Advances in the Stroke System of Care

Adoption and Use of Telemedicine and Digital Health Services Among Older Adults in Light of the COVID-19 Pandemic: Repeated Cross-Sectional Analysis

BACKGROUND

As the population ages and the prevalence of long-term diseases rises, the use of telecare is becoming increasingly frequent to aid older people.

OBJECTIVE

This study aims to explore the use and adoption of 3 types of telehealth services among the older population in Israel before, during, and after the COVID-19 pandemic.

METHODS

We explored the use characteristics of older adults (aged ≥65 years) belonging to Clalit Health Services in several aspects in the use of 3 types of telehealth services: the use of digital services for administrative tasks; the use of synchronous working-hours telehealth visits with the patient's personal physician during clinic business hours; and the use of after-hours consultations during evenings, nights, and weekends when the clinics are closed. The data were collected and analyzed throughout 3 distinct periods in Israel: before the COVID-19 pandemic, during the onset of the COVID-19 pandemic, and following the COVID-19 peak.

RESULTS

Data of 618,850 patients who met the inclusion criteria were extracted. Telehealth services used for administrative purposes were the most popular. The most intriguing finding was that the older population significantly increased their use of all types of telehealth services during the COVID-19 pandemic, and in most types, this use decreased after the COVID-19 peak, but to a level that was higher than the baseline level before the COVID-19 pandemic. Before the COVID-19 pandemic, 23.1% (142,936/618,850) of the study population used working-hours telehealth visits, and 2.2% (13,837/618,850) used after-hours consultations at least once. The percentage of use for these services increased during the COVID-19 pandemic to 59.2% (366,566/618,850) and 5% (30,777/618,850) and then decreased during the third period to 39.5% (244,572/618,850) and 2.4% (14,584/618,850), respectively (P<.001). Multiple patient variables have been found to be associated with the use of the different telehealth services in each period.

CONCLUSIONS

Despite the limitations and obstacles, the older population uses telehealth services and can increase their use when they are needed. These people can learn how to use digital health services effectively, and they should be given the opportunity to do so by creating suitable and straightforward telehealth solutions tailored to this population and enhancing their usability.

Comprehensive Stroke Center Certification Series: Setting the Vision

The road to Comprehensive Stroke Center (CSC) certification is challenging and requires full integration of neurological, neurosurgical, neurointerventional, and neurocritical care and rehabilitation services across the entire continuum of care. To successfully achieve this level of certification, centers must coordinate significant resources and services into an organized program. This paper is the first in a three-part series outlining common pitfalls facing many organizations during their journey to initial CSC certification and re-certification and offers a roadmap and pearls for success on this journey. Setting the vision for certification is a key first step in the certification process. This includes fully understanding the certification standards, requirements, and supporting documents. Program leadership must then conduct a thorough gap analysis and build a business plan to support the program as it transitions to a CSC. These key steps should inform the timeline for certification application.

Streamlined triage and transfer protocols improve door-to-puncture time for endovascular thrombectomy in acute ischemic stroke

OBJECTIVE

Shorter time from symptom onset to treatment is associated with improved outcomes in patients who undergo mechanical thrombectomy for treatment of acute ischemic stroke due to emergent large vessel occlusion. In this work, we detail pre-thrombectomy process improvements in a multi-hospital network and report the effect on door-to-puncture time in patients undergoing mechanical thrombectomy.

PATIENTS AND METHODS

A streamlined workflow was adopted to minimize door-to-puncture time. Key features of this workflow included rapid and concurrent clinical and radiological evaluation with point-of-care image interpretation, pre-transfer IV thrombolysis and CTA for transferred patients, immediate transport to the angiography suite potentially before neurointerventional radiology team arrival, and minimalist room setup. Door-to-puncture time was measured prospectively and analyzed retrospectively for 78 consecutive patients treated between January 2015 and December 2015. Statistical analysis was performed using the F-test on individual coefficients of a linear regression model.

RESULTS

From quarter 1 to quarter 4, the number of thrombectomies performed increased by 173% (11 patients to 30 patients, p = 0.002), and there was a significant increase in the proportion of transferred patients that underwent pre-transfer CTA (p = 0.04). During this interval, overall median door-to-puncture time decreased by 74% (147 min to 39 min, p < 0.001); this decrease was greatest in transferred patients with pre-transfer CTA (81% decrease, 129 min to 25 min, p < 0.001) and smallest in patients presenting directly to the emergency department (52% decrease, 167 min to 87 min, p < 0.001).

CONCLUSION

Simple workflow improvements to streamline in-hospital triage and perform critical workup at transferring hospitals can produce reductions in door-to-puncture time.

A Retrospective Study Investigating: Factors associated with mode of arrival and emergency department management for patients with acute stroke

BACKGROUND

Presentation by ambulance to the emergency department is critical for stroke patients to receive time dependent treatments. However, little is known of the factors that influence presentation by ambulance.

METHODS

Retrospective analysis of all patients with an emergency department medical diagnosis of stroke who presented to one of three Victorian emergency departments over a three-year period (2011-2013). A multivariable model was used to investigate demographic characteristics (including triage assessment category, triage identified as stroke, time to CT, and time to diagnosis within the emergency department) as predictors of arrival by ambulance.

RESULTS

3548 stroke patients were identified; mean age was 70 years, 53% were males, and 92% had an ischemic stroke. Arrival by ambulance occurred in 71% (n=2509) with arrival by private transport accounting for 29% (n=1039) of patients. Factors significantly associated with arrival by ambulance were older age (p=<0.001), being born in Australia (p=<0.001), and speaking English in the home (p=0.003). Arrival by ambulance was independently associated with rapid stroke care in the emergency department, arrival within 2h from symptom onset, attending an advanced stroke service (access to thrombolysis), triaged for stroke, medical assessment within 25min and referral for CT within 45min.

CONCLUSION

In this Australian multicenter study, it was identified that patients who arrived by ambulance received faster acute stroke care within the emergency department. Public health education which targets patients who are younger and from a non-English speaking background is needed as these demographics were not associated with timely arrival by ambulance to the emergency department.

Community-based stroke system of care improves patient outcomes in Chinese rural areas

BACKGROUND

Building effective and efficient stroke care systems is a key step in improving prevention, treatment and rehabilitation of stroke. The aim of this study was to evaluate the effectiveness of this stroke system of care on stroke management during a 2-year follow-up.

METHODS

A stroke system of care was developed from November 2009 to November 2010 in three townships in Ganyu County. Additional three matched townships were invited as controls. We first investigated the stroke incidence of these populations. Subsequently, this stroke system of care and an educational campaign in the three intervention townships were implemented and the effectiveness of the system was evaluated in the next 2 years.

RESULTS

At postintervention, more patients in the intervention communities obtained stroke knowledge and then the proportion of patients with stroke who were admitted within 3 hours of onset markedly increased in 2012 (12.0% vs 8.1%, p=0.044) and in 2013 (15.2% vs 9.7%, p=0.008) compared with those in the control communities. In the intervention communities, this proportion of patients with acute ischaemic stroke who received thrombolytic treatment was markedly raised from 2.1% in 2012 to 3.0% in 2013. More importantly, the fatality rate substantially decreased in 2013 in the intervention communities compared with that in the control communities (6.1% vs 9.7%, p=0.032). Similarly, the disability rate significantly decreased in 2013 (45.3% vs 51.5%, p=0.045).

CONCLUSIONS

The community-based stroke system of care was effective and practical for optimising stroke treatments and improving patient outcomes.

TRIAL REGISTRATION NUMBER

ChiCTR-RCH-13003408, Post-results.

Hospital Discharge Disposition of Stroke Patients in Tennessee

OBJECTIVES

Early determination of hospital discharge disposition status at an acute admission is extremely important for stroke management and the eventual outcomes of patients with stroke. We investigated the hospital discharge disposition of patients with stroke residing in Tennessee and developed a predictive tool for clinical adoption. Our investigational aims were to evaluate the association of selected patient characteristics with hospital discharge disposition status and predict such status at the time of an acute stroke admission.

METHODS

We analyzed 127,581 records of patients with stroke hospitalized between 2010 and 2014. Logistic regression was used to generate odds ratios with 95% confidence intervals to examine the factor outcome association. An easy-to-use clinical predictive tool was built by using integer-based risk scores derived from coefficients of multivariable logistic regression.

RESULTS

Among the 127,581 records of patients with stroke, 86,114 (67.5%) indicated home discharge and 41,467 (32.5%) corresponded to facility discharge. All considered patient characteristics had significant correlations with hospital discharge disposition status. Patients were at greater odds of being discharged to another facility if they were women; older; black; patients with a subarachnoid or intracerebral hemorrhage; those with the comorbidities of diabetes mellitus, heart disease, hypertension, chronic kidney disease, arrhythmia, or depression; those transferred from another hospital; or patients with Medicare as the primary payer. A predictive tool had a discriminatory capability with area under the curve estimates of 0.737 and 0.724 for derivation and validation cohorts, respectively.

CONCLUSIONS

Our investigation revealed that the hospital discharge disposition pattern of patients with stroke in Tennessee was associated with the key patient characteristics of selected demographics, clinical indicators, and insurance status. These analyses resulted in the development of an easy-to-use predictive tool for early determination of hospital discharge disposition status.