved the door to needle time for eligible patients from 18.1% in 2010 to 66.8% under 60 minutes. The data shows that advanced age is not used as often as a contraindication assuming education of age being a warning and not an absolute contraindication has had some effect on treatment decisions. It can also be assumed that referral hospitals are giving more tPA and transferring when necessary as hospitals have increased listing tPA at an outside hospital as a contraindication. Rapid Improvement has fluctuated but is at a five year low

scholarly journals Stroke Code Presentations, Interventions, and Outcomes Before and During the COVID-19 Pandemic

Stroke ◽  
2020 ◽  
Vol 51 (9) ◽  
pp. 2664-2673 ◽  
Author(s):  
Adam S. Jasne ◽  
Pola Chojecka ◽  
Ilavarasy Maran ◽  
Razaz Mageid ◽  
Mohamed Eldokmak ◽  
...  
Keyword(s):  
Public Health ◽  
Piecewise Linear ◽  
Patient Characteristics ◽  
Stroke Severity ◽  
Process Measures ◽  
Level Data ◽  
Health Initiatives ◽  
Artery Disease ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: Anecdotal reports suggest fewer patients with stroke symptoms are presenting to hospitals during the coronavirus disease 2019 (COVID-19) pandemic. We quantify trends in stroke code calls and treatments at 3 Connecticut hospitals during the local emergence of COVID-19 and examine patient characteristics and stroke process measures at a Comprehensive Stroke Center (CSC) before and during the pandemic. Methods: Stroke code activity was analyzed from January 1 to April 28, 2020, and corresponding dates in 2019. Piecewise linear regression and spline models identified when stroke codes in 2020 began to decline and when they fell below 2019 levels. Patient-level data were analyzed in February versus March and April 2020 at the CSC to identify differences in patient characteristics during the pandemic. Results: A total of 822 stroke codes were activated at 3 hospitals from January 1 to April 28, 2020. The number of stroke codes/wk decreased by 12.8/wk from February 18 to March 16 ( P =0.0360) with nadir of 39.6% of expected stroke codes called from March 10 to 16 (30% decrease in total stroke codes during the pandemic weeks in 2020 versus 2019). There was no commensurate increase in within-network telestroke utilization. Compared with before the pandemic (n=167), pandemic-epoch stroke code patients at the CSC (n=211) were more likely to have histories of hypertension, dyslipidemia, coronary artery disease, and substance abuse; no or public health insurance; lower median household income; and to live in the CSC city ( P <0.05). There was no difference in age, sex, race/ethnicity, stroke severity, time to presentation, door-to-needle/door-to-reperfusion times, or discharge modified Rankin Scale. Conclusions: Hospital presentation for stroke-like symptoms decreased during the COVID-19 pandemic, without differences in stroke severity or early outcomes. Individuals living outside of the CSC city were less likely to present for stroke codes at the CSC during the pandemic. Public health initiatives to increase awareness of presenting for non-COVID-19 medical emergencies such as stroke during the pandemic are critical.

Abstract 306: Regional Differences in Stroke Center Designation and Get with The Guidelines (GWTG-S) Participation and Performance: Results From The NorthEast Cerebrovascular Consortium (NECC)

2015 ◽  
Vol 8 (suppl_2) ◽  
Author(s):  
Toby I Gropen ◽  
Charles R Wira ◽  
Shannon Melluzzo ◽  
Zainab Magdon-Ismail ◽  
David Day ◽  
...  
Keyword(s):  
Health Care Providers ◽  
Census Data ◽  
Systems Of Care ◽  
Care Providers ◽  
Performance Achievement ◽  
Primary Stroke Center ◽  
And Performance ◽  
Stroke Systems Of Care ◽  
Stroke Center ◽  
Over Time

Introduction: The NorthEast Cerebrovascular Consortium (NECC) was created in 2006 to unite health care providers, public health officials, legislators and advocacy organizations in an 8-state region to implement and assess a Stroke Systems of Care Model. Objectives: To examine differences in Primary Stroke Center (PSC) designation, participation in GWTG-S and performance of acute care hospitals (ACH) and critical access centers (CAC) in the NECC region compared to non-NECC regions. Methods: We compared percentages of ACHs/CACs with State versus National PSC Designation, GWTG-S participation and Performance Achievement award trends over time in the pre- (2005) and post- NECC (2006-13) time periods. State designation refers to states conducting designation themselves or a combination of their own designation/national designation (Joint Commission, DNV or HFAP). US census data regions were stratified as The NECC region (CT, MA, ME, NH, NJ, NY, RI, VT) vs. Non-NECC regions (PA, South, Midwest, West). ACH/CACs were obtained from CMS. GWTG-S data were used for GWTG-S participation and awards (silver or higher for >1 year). Results: Over the study time period (2005-13) the ACH/CACs per year in The NECC and non-NECC regions were 433 + 10 and 4420 + 172. State PSC designation occurred in CT, MA, FL, MD, NJ, and NYS. OK State designation was excluded due to lack of data. In the NECC region, State PSC designation increased over time from 29.3% in 2005 to 63.2% in 2013, compared to 0.1% in 2005 to 3.6% in 2013 in non-NECC regions (both analyses p<0.0001, Cochran Armitage Trend (CAT)). In the NECC region, National PSC designation increased over time from 2.8% in 2005 to 17.1% in 2013, compared to 35.5% in 2005 to 77.3% in 2013 in non-NECC regions (both analyses p<0.0001, CAT). In the NECC region, GWTG-S participation increased over time from 21.2% in 2005 to 61.5% in 2013 compared to 9.2% in 2005 to 32.4% in 2013 in non-NECC regions (both analyses p<0.0001, CAT), and GWTG-S awards increased over time in the NECC region from 0.5% in 2005 to 42.5% in 2013 compared to 0.1% in 2005 to 16.6% in 2013 in non-NECC regions (both analyses p<0.0001, CAT). After adjusting for year, significantly more NECC ACH/CACs received State PSC designation and significantly more non-NECC ACH/CACs received National PSC designation (both analyses p<0.0001, Cochran-Mantel-Haenszel (CMH)). Significantly more NECC ACH/CACs participated in GWTG-S and received GWTG-S awards than non-NECC ACH/CACs (both analyses p<0.0001, CMH). Conclusions: There has been more rapid growth of State in lieu of National PSC certification, and participation and achievement in GWTG-S in the Northeast from 2006 through 2013 compared to other regions in the U.S. The NECC may compliment and enhance existing regulatory and advocacy initiatives. Further investigation is merited to evaluate the influence of regional networks and State versus National PSC designation.

Validating Four Standard Scales in Spiritually Practicing and Nonpracticing Samples Using Propensity Score Matching

2008 ◽  
Vol 24 (3) ◽  
pp. 165-173 ◽  
Author(s):  
Niko Kohls ◽  
Harald Walach
Keyword(s):  
Propensity Score ◽  
Propensity Score Matching ◽  
Repeated Measures ◽  
Propensity Scores ◽  
Total Sample ◽  
Experimental Manipulation ◽  
Brief Symptom Inventory ◽  
Time Interaction ◽  
Social Support Scale ◽  
Lower Test

Validation studies of standard scales in the particular sample that one is studying are essential for accurate conclusions. We investigated the differences in answering patterns of the Brief-Symptom-Inventory (BSI), Transpersonal Trust Scale (TPV), Sense of Coherence Questionnaire (SOC), and a Social Support Scale (F-SoZu) for a matched sample of spiritually practicing (SP) and nonpracticing (NSP) individuals at two measurement points (t1, t2). Applying a sample matching procedure based on propensity scores, we selected two sociodemographically balanced subsamples of N = 120 out of a total sample of N = 431. Employing repeated measures ANOVAs, we found an intersample difference in means only for TPV and an intrasample difference for F-SoZu. Additionally, a group × time interaction effect was found for TPV. While Cronbach’s α was acceptable and comparable for both samples, a significantly lower test-rest-reliability for the BSI was found in the SP sample (rSP = .62; rNSP = .78). Thus, when researching the effects of spiritual practice, one should not only look at differences in means but also consider time stability. We recommend propensity score matching as an alternative for randomization in variables that defy experimental manipulation such as spirituality.

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