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Mitra B, Law A, Mathew J, Crabtree A, Mertin H, Underhill A, Noonan M, Hunter P, Smit DV. Telehealth consultation before inter-hospital transfer after falls in a subacute hospital (the PREVENT-2 study). Emerg Med Australas 2023; 35:306-311. [PMID: 36358005 DOI: 10.1111/1742-6723.14130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/09/2022] [Accepted: 10/11/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Inter-hospital transfers are increasingly common due to the regionalisation of healthcare, but are associated with patient discomfort, high costs and adverse events. The aim of the present study was to evaluate the effectiveness of a trauma outreach service for preventing inter-hospital transfers to a major trauma centre. METHODS This was an observational pre- and post-intervention study over a 12-month period from 1 October 2020 to 30 September 2021. Eligible patients sustained a fall at Caulfield Hospital, a subacute care hospital specialising in community services, rehabilitation, geriatric medicine and aged mental health. The intervention was delivery of site-specific education at Caulfield Hospital and a trauma outreach service by specialist trauma clinicians at The Alfred Hospital who provided remote assessment, assisted with clinical management decisions and advised on appropriateness of transfer. RESULTS The present study included 160 patients in the pre-intervention phase and 203 after the intervention. The primary outcome of transfer occurred in 19 (11.9%) patients in the pre-intervention phase and 4 (2.0%) in the post-intervention phase (P < 0.001). In the subgroup of patients without pelvis or long bone fractures, pre-intervention transfer occurred for 17 (10.9%) patients and post-intervention transfer occurred for 4 (2.0%) patients (P < 0.001). CT imaging was performed for 54 (33.8%) patients in the pre-intervention and 45 (22.2%) patients in the post-intervention group (P = 0.014). CONCLUSIONS Telehealth consultation with a trauma specialist was associated with significant reduction of inter-hospital transfers, and significant reduction of CT imaging. This supports continuation of the service with scope for expansion and evaluation of patient-centred outcomes.
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Affiliation(s)
- Biswadev Mitra
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Amelia Law
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Joseph Mathew
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Amelia Crabtree
- Health of Older People Unit, Caulfield Hospital, Melbourne, Victoria, Australia
| | - Helen Mertin
- Health of Older People Unit, Caulfield Hospital, Melbourne, Victoria, Australia
| | - Andrew Underhill
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Michael Noonan
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Peter Hunter
- Health of Older People Unit, Caulfield Hospital, Melbourne, Victoria, Australia
| | - De Villiers Smit
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
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Walton NT, Mohr NM. Concept review of regionalized systems of acute care: Is regionalization the next frontier in sepsis care? J Am Coll Emerg Physicians Open 2022; 3:e12631. [PMID: 35024689 PMCID: PMC8733842 DOI: 10.1002/emp2.12631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/21/2021] [Accepted: 11/23/2021] [Indexed: 11/10/2022] Open
Abstract
Regionalization has become a buzzword in US health care policy. Regionalization, however, has varied meanings, and definitions have lacked contextual information important to understanding its role in improving care. This concept review is a comprehensive primer and summation of 8 common core components of the national models of regionalization informed by text-based analysis of the writing of involved organizations (professional, regulatory, and research) guided by semistructured interviews with organizational leaders. Further, this generalized model of regionalized care is applied to sepsis care, a novel discussion, drawing on existing small-scale applications. This discussion highlights the fit of regionalization principles to the sepsis care model and the actualized and perceived potential benefits. The principal aim of this concept review is to outline regionalization in the United States and provide a roadmap and novel discussion of regionalized care integration for sepsis care.
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Affiliation(s)
| | - Nicholas M. Mohr
- Departments of Emergency Medicine, Anesthesia‐Critical Care Medicine, and EpidemiologyUniversity of Iowa–Carver College of MedicineIowa CityIowaUSA
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Preserving Equity and Quality in the Push to Increase Access to Critical Care Services. Crit Care Med 2022; 50:150-153. [PMID: 34914645 DOI: 10.1097/ccm.0000000000005161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Regionalization of Critical Care in the United States: Current State and Proposed Framework From the Academic Leaders in Critical Care Medicine Task Force of the Society of the Critical Care Medicine. Crit Care Med 2021; 50:37-49. [PMID: 34259453 DOI: 10.1097/ccm.0000000000005147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The Society of Critical Care Medicine convened its Academic Leaders in Critical Care Medicine taskforce on February 22, 2016, during the 45th Critical Care Congress to develop a series of consensus papers with toolkits for advancing critical care organizations in North America. The goal of this article is to propose a framework based on the expert opinions of critical care organization leaders and their responses to a survey, for current and future critical care organizations, and their leadership in the health system to design and implement successful regionalization for critical care in their regions. DATA SOURCES AND STUDY SELECTION Members of the workgroup convened monthly via teleconference with the following objectives: to 1) develop and analyze a regionalization survey tool for 23 identified critical care organizations in the United States, 2) assemble relevant medical literature accessed using Medline search, 3) use a consensus of expert opinions to propose the framework, and 4) create groups to write the subsections and assemble the final product. DATA EXTRACTION AND SYNTHESIS The most prevalent challenges for regionalization in critical care organizations remain a lack of a strong central authority to regulate and manage the system as well as a lack of necessary infrastructure, as described more than a decade ago. We provide a framework and outline a nontechnical approach that the health system and their critical care medicine leadership can adopt after considering their own structure, complexity, business operations, culture, and the relationships among their individual hospitals. Transforming the current state of regionalization into a coordinated, accountable system requires a critical assessment of administrative and clinical challenges and barriers. Systems thinking, business planning and control, and essential infrastructure development are critical for assisting critical care organizations. CONCLUSIONS Under the value-based paradigm, the goals are operational efficiency and patient outcomes. Health systems that can align strategy and operations to assist the referral hospitals with implementing regionalization will be better positioned to regionalize critical care effectively.
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Montoy JCC, Shen YC, Brindis RG, Krumholz HM, Hsia RY. Impact of ST-Segment-Elevation Myocardial Infarction Regionalization Programs on the Treatment and Outcomes of Patients Diagnosed With Non-ST-Segment-Elevation Myocardial Infarction. J Am Heart Assoc 2021; 10:e016932. [PMID: 33470136 PMCID: PMC7955417 DOI: 10.1161/jaha.120.016932] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Many communities have implemented systems of regionalized care to improve access to timely care for patients with ST-segment-elevation myocardial infarction. However, patients who are ultimately diagnosed with non-ST-segment-elevation myocardial infarctions (NSTEMIs) may also be affected, and the impact of regionalization programs on NSTEMI treatment and outcomes is unknown. We set out to determine the effects of ST-segment-elevation myocardial infarction regionalization schemes on treatment and outcomes of patients diagnosed with NSTEMIs. Methods and Results The cohort included all patients receiving care in emergency departments diagnosed with an NSTEMI at all nonfederal hospitals in California from January 1, 2005 to September 30, 2015. Data were analyzed using a difference-in-differences approach. The main outcomes were 1-year mortality and angiography within 3 days of the index admission. A total of 293 589 patients with NSTEMIs received care in regionalized and nonregionalized communities. Over the study period, rates of early angiography increased by 0.5 and mortality decreased by 0.9 percentage points per year among the overall population (95% CI, 0.4-0.6 and -1.0 to -0.8, respectively). Regionalization was not associated with early angiography (-0.5%; 95% CI, -1.1 to 0.1) or death (0.2%; 95% CI, -0.3 to 0.8). Conclusions ST-segment-elevation myocardial infarction regionalization programs were not statistically associated with changes in guideline-recommended early angiography or changes in risk of death for patients with NSTEMI. Increases in the proportion of patients with NSTEMI who underwent guideline-directed angiography and decreases in risk of mortality were accounted for by secular trends unrelated to regionalization policies.
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Affiliation(s)
| | - Yu-Chu Shen
- Graduate School of Defense Management, Naval Postgraduate School Monterey CA.,National Bureau of Economic Research Cambridge MA
| | - Ralph G Brindis
- Department of Medicine University of California, San Francisco CA.,Philip R. Lee Institute for Health Policy Studies University of California, San Francisco CA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.,Department of Health Policy and Management Yale School of Public Health New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
| | - Renee Y Hsia
- Department of Emergency Medicine University of California, San Francisco CA.,Philip R. Lee Institute for Health Policy Studies University of California, San Francisco CA
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Hsia RY, Krumholz H, Shen YC. Evaluation of STEMI Regionalization on Access, Treatment, and Outcomes Among Adults Living in Nonminority and Minority Communities. JAMA Netw Open 2020; 3:e2025874. [PMID: 33196809 PMCID: PMC7670311 DOI: 10.1001/jamanetworkopen.2020.25874] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Cardiac care regionalization, specifically for patients with ST-segment elevation myocardial infarction (STEMI), has been touted as a potential mechanism to reduce systematic disparities by protocolizing the treatment of these conditions. However, it is unknown whether such regionalization arrangements have widened or narrowed disparities in access, treatment, and outcomes for minority communities. OBJECTIVE To determine the extent to which disparities in access, treatment, and outcomes have changed for patients with STEMI living in zip codes that are in the top tertile of the Black or Hispanic population compared with patients in nonminority zip codes in regionalized vs nonregionalized counties. DESIGN, SETTING, AND PARTICIPANTS This cohort study used a quasi-experimental approach exploiting the different timing of regionalization across California. Nonpublic inpatient data for all patients with STEMI from January 1, 2006, to October 31, 2015, were analyzed using a difference-in-difference-in-differences estimation approach. EXPOSURE Exposure to the intervention was defined as on and after the year a patient's county was exposed to regionalization. MAIN OUTCOMES AND MEASURES Access to percutaneous coronary intervention (PCI)-capable hospital, receipt of PCI on the same day and at any time during the hospitalization, and time-specific all-cause mortality. RESULTS This study included 139 494 patients with STEMI; 61.9% of patients were non-Hispanic White, 5.6% Black, 17.8% Hispanic, and 9.0% Asian; 32.8% were women. Access to PCI-capable hospitals improved by 6.3 percentage points (95% CI, 5.5 to 7.1 percentage points; P < .001) when patients in nonminority communities were exposed to regionalization. Patients in minority communities experienced a 1.8-percentage point smaller improvement in access (95% CI, -2.8 to -0.8 percentage points; P < .001), or 28.9% smaller, compared with those in nonminority communities when both were exposed to regionalization. Regionalization was associated with an improvement to same-day PCI and in-hospital PCI by 5.1 percentage points (95% CI, 4.2 to 6.1 percentage points; P < .001) and 5.0 percentage points (95% CI, 4.2 to 5.9 percentage points; P < .001), respectively, for patients in nonminority communities. Patients in minority communities experienced only 33.3% and 15.1% of that benefit. Only White patients in nonminority communities experienced mortality improvement from regionalization. CONCLUSIONS AND RELEVANCE Although regionalization was associated with improved access to PCI hospitals and receipt of PCI treatment, patients in minority communities derived significantly smaller improvement relative to those in nonminority communities.
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Affiliation(s)
- Renee Y. Hsia
- Department of Emergency Medicine, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Harlan Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
| | - Yu-Chu Shen
- Graduate School of Defense Management, Naval Postgraduate School, Monterey, California
- National Bureau of Economic Research, Cambridge, Massachusetts
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Schwartz AM, Staley CA, Wilson JM, Reisman WM, Schenker ML. High acuity polytrauma centers in orthopaedic trauma: Decreasing patient mortality with effective resource utilization. Injury 2020; 51:2235-2240. [PMID: 32620327 DOI: 10.1016/j.injury.2020.06.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 06/12/2020] [Accepted: 06/24/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is a select number of massive-volume, high-acuity trauma centers (HACs) in the United States. Expertise in polytrauma care has been associated with improved mortality in general surgery trauma, though has not been investigated in orthopaedic trauma. With complex polytrauma proficiency comes the inherent risk of intensive care, complications, and prolonged inpatient stays, without a commensurate increase in allocated resources. The purpose of this study was to compare mortality, complications, and length of stay in polytraumatized orthopaedic patients treated at HACs vs. low-acuity trauma centers (LACs). METHODS The National Trauma Data Bank was queried for orthopaedic injuries with injury severity score (ISS)>15 and mortality, complications, hospital length of stay, ICU length of stay, ventilation duration, and demographics. Hospitals where at least 13% (median percentage of patients with ISS > 15 admitted to all hospitals) of total admissions had an ISS>15 were classified as HAC; all others were LACs. RESULTS HACs admitted 86.8% of 28,314 patients with ISS>15. On univariate analysis, patients at HACs have 16% decreased odds of in-hospital mortality vs. LACs (p=0.005); the effect increased to 27% (p=0.002) on multivariate analysis. Patients at HACs have 63% greater odds of ICU admission (p<0.001), 48% higher odds of ventilatory support (p=<0.001), 38% increased odds of unplanned reoperation (p=0.007), and 37% increased odds of medical complications (p<0.001). On multivariate analysis, secondary outcome measures showed no significant difference between HACs and LACs. Patients at HACs had 2.8 days longer length-of-stay (p<0.001). CONCLUSION Severely injured orthopaedic trauma patients have decreased mortality at HACs, despite having a higher average ISS and a higher prevalence of obesity and active smoking. While there is a higher incidence of ICU admission, mechanical ventilation, complications, and unplanned reoperation on univariate analysis, correction for ISS and patient factors enhances the effect of HACs on mortality, but removes the effect on secondary measures. Thus, HACs are life-saving institutions for polytraumatized orthopaedic patients, and the known resource demand of these hospitals is supported by their favorable outcome profile. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Andrew M Schwartz
- Emory University School of Medicine. Atlanta, GA.100 Woodruff Circle, Atlanta, GA 30322, USA.
| | - Christopher A Staley
- Emory University School of Medicine. Atlanta, GA.100 Woodruff Circle, Atlanta, GA 30322, USA.
| | - Jacob M Wilson
- Emory University School of Medicine. Atlanta, GA.100 Woodruff Circle, Atlanta, GA 30322, USA.
| | - William M Reisman
- Emory University School of Medicine. Atlanta, GA.100 Woodruff Circle, Atlanta, GA 30322, USA; Grady Memorial Hospital. Atlanta, GA. 49 Jesse Hill Drive, Atlanta, GA 30303, USA.
| | - Mara L Schenker
- Emory University School of Medicine. Atlanta, GA.100 Woodruff Circle, Atlanta, GA 30322, USA; Grady Memorial Hospital. Atlanta, GA. 49 Jesse Hill Drive, Atlanta, GA 30303, USA.
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Predicted effect of regionalised delivery care on neonatal mortality, utilisation, financial risk, and patient utility in Malawi: an agent-based modelling analysis. LANCET GLOBAL HEALTH 2020; 7:e932-e939. [PMID: 31200892 PMCID: PMC6581692 DOI: 10.1016/s2214-109x(19)30170-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 02/27/2019] [Accepted: 03/21/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Health-care regionalisation, in which selected services are concentrated in higher-level facilities, has successfully improved the quality of complex medical care. However, the effectiveness of this strategy in routine maternal care is unknown. Malawi has established a national goal of halving its neonatal mortality by 2030. In this study, we aimed to assess the effect of obstetric service regionalisation in pregnant women and their newborn babies in Malawi. METHODS In this analysis, we assessed regionalisation through the use of an agent-based simulation model. We used a previously estimated utilisation function, incorporating both patient-specific and health-facility-specific characteristics, to inform patient choice. The model was validated against known utilisation patterns in Malawi. Four regionalisation scenarios were compared with the status quo: scenario 1 restricted deliveries to facilities currently capable of providing caesarean sections; scenario 2 had the same restrictions as scenario 1, but with selected facilities upgraded to provide caesarean sections; scenario 3 restricted delivery to facilities that provided five or more basic emergency obstetric and neonatal care services in the preceding 3 months; and scenario 4 had the same restrictions as scenario 3, but with selected facilities upgraded to provide at least five basic emergency obstetric and neonatal care services. We assessed neonatal mortality, utilisation, travel distance, median out-of-pocket expenditure, and proportion of women facing catastrophic expenditure. The effects of upgrading the obstetric readiness of all facilities, of removing all user fees, and of upgrading without restriction were considered in scenario analyses. Heterogeneity and parameter uncertainty were incorporated to create 95% posterior credible intervals (PCIs). FINDINGS Scenarios restricting women to give birth in facilities with caesarean section capabilities reduced neonatal mortality by 11·4 deaths per 1000 livebirths (scenario 1; 95% PCI 9·8-13·1) and 11·6 deaths per 1000 livebirths (scenario 2; 10·2-13·1), whereas scenarios restricting women to facilities that provided five or more basic emergency obstetric and neonatal care services did not affect neonatal mortality. Similarly, the caesarean section rate in Malawi, which is 4·6% under the status quo, was predicted to rise significantly in scenario 1 (14·7%, 95% PCI 14·5-14·9; p<0·0001) and scenario 2 (10·4%, 10·2-10·6; p<0·0001), but not in scenarios 3 and 4. Women were required to travel longer distances in scenario 1 (increase of 7·2 km, 95% PCI 4·5-9·9) and in scenario 2 (4·4 km, 1·5-7·2) than in the status quo (p<0·0001). Out-of-pocket costs tripled (p<0·0001; status quo vs scenario 1 and scenario 2), and the risk of catastrophic expenditure significantly increased from a baseline of 6·4% (95% PCI 6·1-6·6) to 14·7% (14·5-14·9) in scenario 1 and 11·3% (11·0-11·5) in scenario 2. This increase was especially pronounced among the poor (p<0·0001; status quo vs scenario 1 and scenario 2). INTERPRETATION Policies restricting women to give birth in facilities with caesarean section capabilities is likely to result in significant decreases in neonatal mortality and might allow Malawi to meet its goal of halving its neonatal mortality by 2030. However, this improvement comes at the cost of increased distances to care and worsening financial risks among women. FUNDING Bill & Melinda Gates Foundation, Damon Runyon Cancer Research Foundation.
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Craig LE, Middleton S, Hamilton H, Cudlip F, Swatzell V, Alexandrov AV, Lightbody E, Watkins DC, Philip S, Cadilhac DA, McInnes E, Dale S, Alexandrov AW. Does the Addition of Non-Approved Inclusion and Exclusion Criteria for rtPA Impact Treatment Rates? Findings in Australia, the UK, and the USA. INTERVENTIONAL NEUROLOGY 2020; 8:1-12. [PMID: 32231690 PMCID: PMC7098288 DOI: 10.1159/000493020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 08/16/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Strict criteria for recombinant tissue plasminogen activator (rtPA) eligibility are stipulated on licences for use in ischaemic stroke; however, practitioners may also add non-standard rtPA criteria. We examined eligibility criteria variation in 3 English-speaking countries including use of non-standard criteria, in relation to rtPA treatment rates. METHODS Surveys were mailed to 566 eligible hospitals in Australia (AUS), the UK, and the USA. Criteria were pre-classified as standard (approved indication and contraindications) or non-standard (approved warning or researcher "decoy"). Percentage for criterion selection was calculated/compared; linear regression was used to assess the association between use of non-standard criteria and rtPA treatment rates, and to identify factors associated with addition of non-standard criteria. RESULTS Response rates were 74% AUS, 65% UK, and 68% USA; mean rtPA treatment rates were 8.7% AUS, 12.7% UK, and 8.7% USA. Median percentage of non-standard inclusions was 33% (all 3 countries) and included National Institutes of Health Stroke Scale (NIHSS) scores > 4, computed tomography (CT) angiography documented occlusion, and favourable CT perfusion. Median percentage of non-standard exclusions was 25% AUS, 28% UK, and 60% USA, and included depressed consciousness, NIHSS > 25, and use of antihypertensive infusions. No AUS or UK sites selected 100% of standard exclusions. CONCLUSIONS Non-standard criteria for rtPA eligibility were evident in all three countries and could, in part, explain comparably low use of rtPA. Differences in the use of standard criteria may signify practitioner intolerance for those derived from original efficacy studies that are no longer relevant.
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Affiliation(s)
- Louise E Craig
- Nursing Research Institute, St Vincent's Health AUS (Sydney) and Australian Catholic University, Sydney, New South Wales, Australia
- Centre for Research in Evidence-Based Practice (CREBP), Bond University, Robina, Queensland, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health AUS (Sydney) and Australian Catholic University, Sydney, New South Wales, Australia
| | - Helen Hamilton
- Nursing Research Institute, St Vincent's Health AUS (Sydney) and Australian Catholic University, Sydney, New South Wales, Australia
| | - Fern Cudlip
- Stroke Team, Good Samaritan Comprehensive Stroke Center, San Jose, California, USA
| | - Victoria Swatzell
- Mobile Stroke Unit, University of Tennessee Health Science Center at Memphis, Memphis, Tennessee, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center at Memphis, Memphis, Tennessee, USA
| | - Elizabeth Lightbody
- College of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom
| | - Dame Caroline Watkins
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom
| | - Sheeba Philip
- East Lancashire Hospitals NHS Trust, Blackburn, United Kingdom
| | - Dominique A Cadilhac
- Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health AUS (Sydney) and Australian Catholic University, Sydney, New South Wales, Australia
| | - Simeon Dale
- Nursing Research Institute, St Vincent's Health AUS (Sydney) and Australian Catholic University, Sydney, New South Wales, Australia
| | - Anne W Alexandrov
- Mobile Stroke Unit, University of Tennessee Health Science Center at Memphis, Memphis, Tennessee, USA
- College of Medicine, Department of Neurology & College of Nursing, University of Tennessee Health Science Center at Memphis, Memphis, Tennessee, USA
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Time Delays in Acute Myocardial Infarction – the Gender Perspective. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2018. [DOI: 10.2478/jce-2018-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Rhudy JP, Bakitas MA, Hyrkäs K, Jablonski-Jaudon RA, Pryor ER, Wang HE, Alexandrov AW. Effectiveness of regionalized systems for stroke and myocardial infarction. Brain Behav 2015; 5:e00398. [PMID: 26516616 PMCID: PMC4614047 DOI: 10.1002/brb3.398] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 07/18/2015] [Accepted: 08/16/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Acute ischemic stroke (AIS) and ST-segment elevation myocardial infarction (STEMI) are ischemic emergencies. Guidelines recommend care delivery within formally regionalized systems of care at designated centers, with bypass of nearby centers of lesser or no designation. We review the evidence of the effectiveness of regionalized systems in AIS and STEMI. METHODS Literature was searched using terms corresponding to designation of AIS and STEMI systems and from 2010 to the present. Inclusion criteria included report of an outcome on any dependent variable mentioned in the rationale for regionalization in the guidelines and an independent variable comparing care to a non- or pre-regionalized system. Designation was defined in the AIS case as certification by the Joint Commission as either a primary (PSC) or comprehensive (CSC) stroke center. In the STEMI case, the search was conducted linking "regionalization" and "myocardial infarction" or citation as a model system by any American Heart Association statement. RESULTS For AIS, 17 publications met these criteria and were selected for review. In the STEMI case, four publications met these criteria; the search was therefore expanded by relaxing the criteria to include any historical or anecdotal comparison to a pre- or nonregionalized state. The final yield was nine papers from six systems. CONCLUSION Although regionalized care results in enhanced process and reduced unadjusted rates of disparity in access and adverse outcomes, these differences tend to become nonsignificant when adjusted for delayed presentation and hospital arrival by means other than emergency medical services. The benefits of regionalized care occur along with a temporal trend of improvement due to uptake of quality initiatives and guideline recommendations by all systems regardless of designation. Further research is justified with a randomized registry or cluster randomized design to support or refute recommendations that regionalization should be the standard of care.
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Affiliation(s)
- James P Rhudy
- School of Nursing University of Alabama at Birmingham Alabama
| | - Marie A Bakitas
- School of Nursing University of Alabama at Birmingham Alabama
| | - Kristiina Hyrkäs
- Center for Nursing Research and Quality Outcomes Maine Medical Center Birmingham Alabama
| | | | - Erica R Pryor
- School of Nursing University of Alabama at Birmingham Alabama
| | - Henry E Wang
- Department of Emergency Medicine University of Alabama at Birmingham Birmingham Alabama
| | - Anne W Alexandrov
- College of Nursing University of Tennessee Health Sciences Center Memphis Tennessee
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