Stroke Care: Stroke Units, New Therapies, Advances and the Future

Introduction: Stroke is a serious health problem, given it is the second leading cause of death and a major cause of disability in the European Union. Our study aimed to assess the impact of stroke care organization measures (such as the development of stroke units, implementation of a regional stroke code, and treatment with intravenous thrombolysis and mechanical thrombectomy) implemented from 1997 to 2017 on hospital admissions due to stroke and mortality attributed to stroke in the Madrid health region. Methods: Epidemiological data were obtained from the National Statistics Institute public website. We collected data on the number of patients discharged with a diagnosis of stroke, in-hospital mortality due to stroke and the number of inhabitants in the Madrid health region each year. We calculated rates of discharges and mortality due to stroke and the number of inhabitants per SU bed, and we analysed temporal trends in in-hospital mortality due to stroke using the Daniels test in 2 separate time periods (before and after 2011). Figures representing annual changes in these data from 1997 to 2017 were elaborated, marking stroke care organizational measures in the year they were implemented to visualize their temporal relation with changes in stroke statistics. Results: Hospital discharges with a diagnosis of stroke have increased from 170.3/100,000 inhabitants in 1997 to 230.23/100,000 inhabitants in 2017. However, the in-hospital mortality rate due to stroke has decreased (from 33.3 to 15.2%). A statistically significant temporal trend towards a decrease in the mortality percentage and rate was found from 1997 to 2011. Conclusions: Our study illustrates how measures such as the development of stroke units, implementation of a regional stroke code and treatment with intravenous thrombolysis coincide in time with a reduction in in-hospital mortality due to stroke.

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Organizational issues in stroke treatment: The Swiss paradigm - Stroke units

Journal of Neurosciences in Rural Practice ◽

10.4103/0976-3147.116450 ◽

2013 ◽

Vol 04 (S 01) ◽

pp. S131-S133 ◽

Cited By ~ 2

Author(s):

Georgios K Matis ◽

Olga I Chrysou ◽

Theodossios A Birbilis

Keyword(s):

Multidisciplinary Care ◽

Stroke Care ◽

Stroke Units ◽

Stroke Treatment ◽

Organizational Issues ◽

Standardized Treatment ◽

Socioeconomic Burden ◽

New Guidelines ◽

Acute Rehabilitation ◽

Prompt Diagnosis

ABSTRACTStroke represents the leading cause of acquired disability in adults and poses a tremendous socioeconomic burden both on patients and the society. In this sense, prompt diagnosis and urgent treatment are needed in order to radically reduce the devastating consequences of this disease. Herein the authors present the new guidelines recently adopted by the Swiss Stroke Society concerning the establishment of stroke units. Standardized treatment and allocation protocols along with an acute rehabilitation concept seem to be the core of the Swiss stroke management system. Coordinated multidisciplinary care provided by specialized medical, nursing and therapy staff is of utmost importance for achieving a significant dependency and death reduction. It is believed that the implementation of these guidelines in the stroke care system would be beneficial not only for the stroke patients, but also for the health system.

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Can we afford the future: effectiveness or cost-effectiveness as the criterion for introducing new therapies for breast cancer?

European Journal of Cancer Supplements ◽

10.1016/s1359-6349(08)70318-5 ◽

2008 ◽

Vol 6 (7) ◽

pp. 51

Author(s):

I.F. Tannock

Keyword(s):

Breast Cancer ◽

Cost Effectiveness ◽

New Therapies ◽

The Future

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Stroke Units, Regional Systems of Emergency Stroke Care, and Telestroke Networks

Rational Basis for Clinical Translation in Stroke Therapy ◽

10.1201/b16285-5 ◽

2014 ◽

pp. 24-43

Keyword(s):

Stroke Care ◽

Stroke Units ◽

Regional Systems

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Establishing Stroke Services in the Republic of Georgia

European Neurology ◽

10.1159/000518845 ◽

2021 ◽

pp. 1-9

Author(s):

Zaza Katsarava ◽

Tamar Akhvlediani ◽

Tamar Janelidze ◽

Tamar Gudadze ◽

Marina Todua ◽

...

Keyword(s):

Treatment Process ◽

Stroke Care ◽

Subsequent Treatment ◽

National Guidelines ◽

Ethical Problems ◽

Stroke Units ◽

Systemic Thrombolysis ◽

Stroke Services ◽

The Republic ◽

Quality Reports

Introduction: This article summarizes the medical experience in establishing stroke units and systemic thrombolysis in Georgia, which, like many other post-Soviet countries, still faces problems in organizing stroke care even after 30 years of independence. Patients and Methods: We created an example of treating acute stroke with systemic thrombolysis and introduced stroke units in several hospitals in the country, including standardization of the diagnostic and treatment process, consistent evaluation, and monthly feedback to the stroke unit staff. Results: Systemic thrombolysis has become a clinical routine in some large hospitals and is meanwhile reimbursed by the state insurance. The data of consecutive 1,707 stroke patients in 4 major cities demonstrated significant time lost at the prehospital level, due to failure in identifying stroke symptoms, delay in notification, or transportation. The consequent quality reports resulted in a dramatic increase in adherence to the European and national guidelines. A mandatory dysphagia screening and subsequent treatment led to a decrease in pneumonia rates. Discussion: We discuss our experience and suggestions on how to overcome clinical, financial, and ethical problems in establishing a stroke services in a developing country. Conclusion: The Georgian example might be useful for doctors in other post-Soviet countries or other parts of the world.

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Abstract 116: Relationship of Stroke Unit Status With Quality of Care and Outcome for Acute Stroke Patients: Results From China National Stroke Registry II

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.10.suppl_3.116 ◽

2017 ◽

Vol 10 (suppl_3) ◽

Author(s):

Xinmiao Zhang ◽

Zixiao Li ◽

Chunjuan Wang ◽

Caiyun Wang ◽

Xin Yang ◽

...

Keyword(s):

Clinical Outcomes ◽

Cox Model ◽

Frailty Model ◽

Stroke Care ◽

Estimating Equation ◽

Composite Score ◽

Stroke Recurrence ◽

Stroke Units ◽

Stroke Registry ◽

Processes Of Care

Introduction: A key element in modern stroke care is dedicated stroke units. However, it is unclear whether processes of acute ischemic stroke (AIS) care and outcomes are different between hospitals with and without stroke units in China. Methods: We analyzed the China National Stroke Registry II data from June 2012 to January 2013. Processes of care were examined by 13 individual national guideline-recommended indicators and composite score. Patients’ outcomes included all caused death, stroke recurrence, and disability (modified Rankin Score ≥3) at 3, 6 and 12month after discharge. Propensity score matching was used to balance the baseline characteristics. We used cox model with shared frailty model and logistic regression with generalized estimating equation to analysis the relationship between stroke units and clinical outcomes. Results: Among 19 604 AIS patients, there were 11050 (56.4%) patients in 121 hospitals with stroke units, and 8554 (43.6%) patients in 96 hospitals without stroke units. After matching, 8125 pairs of patients were analyzed. Totally, the composite score of processes was higher in hospitals with stroke units than that without(77% versus 74%, p<0.05). Hospitals with stroke units were more likely to conduct anticoagulation for atrial fibrillation, early antithrombotic treatment, smoking cessation, and stroke education (Figure 1). However, there are no differences between patients in hospitals with and without stroke units in clinical outcomes(Table 1). Conclusions: Our study showed that processes of care of AIS were better in patients in hospitals with stroke units. However, patients in hospitals with stroke units didn’t performance differences in clinical outcomes after discharge.

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Ten Years of Improving Acute Stroke Management in a Metropolitan Area: A Population-Based Quantification of Quality Indicators

European Neurology ◽

10.1159/000518428 ◽

2021 ◽

pp. 1-11

Author(s):

Anna Alegiani ◽

Michael Rosenkranz ◽

Leonie Schmitz ◽

Susanne Lezius ◽

Günter Seidel ◽

...

Keyword(s):

Acute Stroke ◽

Quality Indicators ◽

Metropolitan Area ◽

Stroke Care ◽

Care Quality ◽

Acute Stroke Care ◽

Stroke Units ◽

Stroke Treatment ◽

Acute Stroke Treatment ◽

Over Time

Background and Purpose: Rapid access to acute stroke treatment improves clinical outcomes in patients with ischemic stroke. We aimed to shorten the time to admission and to acute stroke treatment for patients with acute stroke in the Hamburg metropolitan area by collaborative multilevel measures involving all hospitals with stroke units, the Emergency Medical Services (EMS), and health-care authorities. Methods: In 2007, an area-wide stroke care quality project was initiated. The project included mandatory admission of all stroke patients in Hamburg exclusively to hospitals with stroke units, harmonized acute treatment algorithms among all hospitals, repeated training of the EMS staff, a multimedia educational campaign, and a mandatory stroke care quality monitoring system based on structured data assessment and quality indicators for procedural measures. We analyzed data of all patients with acute stroke who received inhospital treatment in the city of Hamburg during the evaluation period from the quality assurance database data and evaluated trends of key quality indicators over time. Results: From 2007 to 2016, a total of 83,395 patients with acute stroke were registered. During this period, the proportion of patients admitted within ≤3 h from symptom onset increased over time from 27.8% in 2007 to 35.2% in 2016 (p < 0.001). The proportion of patients who received rapid thrombolysis (within ≤30 min after admission) increased from 7.7 to 54.1% (p < 0.001). Conclusions: Collaborative stroke care quality projects are suitable and effective to improve acute stroke care.

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Effects of centralizing acute stroke services

Neurology ◽

10.1212/wnl.0000000000005822 ◽

2018 ◽

Vol 91 (3) ◽

pp. e236-e248 ◽

Cited By ~ 6

Author(s):

Sidsel Hastrup ◽

Soren P. Johnsen ◽

Thorkild Terkelsen ◽

Heidi H. Hundborg ◽

Paul von Weitzel-Mudersbach ◽

...

Keyword(s):

Hospital Stay ◽

Acute Stroke ◽

Stroke Care ◽

Acute Hospital ◽

Acute Stroke Care ◽

Difference In Differences ◽

Stroke Units ◽

Before And After ◽

Stroke Services

ObjectiveTo investigate the effects of centralizing the acute stroke services in the Central Denmark Region (CDR).MethodsThe CDR (1.3 million inhabitants) centralized acute stroke care from 6 to 2 designated acute stroke units with 7-day outpatient clinics. We performed a prospective “before-and-after” cohort study comparing all strokes from the CDR with strokes in the rest of Denmark to discover underlying general trends, adopting a difference-in-differences approach. The population comprised 22,141 stroke cases hospitalized from May 2011 to April 2012 and May 2013 to April 2014.ResultsCentralization was associated with a significant reduction in length of acute hospital stay from a median of 5 to 2 days with a length-of-stay ratio of 0.53 (95% confidence interval 0.38–0.75, data adjusted) with no corresponding change seen in the rest of Denmark. Similarly, centralization led to a significant increase in strokes with same-day admission (mainly outpatients), whereas this remained unchanged in the rest of Denmark. We observed a significant improvement in quality of care captured in 11 process performance measures in both the CDR and the rest of Denmark. Centralization was associated with a nonsignificant increase in thrombolysis rate. We observed a slight increase in readmissions at day 30, but this was not significantly different from the general trend. Mortality at days 30 and 365 remained unchanged, as in the rest of Denmark.ConclusionsCentralizing acute stroke care in the CDR significantly reduced the length of acute hospital stay without compromising quality. Readmissions and mortality stayed comparable to the rest of Denmark.

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European Stroke Organisation certification of stroke units and stroke centres

European Stroke Journal ◽

10.1177/2396987318778971 ◽

2018 ◽

Vol 3 (3) ◽

pp. 220-226 ◽

Cited By ~ 14

Author(s):

Ulrike Waje-Andreassen ◽

Darius G Nabavi ◽

Stefan T Engelter ◽

Diederik WJ Dippel ◽

Damian Jenkinson ◽

...

Keyword(s):

Stroke Unit ◽

Stroke Care ◽

Evidence Base ◽

Final Decision ◽

Major Step ◽

High Quality ◽

Stroke Units ◽

Stroke Treatment ◽

Research Activities ◽

Stroke Centre

To improve quality and to overcome the wide discrepancies in stroke care both within- and between European countries, the European Stroke Organisation Executive Committee initiated in 2007 activities to establish certification processes for stroke units and stroke centres. The rapidly expanding evidence base in stroke care provided the mandate for the European Stroke Organisation Stroke Unit-Committee to develop certification procedures for stroke units and stroke centres with the goals of setting standards for stroke treatment in Europe, improving quality and minimising variation. The purpose of this article is to present the certification criteria and the auditing process for stroke units and stroke centres that aim to standardise and harmonise care for stroke patients, and hence become members of the European Stroke Organisation Stroke Unit and Stroke Centre network. Standardised application forms and guidelines for national and international auditors have been developed and updated by members of the European Stroke Organisation Stroke Unit-Committee. Key features are availability of trained personnel, diagnostic equipment, acute treatment and collaboration with other stroke-caregivers. After submission, the application is reviewed by one national and two international auditors. Based on their reports, the Stroke Unit-Committee will make a final decision. Validating on-site visits for a subset of stroke units and stroke centres are planned. We herein describe a novel, European Stroke Organisation-based online certification process of stroke units and stroke centres. This is a major step forward towards high-quality stroke care across Europe. The additional value by connecting high-quality European Stroke Organisation Stroke Unit and Stroke Centre is facilitation of future collaboration and research activities, enabling building and maintenance of a high-quality stroke care network in Europe.

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