Einflussfaktoren auf die stationäre Liegezeit nach Schlaganfall in Deutschland

Effect of a physical and rehabilitation medicine doctor in a neurology department on the length of hospital stay for patients recovering from stroke

Background/Aims

Although in Israel a physical and rehabilitation medicine doctor is not an integral part of neurology department team, their attendance can have a positive effect on the management of patients recovering from stroke and their optimal transfer to rehabilitation setting. The aim of this study was to investigate if the presence of a physical and rehabilitation medicine doctor in a neurology department can influence the length of stay for patients recovering from stroke.

Methods

A retrospective comparative electronic data analysis of periods with and without a physical and rehabilitation medicine doctor was undertaken in an inpatient neurology department of an urban, periphery, academic medical centre.

Results

A total of 118 patients with stroke were included in the study; 32 were treated 3 months before the physical and rehabilitation medicine doctor worked on the ward, 43 during, and 43 after the physical and rehabilitation medicine doctor left the department. Statistical comparative analysis showed that length of stay was significantly reduced when there is a physical and rehabilitation medicine doctor present among the neurology ward physicians (18.06 days before intervention, 12.39 days during and 14.12 days after).

Conclusions

Having a physical and rehabilitation medicine doctor in the neurology department can shorten the length of stay in patients with stroke. Were larger studies to confirm these findings, the authors would recommend incorporating a physical and rehabilitation medicine doctor in neurology departments.

[Surgical closure of the left atrial appendage in patients with atrial fibrillation. Indications, techniques and results]

Cardiac embolisation in patients with atrial fibrillation accounts for the most serious complication of cerebral infarction. The left atrial appendage resembles the origin of these cardiac emboli in the majority of cases, although other anatomical areas of the left atrium might also be prerequisites for thrombus formation. Surgical closure of the left atrial appendage during an ablation therapy incorporates the theoretical possibility of reducing the rate of cardiac cerebral infarction. In order to achieve closure, different surgical strategies exist: either exclusion by over-sewing or snaring or excision by using scissors or a stapling device. All therapies incorporate pros and cons. One of the major complications and most feared side-effect is the recanalisation of a formerly closed left atrial appendage, especially in a thrombus filled left atrial appendage cavity. But also reopening of the formerly closed orificium and still existing remnants with communication to the left atrium might stand for an increased risk. Due to the good results of left atrial appendage excision, this surgical therapy at the moment presents the surgical gold standard, as this therapy is recommended in the updated ESC guidelines for the management of atrial fibrillation. If excision of the left atrial appendage will reduce the risk of cardiac embolisation needs to be examined in large prospective-randomized trials with a controlled systemic follow-up. So far, excision of the left atrial appendage as an alternative to oral anticoagulation, especially in patients with atrial fibrillation, is not recommended.

[Surgical atrial fibrillation ablation therapy and postoperative monitoring]

Atrial fibrillation represents the most common atrial arrhythmia seen in clinical practice. The surgical treatment of atrial fibrillation is recommended in symptomatic patients as well as in asymptomatic patients at low postoperative risk. As a "stand alone" procedure, surgical ablation therapy is indicated after failed catheter ablation therapy, which occurs increasingly due to the high number of catheter-based ablation techniques. In order to gain acceptance among patients as well as referring cardiologists, the surgical ablation procedure ought to be performed in a minimally invasive fashion and with a very high success rate. When applied in an interdisciplinary approach by cardiologists/electrophysiologists and cardiothoracic surgeons, both ablative techniques have the potential to treat atrial fibrillation effectively and in the long-term. In order to document the true heart rhythm after ablation therapy, intermittent "snapshot" ECG documentation ought to be avoided. Small leadless devices that can be implanted subcutaneously enable full heart rhythm disclosure with documentation of atrial arrhythmias. The modern technique of implantable loop recorders permits individualized treatment for each patient.

Age and gender variations in the management of ischaemic stroke in China

BACKGROUND

Stroke is a major health issue in China.

AIMS

We aimed to describe the management of patients admitted to hospitals in China with acute ischaemic stroke, and to determine whether there were any differences by age and gender.

METHODS

Using a multicentre prospective hospital register across all eight major economic (geographic) regions in China, data on the socioeconomic characteristics, medical history, clinical features, and in-hospital investigations, management, and outcomes were collected on consecutive patients with acute stroke due to cerebral ischaemia during a 5-month period in 2006.

RESULTS

Overall, traditional Chinese medicine and neuroprotectant use were remarkably high, with nearly 80% of patients receiving the former and >70% receiving the latter in hospital. Length of hospital stay was also long (median duration 16-days). Multivariate analyses revealed no clinically important differences in management between the genders. For the age-specific analyses, there were significant trends of decreasing use of thrombolysis (P=0·04), warfarin (P=0·01), corticosteroids (P=0·03), and lipid-lowering therapy (P=0·001); however, more assisted feeding (P=0·004) and rising rates of disability and in-hospital complications occurred with increasing age.

CONCLUSIONS

New information is provided regarding the current state of ischaemic stroke management in China. Notably, there is high use of traditional Chinese medicine and neuroprotectants and long lengths of hospital stay. Similar to many other countries, differences in stroke care and management by age and gender also exist to a small extent in China.

[Billing based on a case-based lump sum for stroke. Did this lead to discharge of patients in a worse clinical condition?]

BACKGROUND

It has been supposed that the introduction of a new inpatient reimbursement system starting in 2004 in Germany using the German diagnosis-related groups (G-DRG) may lead to false incentives with encouragement of premature hospital discharge of patients. Exploring a large database on stroke patients, we addressed the question whether length of stay (LOS) and discharge in more severe condition were associated with the introduction of the G-DRG. We further examined other factors with probable effect on LOS such as variations of patient characteristics and treatment during the observation period.

PATIENTS AND METHODS

All stroke patients treated in 2003-2006 in the German state of Hesse (6,100,000 inhabitants) were assessed with respect to stroke severity, symptoms on admission and discharge, LOS and stroke-related deficits on discharge. We compared LOS and outcome in 2003 (before introduction of the G-DRG) with 2004 when the G-DRG had recently been introduced and with 2006 when the G-DRG was already well established in the clinical routine. The effects of LOS and treatment year on outcome were assessed using a logistic regression model.

RESULTS

During the observation period, we evaluated 37,396 stroke patients. The length of stay was reduced significantly from 12.2 to 10.4 days (p<0.001). Both severity of stroke on admission and outcome on discharge decreased during the observation period. A multivariate analysis revealed a minor but significant association [odds ratio (OR): 1.020 per day of hospital treatment; 95% confidence interval (CI): 1.016-1.024] of LOS on outcome. Treatment in 2006 compared to 2003 led to good outcome with an OR of 1.378 (95% CI: 1.279-1.485). Subgroup analysis limited to patients with severe stroke revealed that LOS was significantly lower in 2006 compared to 2003 also in this patient subgroup; moreover, the proportion of patients discharged with severe outcome was lower in 2006 compared to 2003.

CONCLUSIONS

This study reveals a significant reduction of LOS during the years after introduction of the G-DRG. However, reduction of LOS was not associated with more severe outcome on discharge, possibly due to changes in stroke treatment implemented during the observational period. Our results do not support the conjecture that changes in the reimbursement system were associated with compromised patient care.

Factors that influence the stroke care team's effectiveness in reducing the length of hospital stay

BACKGROUND AND PURPOSE

The purpose of this study was to explore the effects of a quality improvement program for improving stroke care and the determinants of success at the team and hospital levels. Method- For 16 months, 23 multidisciplinary stroke service teams participated in a quality improvement collaborative designed to set up stroke services and reduce the length of hospital stay (LOHS). We monitored the LOHS and the discharge delay during the project and measured indicators of well organized stroke services at baseline and after the intervention. A multiple and multilevel regression model was used to relate the outcome variables to the team and hospital characteristics. National LOHS figures served as reference data.

RESULTS

Data regarding 4549 stroke patients were included in the analyses. The LOHS decreased significantly from 18.3 to 13.3 days. The mean LOHS varied substantially (9.2 to 20.9 days) after the intervention. Teams with higher team functioning scores showed lower LOHS scores and higher scores for the indicators of well organized stroke services. Team characteristics explain almost 40% of the variance in LOHS and 53% in the indicators of well organized stroke care.

CONCLUSIONS

Participation in a national quality improvement collaborative effected a significant decrease of the LOHS and a significant increase in the presence of key features of stroke services. Variation in ability to reduce the LOHS and increase key features of stroke services were related to team functioning. The data suggest that the composite of team functioning is pivotal in quality-of-care improvement and may need specific attention in any quality improvement program.

[Neurological Reha-Score. An instrument to measure outcome and expenditure of neurologic rehabilitation]

BACKGROUND

A new measurement instrument was developed to combine common scores with the parameter of effort for rehabilitation, the latter being a control instrument for medical professionals and rehabilitational health organisations.

METHODS

The Neurological Rehabilitation Score (NRS) contains 61 items (including the ten from the Barthel Index) resulting in scores of 0 (worst patient condition) to 600 (best). The items are grouped into seven categories: activities of daily life (13), mobility (8), communication and social skills (7), arm and hand function (7), orientation and cognition skills (10), strength and pain (8), and coping and miscellaneous (8). We investigated 8,139 patients and determined reliability (kappa statistic) and responsivity (standardised response means). In 100 consecutive patients, we also measured the Functional Independence Measure (FIM) and Scandinavian Stroke Scale (SSS) to address validity.

RESULTS

With an average kappa value of 0.86 (range 0.62-0.98), the NRS showed excellent inter-rater reliability. There was a good correlation between NRS, FIM, and SSS. Response was good at 0.84. The ceiling effect was also less than 1%, compared to 17% in the Barthel Index.

CONCLUSION

The NRS was shown to be effective for evaluation of outcome and expenditure in neurological rehabilitation.

Prolongierte Migräneaura vs. akuter ischämischer Insult

BACKGROUND

According to the "time is brain" concept, differential diagnosis of acute stroke and prolonged migrainous aura is of vital importance in this era of systemic thrombolysis for acute cerebral ischemia. We demonstrate the value of cerebral magnetic resonance imaging (cMRI) in acute situations by presenting two patients.

PATIENTS AND METHODS

Two patients were sent to our hospital for lysis treatment after the sudden appearance of global aphasia and slight right-sided hemiparesis. Further exploration was impossible due to the aphasia, and therefore we performed diffusion- and perfusion-weighted cMRI.

RESULTS

We excluded acute cerebral infarction by the aid of diffusion-weighted cMRI, however left-sided cerebral hypoperfusion was seen in both patients. After resolution of neurologic symptoms, unilateral headache occurred and both patients reported pre-existing migraine with aura.

CONCLUSION

Hypoperfusion of the malfunctioning brain region contralateral to the affected side of the body has been described on cMRI in only a few patients with prolonged migrainous aura. We conclude from our two cases that--provided rapid availability--cMRI can add important information for differential diagnosis, in particular when lysis therapy is a treatment option.

Long-term cost-effectiveness of clopidogrel in patients with acute coronary syndrome without ST-segment elevation in Germany

Patients with acute coronary syndrome without ST-segment elevation receiving clopidogrel in addition to acetylsalicylic acid (ASA) showed a 20% risk reduction in comparison to patients receiving ASA monotherapy (CURE trial). Economic models for assessing the impact on costs exist for several countries but not for Germany on a long-term basis. The objective of this model adaptation is to assess the long-term economic impact of clopidogrel taken in addition to ASA in Germany. A Markov model with six states [at risk, first year with stroke, following years with stroke, first year with new myocardial infarction (MI), following years with MI, and death] was adapted for Germany. Model outcome was life-years saved. Effects of 1-year treatment were calculated based on the CURE trial. Resource use for the different health states was based on published data, which included costs for drugs, outpatient care, hospitalization, rehabilitation and nursing. Risk data for MI and stroke were based on Swedish data and validated for the German adaptation. The model calculates lifetime costs and survival length. Costs were estimated from the payers' perspective. A series of one-way sensitivity analyses was conducted (follow-up costs, discount rates). The Markov analysis predicts a survival of 8.89years in the placebo treatment group and 9.02 years in the clopidogrel treatment group. The cumulated costs were euro 8,548 and euro 8,953, respectively. The incremental cost-effectiveness ratio (ICER) was euro 3,113 for each life-year saved. The model was robust regarding variations in key parameters in the sensitivity analysis, resulting in a range of ICER from euro 1,338 to euro 9,322. Our results are in line with the results for other healthcare systems. Adding clopidogrel to ASA for patients with acute coronary syndrome without ST-segment elevation generated an additional life-year saved at a comparably low value of euro 3,113. One-year treatment with clopidogrel is a cost-effective treatment option in patients with acute coronary syndrome from the perspective of a third-party payer in Germany.