The Cost-Effectiveness of Primary Stroke Centers for Acute Stroke Care

Objectives: To guide policy when planning reperfusion thrombolysis (IVT) and thrombectomy (MT) services for acute stroke in England, focussing on the choice between ‘mothership’ (direct conveyance to an MT centre) and ‘drip-and-ship' (secondary transfer for MT after local IVT) provision and the impact of bypassing local acute stroke centres.Methods: Computer modelling was used to estimate the likely outcomes from reperfusion therapies, along with admission numbers to units, based on expected times to IVT and MT.Results: Without pre-hospital selection for LAO, 94% of the population of England live in areas where the greatest clinical benefit accrues from direct conveyance to an IVT/MT centre. If this model was followed then net benefit from reperfusion is predicted to be increased from 31 to 34 additional disability-free outcomes / 1,000 admissions. However, this policy produces unsustainable admission numbers at these centres, and depletes all but 19 IVT-only units of all stroke admissions. Implementing a maximum permitted additional travel time to bypass an IVT-only unit, or using a pre-hospital test for LAO, both increase net benefit over the current drip-and-ship model, but produce a similar destabilising effect on acute systems of care. Use of IVT-only units manage admission numbers to IVT/MT centres.Conclusions: The mothership model reduces time to MT at the cost of increased time to IVT, but the benefit of faster MT is predicted to lead to a modest improvement in overall outcomes. Providing a sustainable national system of acute stroke care requires a hybrid of mothership and drip-and-ship provision.

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Cost burden and cost-effective analysis of the nationwide implementation of the Quality in Acute Stroke Care protocol in Australia

European Heart Journal ◽

10.1093/eurheartj/ehab724.3157 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

C M Marquina ◽

Z A Ademi ◽

E Z Zomer ◽

R O A Ofori-Asenso ◽

R T Tate ◽

...

Keyword(s):

Acute Stroke ◽

Societal Perspective ◽

Stroke Care ◽

Decision Analytic Model ◽

Stroke Severity ◽

Acute Stroke Care ◽

Stroke Incidence ◽

Care Protocol ◽

Life Years ◽

The Cost

Abstract Background The Quality in Acute Stroke Care (QASC) protocol is a multidisciplinary approach to implement evidence-based treatment after acute stroke that reduces death and disability. Aim This study sought to evaluate the cost-effectiveness of implementing the QASC protocol across Australia, from a healthcare and a societal perspective. Methods A decision-analytic model was constructed to reflect one-year outcomes post-stroke, aligned with the stroke severity categories of the modified Rankin scale (mRS). Decision analysis compared outcomes following implementation of the QASC protocol versus no implementation. Population data were extracted from Australian databases and data inputs regarding stroke incidence, costs, and utilities were drawn from published sources. The analysis assumed a progressive uptake and efficacy of the QASC protocol over five years. Health benefits and costs were discounted by 5% annually. The cost of each year lived by an Australian, from a societal perspective, was based on the Australian Government's “value of statistical life year” (AUD 213,000). Results Over five years, the model predicted 263,722 strokes among the Australian population. The implementation of the QASC protocol was predicted to prevent 1,154 deaths and yield a gain of 876 years of life (0.003 per stroke), and 3,180 quality-adjusted life years (QALYs) (0.012 per stroke). There was an estimated net saving of AUD 65.2 million in healthcare costs (AUD 247 per stroke) and AUD 251.7 million in societal costs (AUD 955 per stroke). Conclusions Implementation of the QASC protocol in Australia represents both a dominant (cost-saving) strategy, from a healthcare and a societal perspective. FUNDunding Acknowledgement Type of funding sources: None. Decision tree PSA

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A review of early supported discharge after stroke

Reviews in Clinical Gerontology ◽

10.1017/s0959259810000249 ◽

2010 ◽

Vol 20 (4) ◽

pp. 327-337 ◽

Cited By ~ 3

Author(s):

Linda Brewer ◽

David Williams

Keyword(s):

Cost Effectiveness ◽

Discharge Planning ◽

Stroke Care ◽

International Studies ◽

Acute Stroke Care ◽

Rehabilitation Team ◽

Early Supported Discharge ◽

Essential Components ◽

Bed Days ◽

The Cost

SummaryStroke is a leading cause of disability worldwide and patients with stroke frequently require prolonged periods of in-patient rehabilitation prior to discharge. This poses a large economic strain on health services, and the cost-effectiveness of this system has been questioned. However, in implementing changes in the delivery of post-acute stroke care it is important that patient outcome is not compromised. Early supported discharge (ESD) was introduced approximately 15 years ago and allows suitable patients to be discharged home early with increased support from a well co-ordinated, multi-disciplinary rehabilitation team in the patient's own home. This paper focuses upon the evidence available from multiple international studies of ESD over the last decade, including both clinical benefit and cost-effectiveness. Findings from these trials are largely positive resulting from a reduction in bed days, therefore overall cost, and an improvement in function and independence reported in many studies. Suitable patient selection, careful discharge planning and continuity of care by the ESD linked to a stroke unit are essential components of the success of this service.

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Berlin PRehospital Or Usual Delivery of Acute Stroke Care 2.0 (B_PROUD 2.0)

Case Medical Research ◽

10.31525/ct1-nct03931616 ◽

2019 ◽

Author(s):

Keyword(s):

Acute Stroke ◽

Stroke Care ◽

Acute Stroke Care

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Essential Acute Stroke Care in Low Resource Settings: a Pilot studY

Case Medical Research ◽

10.31525/ct1-nct04157231 ◽

2019 ◽

Author(s):

Keyword(s):

Pilot Study ◽

Acute Stroke ◽

Stroke Care ◽

Acute Stroke Care ◽

Low Resource Settings ◽

Low Resource

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Faculty Opinions recommendation of Provision of acute stroke care and associated factors in a multiethnic population: prospective study with the South London Stroke Register.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.8785964.9312066 ◽

2011 ◽

Author(s):

Erik Buskens

Keyword(s):

Prospective Study ◽

Acute Stroke ◽

Associated Factors ◽

Stroke Care ◽

The South ◽

Acute Stroke Care ◽

Multiethnic Population ◽

Stroke Register

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Bottlenecks in the Acute Stroke Care System during the COVID-19 Pandemic in Catalonia

Cerebrovascular Diseases ◽

10.1159/000516309 ◽

2021 ◽

pp. 1-9

Author(s):

Anna Ramos-Pachón ◽

Álvaro García-Tornel ◽

Mònica Millán ◽

Marc Ribó ◽

Sergi Amaro ◽

...

Keyword(s):

Acute Stroke ◽

Functional Outcome ◽

Stroke Care ◽

Care Quality ◽

Point Of View ◽

Stroke Severity ◽

Acute Stroke Care ◽

Vessel Occlusion ◽

Prehospital Delays ◽

The Impact

Introduction: The COVID-19 pandemic resulted in significant healthcare reorganizations, potentially striking standard medical care. We investigated the impact of the COVID-19 pandemic on acute stroke care quality and clinical outcomes to detect healthcare system’s bottlenecks from a territorial point of view. Methods: Crossed-data analysis between a prospective nation-based mandatory registry of acute stroke, Emergency Medical System (EMS) records, and daily incidence of COVID-19 in Catalonia (Spain). We included all stroke code activations during the pandemic (March 15–May 2, 2020) and an immediate prepandemic period (January 26–March 14, 2020). Primary outcomes were stroke code activations and reperfusion therapies in both periods. Secondary outcomes included clinical characteristics, workflow metrics, differences across types of stroke centers, correlation analysis between weekly EMS alerts, COVID-19 cases, and workflow metrics, and impact on mortality and clinical outcome at 90 days. Results: Stroke code activations decreased by 22% and reperfusion therapies dropped by 29% during the pandemic period, with no differences in age, stroke severity, or large vessel occlusion. Calls to EMS were handled 42 min later, and time from onset to hospital arrival increased by 53 min, with significant correlations between weekly COVID-19 cases and more EMS calls (rho = 0.81), less stroke code activations (rho = −0.37), and longer prehospital delays (rho = 0.25). Telestroke centers were afflicted with higher reductions in stroke code activations, reperfusion treatments, referrals to endovascular centers, and increased delays to thrombolytics. The independent odds of death increased (OR 1.6 [1.05–2.4], p 0.03) and good functional outcome decreased (mRS ≤2 at 90 days: OR 0.6 [0.4–0.9], p 0.015) during the pandemic period. Conclusion: During the COVID-19 pandemic, Catalonia’s stroke system’s weakest points were the delay to EMS alert and a decline of stroke code activations, reperfusion treatments, and interhospital transfers, mostly at local centers. Patients suffering an acute stroke during the pandemic period had higher odds of poor functional outcome and death. The complete stroke care system’s analysis is crucial to allocate resources appropriately.

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Acute Stroke Care during the COVID-19 Pandemic: Reduction in the Number of Admissions of Elderly Patients and Increase in Prehospital Delays

Cerebrovascular Diseases ◽

10.1159/000514140 ◽

2021 ◽

pp. 1-7

Author(s):

Gabriel Velilla-Alonso ◽

Andrés García-Pastor ◽

Ángela Rodríguez-López ◽

Ana Gómez-Roldós ◽

Antonio Sánchez-Soblechero ◽

...

Keyword(s):

Elderly Patients ◽

Acute Stroke ◽

Time Course ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Acute Stroke Care ◽

Group Data ◽

Radiological Data ◽

History Of ◽

Prehospital Delays

Introduction: We analyzed whether the coronavirus disease 2019 (COVID-19) crisis affected acute stroke care in our center during the first 2 months of lockdown in Spain. Methods: This is a single-center, retrospective study. We collected demographic, clinical, and radiological data; time course; and treatment of patients meeting the stroke unit admission criteria from March 14 to May 14, 2020 (COVID-19 period group). Data were compared with the same period in 2019 (pre-COVID-19 period group). Results: 195 patients were analyzed; 83 in the COVID-19 period group, resulting in a 26% decline of acute strokes and transient ischemic attacks (TIAs) admitted to our center compared with the previous year (p = 0.038). Ten patients (12%) tested positive for PCR SARS-CoV-2. The proportion of patients aged 65 years and over was lower in the COVID-19 period group (53 vs. 68.8%, p = 0.025). During the pandemic period, analyzed patients were more frequently smokers (27.7 vs. 10.7%, p = 0.002) and had less frequently history of prior stroke (13.3 vs. 25%, p = 0.043) or atrial fibrillation (9.6 vs. 25%, p = 0.006). ASPECTS score was lower (9 [7–10] vs. 10 [8–10], p = 0.032), NIHSS score was slightly higher (5 [2–14] vs. 4 [2–8], p = 0.122), onset-to-door time was higher (304 [93–760] vs. 197 [91.25–645] min, p = 0.104), and a lower proportion arrived within 4.5 h from onset of symptoms (43.4 vs. 58%, p = 0.043) during the COVID-19 period. There were no differences between proportion of patients receiving recanalization treatment (intravenous thrombolysis and/or mechanical thrombectomy) and in-hospital delays. Conclusion: We observed a reduction in the number of acute strokes and TIAs admitted during the COVID-19 period. This drop affected especially elderly patients, and despite a delay in their arrival to the emergency department, the proportion of patients treated with recanalization therapies was preserved.

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