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Yue J, Kazi S, Nguyen T, Chow CK. Comparing secondary prevention for patients with coronary heart disease and stroke attending Australian general practices: a cross-sectional study using nationwide electronic database. BMJ Qual Saf 2023:bmjqs-2022-015699. [PMID: 37487712 DOI: 10.1136/bmjqs-2022-015699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 05/11/2023] [Indexed: 07/26/2023]
Abstract
OBJECTIVES To compare secondary prevention care for patients with coronary heart disease (CHD) and stroke, exploring particularly the influences due to frequency and regularity of primary care visits. SETTING Secondary prevention for patients (≥18 years) in the National Prescription Service administrative electronic health record database collated from 458 Australian general practice sites across all states and territories. DESIGN Retrospective cross-sectional and panel study. Patient and care-level characteristics were compared for differing CHD/stroke diagnoses. Associations between the type of cardiovascular diagnosis and medication prescription as well as risk factor assessment were examined using multivariable logistic regression. PARTICIPANTS Patients with three or more general practice encounters within 2 years of their latest visit during 2016-2020. OUTCOME MEASURES Proportions and odds ratios (ORs) for (1) prescription of antihypertensives, antilipidaemics and antiplatelets and (2) assessment of blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) in patients with stroke only compared against those with CHD only and those with both conditions. RESULTS There were 111 892 patients with CHD only, 27 863 with stroke only and 9791 with both conditions. Relative to patients with CHD, patients with stroke were underprescribed antihypertensives (70.8% vs 82.8%), antilipidaemics (63.1% vs 78.7%) and antiplatelets (42.2% vs 45.7%). With sociodemographic factors, comorbidities and level of care considered as covariates, the odds of non-prescription of any recommended secondary prevention medications were higher in patients with stroke only (adjusted OR 1.37; 95% CI (1.31, 1.44)) compared with patients with CHD only. Patients with stroke only were also more likely to have neither BP nor LDL-C monitored (adjusted OR 1.26; 95% CI (1.18, 1.34)). Frequent and regular general practitioner encounters were independently associated with the prescription of secondary prevention medications (p<0.001). CONCLUSIONS Secondary prevention management is suboptimal in cardiovascular disease patients and worse post-stroke compared with post-CHD. More frequent and regular primary care encounters were associated with improved secondary prevention.
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Affiliation(s)
- Jason Yue
- Westmead Applied Research Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Samia Kazi
- Westmead Applied Research Centre, The University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Tu Nguyen
- Westmead Applied Research Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Clara Kayei Chow
- Westmead Applied Research Centre, The University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
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2
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Guo X, Li J, Yin X, Zhang Z, Zhong Q, Zhu F. Trends in deaths and disability-adjusted life-years of stroke attributable to high body-mass index worldwide, 1990-2019. Front Neurol 2023; 14:1211642. [PMID: 37456638 PMCID: PMC10348385 DOI: 10.3389/fneur.2023.1211642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/14/2023] [Indexed: 07/18/2023] Open
Abstract
Background High body mass index (HBMI) is an independent risk factor for stroke. Previous studies on the incremental burden of the rapid growth of stroke attributable to HBMI are incomplete and lag behind. We aim to assess the global burden of stroke attributable to HBMI based on a public database online. Materials and methods Study data were taken from the Global Burden of Disease, Injuries, and Risk Factors Study; deaths, the Disability-Adjusted Life-Years (DALYs), and their age-standardized rates were screened. The join point regression was used, wherein age-standardized rates were referred to as temporal trends in disease burden. Results Deaths from stroke attributable to HBMI worldwide were on the rise during 1990-2019, with an increase of 88.75%. Age-standardized DALYs were on the rise during 1990-2003 but declined during 2003-2013, with a turning point in 2013 and an increasing trend since then [the Annual Percentage Change (APC) = 0.30%, p < 0.05]. China, India, Indonesia, the Russian Federation, and the United States of America shared in sequence the rate of leading deaths and DALYs in 2019. The Socio-Demographic Index (SDI) was associated with an increasing trend in age-standardized deaths (R = -0.24, p < 0.001) and age-standardized DALYs (R = -0.22, p = 0.0018). Conclusion A range of indicators for the global burden of stroke attributable to HBMI have been on the rise for the past three decades. Tremendous efforts worldwide should be in place to control and treat stroke attributable to HBMI, especially in regions with high-middle and middle SDIs and among middle-aged and aged populations.
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Affiliation(s)
- Xiucai Guo
- Pharmaceutical Department and Central Laboratory, Guangzhou Twelfth People’s Hospital, Guangzhou, China
| | - Junxiao Li
- Pharmaceutical Department and Central Laboratory, Guangzhou Twelfth People’s Hospital, Guangzhou, China
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, China
| | - Xueyan Yin
- Pharmaceutical Department and Central Laboratory, Guangzhou Twelfth People’s Hospital, Guangzhou, China
| | - Ziping Zhang
- Pharmaceutical Department and Central Laboratory, Guangzhou Twelfth People’s Hospital, Guangzhou, China
| | - Qiongqiong Zhong
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, China
| | - Feng Zhu
- Pharmaceutical Department and Central Laboratory, Guangzhou Twelfth People’s Hospital, Guangzhou, China
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, China
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Johnson VL, Apps L, Kreit E, Mullis R, Mant J, Davies MJ. The feasibility of a self-management programme (My Life After Stroke; MLAS) for stroke survivors. Disabil Rehabil 2023; 45:235-243. [PMID: 35104171 DOI: 10.1080/09638288.2022.2029960] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE An evidence-based, theory-driven self-management programme "My Life After Stroke" (MLAS) was developed to address the longer-term unmet needs of stroke survivors.This study's aim was to test the acceptability and feasibility of MLAS as well as exploring what outcomes measures to include as part of further testing. METHODS Stroke registers in four GP practices across Leicester and Cambridge were screened, invite letters sent to eligible stroke survivors and written, informed consent gained. Questionnaires including Southampton Stroke Self-Management Questionnaire (SSSMQ) were completed before and after MLAS.Participants (and carers) attended MLAS (consisting of two individual appointments and four group sessions) over nine weeks, delivered by two trained facilitators. Feedback was gained from participants (after the final group session and final individual appointment) and facilitators. RESULTS Seventeen of 36 interested stroke survivors participated alongside seven associated carers. 15/17 completed the programme and attendance ranged from 13-17 per session. A positive change of 3.5 of the SSSMQ was observed. Positive feedback was gained from facilitators and 14/15 participants recommended MLAS (one did not respond). CONCLUSIONS MLAS was a feasible self-management programme for stroke survivors and warrants further testing as part of the Improving Primary Care After Stroke (IPCAS) cluster randomised controlled trial.IMPLICATIONS FOR REHABILITATIONMy Life After Stroke is a self-management programme developed for stroke survivors living in the community.MLAS is feasible and acceptable to stroke survivors.MLAS could be considered to help address the unmet educational and psychological needs of stroke survivors.
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Affiliation(s)
- V L Johnson
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - L Apps
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
- De Montfort University, Leicester, UK
| | - E Kreit
- University of Cambridge, Cambridge, UK
| | - R Mullis
- University of Cambridge, Cambridge, UK
| | - J Mant
- University of Cambridge, Cambridge, UK
| | - M J Davies
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Leicester Biomedical Research Centre, NIHR, Leicester, UK
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Boutros CF, Khazaal W, Taliani M, Said Sadier N, Salameh P, Hosseini H. One-year recurrence of stroke and death in Lebanese survivors of first-ever stroke: Time-to-Event analysis. Front Neurol 2022; 13:973200. [PMID: 36452174 PMCID: PMC9702576 DOI: 10.3389/fneur.2022.973200] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 10/14/2022] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND To date, despite the application of secondary prevention worldwide, first-ever stroke survivors remain at imminent risk of stroke recurrence and death in the short and long term. The present study aimed to assess the cumulative risk rates and identify baseline differences and stroke characteristics of Lebanese survivors. METHODS A prospective longitudinal study was conducted among survivors ≥18 years old who were followed-up for 15 months through a face-to-face interview. Kaplan-Meier method was used to calculate the cumulative rates of stroke mortality and recurrence. Cox-regression univariate and multivariable analyses were performed to identify the predictors of both outcomes. RESULTS Among 150 subjects (mean age 74 ± 12 years; 58.7% men vs. 44.3% women; 95.3% with ischemic stroke vs. 4.3% with intracerebral hemorrhage), high cumulative risk rates of stroke recurrence (25%) and death (21%) were highlighted, especially in the acute phase. Survival rates were lesser in patients with stroke recurrence compared to those without recurrence (Log rank test p < 0.001). Older age was the main predictor for both outcomes (p < 0.02). Large artery atherosclerosis was predominant in patients with stroke recurrence and death compared to small vessel occlusion (p < 0.02). Higher mental component summary scores of quality of life were inversely associated with stroke recurrence (p < 0.01). Lebanese survivors exhibited the highest percentages of depression and anxiety; elevated Hospital Anxiety and Depression Scale (HADS) scores were seen in those with stroke recurrence and those who died (≥80% with mean HADS scores ≥8). Lower Mini-Mental State Examination scores at the acute phase increased the risk of both outcomes by 10% (p < 0.03). Three out of 13 mortalities (23.1%) were presented with early epileptic seizures (p = 0.012). High educational level was the protective factor against stroke recurrence (p = 0.019). Administration of intravenous thrombolysis decreased the risk of both outcomes by 10% (p > 0.05). CONCLUSION Higher rates of stroke recurrence and death were observed in the first year following a stroke in Lebanon. Various factors were identified as significant determinants. Thus, health care providers and officials in Lebanon can use these findings to implement effective preventive strategies to best address the management of these factors to reduce the stroke burden and improve the short and long-term prognosis of stroke survivors.
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Affiliation(s)
- Celina F. Boutros
- Institut Mondor de Recherche Biomédicale (IMRB)-INSERM U955, Ecole Doctorale Science de la Vie et de la Santé, Université Paris-Est Créteil, Paris, France
| | - Walaa Khazaal
- Faculty of Medical Sciences, Neuroscience Research Center, Lebanese University, Hadath, Lebanon
| | - Maram Taliani
- Faculty of Medical Sciences, Neuroscience Research Center, Lebanese University, Hadath, Lebanon
| | - Najwane Said Sadier
- Faculty of Medical Sciences, Neuroscience Research Center, Lebanese University, Hadath, Lebanon
- College of Health Sciences, Abu Dhabi University, Abu Dhabi, United Arab Emirates
| | - Pascale Salameh
- Institut National de Santé Publique, Epidémiologie Clinique et Toxicologie (INSPECT-LB), Beirut, Lebanon
- Faculty of Pharmacy, Lebanese University, Hadath, Lebanon
- University of Nicosia Medical School, Nicosia, Cyprus
| | - Hassan Hosseini
- Institut Mondor de Recherche Biomédicale (IMRB)-INSERM U955, Ecole Doctorale Science de la Vie et de la Santé, Université Paris-Est Créteil, Paris, France
- Institut National de Santé Publique, Epidémiologie Clinique et Toxicologie (INSPECT-LB), Beirut, Lebanon
- Hôpital Henri Mondor, AP-HP, Créteil, France
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Attention to acute cerebrovascular disease in Guipúzcoa: description of the results of a reference hospital in a centralized care model. NEUROLOGÍA (ENGLISH EDITION) 2022; 37:355-361. [PMID: 35672122 DOI: 10.1016/j.nrleng.2019.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 03/03/2019] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION In the last 15 years, considerable improvements have been made in acute stroke care in Guipuzkoa, including the implementation of a centralised care model at Hospital Universitario Donostia (HUD), improved coordination between professionals, early detection campaigns, new treatments, a stroke unit, and specific rehabilitation. The aim of this work is to describe the results of a reference hospital (HUD) in a centralised care model. MATERIAL AND METHODS We performed a retrospective observational study of a sample of patients discharged between August and December 2015 from the HUD with a diagnosis of acute stroke (ICD-9-CM codes 430-436, except 433.10). We review patients' baseline characteristics, acute-phase care, and functional outcomes and mortality at discharge and at one year. RESULTS AND DISCUSSION We identified 536 patients, with a mean age of 73.6 years and a high comorbidity rate. Ischaemic stroke accounted for 64.8% of patients, followed by haemorrhagic stroke (20%) and transient ischaemic attack (14.8%). A total of 53% of patients were attended in < 6 hours, with code stroke being activated in 37.1%; 52.2% of patients were admitted to the stroke unit. Intravenous therapy was administered to 8.3% of patients with ischaemic stroke, and 9.5% underwent mechanical thrombectomy. Surgery was performed in 12.1% patients with haemorrhagic stroke. Rehabilitation was started at hospital in 56% of patients, and 39.6% continued with this treatment at discharge. Mortality was 13.8% at discharge and 25.9% at one year (ischaemic stroke, 25.3%; haemorrhagic stroke, 47.5%); these figures are lower than those previously reported in Guipuzkoa. At one year, 62.5% of patients had a Barthel Index score of 95-100, and 50% a modified Rankin Scale score of 0-2. CONCLUSIONS After the strategic changes implemented in acute stroke care in Guipuzkoa, including the centralisation of the acute stroke care model, mortality rates at discharge and at one year are lower in 2015 than the previously reported rates, with similar rates of independence. These results are consistent with those published by other Spanish and European centres.
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Fernández-Eulate G, Arocena P, Muñoz-Lopetegi A, Rodriguez-Antigüedad J, Campo-Caballero D, Equiza J, Andrés N, de Arce A, Gonzalez F, Diez N, Basterrechea J, Suquia E, de la Riva P, Martinez-Zabaleta M. Attention to acute cerebrovascular disease in Guipúzcoa: Description of the results of a reference hospital in a centralized care model. Neurologia 2022; 37:355-361. [PMID: 31053483 DOI: 10.1016/j.nrl.2019.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 02/22/2019] [Accepted: 03/03/2019] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION In the last 15 years, considerable improvements have been made in acute stroke care in Guipuzkoa, including the implementation of a centralised care model at Hospital Universitario Donostia (HUD), improved coordination between professionals, early detection campaigns, new treatments, a stroke unit, and specific rehabilitation. The aim of this work is to describe the results of a reference hospital (HUD) in a centralised care model. MATERIAL AND METHODS We performed a retrospective observational study of a sample of patients discharged between August and December 2015 from the HUD with a diagnosis of acute stroke (ICD-9-CM codes 430-436, except 433.10). We review patients' baseline characteristics, acute-phase care, and functional outcomes and mortality at discharge and at one year. RESULTS AND DISCUSSION We identified 536 patients, with a mean age of 73.6 years and a high comorbidity rate. Ischaemic stroke accounted for 64.8% of patients, followed by haemorrhagic stroke (20%) and transient ischaemic attack (14.8%). A total of 53% of patients were attended in <6 hours, with code stroke being activated in 37.1%; 52.2% of patients were admitted to the stroke unit. Intravenous therapy was administered to 8.3% of patients with ischaemic stroke, and 9.5% underwent mechanical thrombectomy. Surgery was performed in 12.1% patients with haemorrhagic stroke. Rehabilitation was started at hospital in 56% of patients, and 39.6% continued with this treatment at discharge. Mortality was 13.8% at discharge and 25.9% at one year (ischaemic stroke, 25.3%; haemorrhagic stroke, 47.5%); these figures are lower than those previously reported in Guipuzkoa. At one year, 62.5% of patients had a Barthel Index score of 95-100, and 50% a modified Rankin Scale score of 0-2. CONCLUSIONS After the strategic changes implemented in acute stroke care in Guipuzkoa, including the centralisation of the acute stroke care model, mortality rates at discharge and at one year are lower in 2015 than the previously reported rates, with similar rates of independence. These results are consistent with those published by other Spanish and European centres.
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Affiliation(s)
- G Fernández-Eulate
- Servicio de Neurología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España.
| | - P Arocena
- Facultad de Medicina, UPV, San Sebastián, Guipúzcoa, España
| | - A Muñoz-Lopetegi
- Servicio de Neurología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - J Rodriguez-Antigüedad
- Servicio de Neurología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - D Campo-Caballero
- Servicio de Neurología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - J Equiza
- Servicio de Neurología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - N Andrés
- Servicio de Neurología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - A de Arce
- Servicio de Neurología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - F Gonzalez
- Servicio de Neurología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - N Diez
- Servicio de Neurología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - J Basterrechea
- Servicio de Calidad, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - E Suquia
- Servicio de Calidad, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - P de la Riva
- Servicio de Neurología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - M Martinez-Zabaleta
- Servicio de Neurología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España; Facultad de Medicina, UPV, San Sebastián, Guipúzcoa, España
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Zhao M, Woodward M, Vaartjes I, Millett ERC, Klipstein-Grobusch K, Hyun K, Carcel C, Peters SAE. Sex Differences in Cardiovascular Medication Prescription in Primary Care: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2020; 9:e014742. [PMID: 32431190 PMCID: PMC7429003 DOI: 10.1161/jaha.119.014742] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Sex differences in the management of cardiovascular disease have been reported in secondary care. We conducted a systematic review with meta‐analysis of systematically investigated sex differences in cardiovascular medication prescription among patients at high risk or with established cardiovascular disease in primary care. Methods and Results PubMed and Embase were searched between 2000 and 2019 for observational studies reporting on the sex‐specific prevalence of aspirin, statins, and antihypertensive medication prescription, including beta blockers, calcium channel blockers, angiotensin‐converting enzyme inhibitors, and diuretics, in primary care. Random effects meta‐analysis was used to obtain pooled women‐to‐men prevalence ratios for each cardiovascular medication prescription. Metaregression models assessed the impact of age and year on the findings. A total of 43 studies were included, involving 2 264 600 participants (28% women) worldwide. Participants’ mean age ranged from 51 to 76 years. The pooled prevalence of cardiovascular medication prescription for women was 41% for aspirin, 60% for statins, and 68% for any antihypertensive medications. Corresponding rates for men were 56%, 63%, and 69% respectively. The pooled women‐to‐men prevalence ratios were 0.81 (95% CI, 0.72–0.92) for aspirin, 0.90 (95% CI, 0.85–0.95) for statins, and 1.01 (95% CI, 0.95–1.08) for any antihypertensive medications. Women were less likely to be prescribed angiotensin‐converting enzyme inhibitors (0.85; 95% CI, 0.81–0.89) but more likely with diuretics (1.27; 95% CI, 1.17–1.37). Mean age, mean age difference between the sexes, and year of study had no significant impact on findings. Conclusions Sex differences in the prescription of cardiovascular medication exist among patients at high risk or with established cardiovascular disease in primary care, with a lower prevalence of aspirin, statins, and angiotensin‐converting enzyme inhibitors prescription in women and a lower prevalence of diuretics prescription in men.
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Affiliation(s)
- Min Zhao
- Julius Global Health Julius Centre for Health Sciences and Primary Care Utrecht Medical Centre Utrecht University Utrecht Netherlands
| | - Mark Woodward
- The George Institute for Global Health University of Oxford United Kingdom.,The George Institute for Global Health University of New South Wales Sydney Australia.,Department of Epidemiology John Hopkins University Baltimore MD
| | - Ilonca Vaartjes
- Julius Global Health Julius Centre for Health Sciences and Primary Care Utrecht Medical Centre Utrecht University Utrecht Netherlands.,Global Geo and Health Data center Utrecht University Utrecht The Netherlands
| | | | - Kerstin Klipstein-Grobusch
- Julius Global Health Julius Centre for Health Sciences and Primary Care Utrecht Medical Centre Utrecht University Utrecht Netherlands.,Division of Epidemiology & Biostatistics School of Public Health Faculty of Health Sciences University of the Witwatersrand Johannesburg South Africa
| | - Karice Hyun
- Faculty of Medicine and Health Westmead Applied Research Centre University of Sydney Australia
| | - Cheryl Carcel
- The George Institute for Global Health University of New South Wales Sydney Australia.,Sydney School of Public Health Sydney Medical School University of Sydney New South Wales Australia
| | - Sanne A E Peters
- Julius Global Health Julius Centre for Health Sciences and Primary Care Utrecht Medical Centre Utrecht University Utrecht Netherlands.,The George Institute for Global Health University of Oxford United Kingdom
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Mullis R, Aquino MRJR, Dawson SN, Johnson V, Jowett S, Kreit E, Mant J. Improving Primary Care After Stroke (IPCAS) trial: protocol of a randomised controlled trial to evaluate a novel model of care for stroke survivors living in the community. BMJ Open 2019; 9:e030285. [PMID: 31427339 PMCID: PMC6701584 DOI: 10.1136/bmjopen-2019-030285] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Survival after stroke is improving, leading to increased demand on primary care and community services to meet the long-term care needs of people living with stroke. No formal primary care-based holistic model of care with clinical trial evidence exists to support stroke survivors living in the community, and stroke survivors report that many of their needs are not being met. We have developed a multifactorial primary care model to address these longer term needs. We aim to evaluate the clinical and cost-effectiveness of this new model of primary care for stroke survivors compared with standard care. METHODS AND ANALYSIS Improving Primary Care After Stroke (IPCAS) is a two-arm cluster-randomised controlled trial with general practice as the unit of randomisation. People on the stroke registers of general practices will be invited to participate. One arm will receive the IPCAS model of care including a structured review using a checklist; a self-management programme; enhanced communication pathways between primary care and specialist services; and direct point of contact for patients. The other arm will receive usual care. We aim to recruit 920 people with stroke registered with 46 general practices. The primary endpoint is two subscales (emotion and handicap) of the Stroke Impact Scale (SIS) as coprimary outcomes at 12 months (adjusted for baseline). Secondary outcomes include: SIS Short Form, EuroQol EQ-5D-5L, ICEpop CAPability measure for Adults, Southampton Stroke Self-management Questionnaire, Health Literacy Questionnaire and medication use. Cost-effectiveness of the new model will be determined in a within-trial economic evaluation. ETHICS AND DISSEMINATION Favourable ethical opinion was gained from Yorkshire and the Humber-Bradford Leeds NHS Research Ethics Committee. Approval to start was given by the Health Research Authority prior to recruitment of participants at any NHS site. Data will be presented at national and international conferences and published in peer-reviewed journals. Patient and public involvement helped develop the dissemination plan. TRIAL REGISTRATION NUMBER NCT03353519.
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Affiliation(s)
- Ricky Mullis
- General Practice and Primary Care Research Centre, University of Cambridge, Cambridge, UK
| | | | - Sarah Natalie Dawson
- MRC Biostatistics Unit, University of Cambridge Institute of Public Health, Cambridge, UK
| | - Vicki Johnson
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sue Jowett
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Elizabeth Kreit
- General Practice and Primary Care Research Centre, University of Cambridge, Cambridge, UK
| | - Jonathan Mant
- General Practice and Primary Care Research Centre, University of Cambridge, Cambridge, UK
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9
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Hansson P, Andersson Hagiwara M, Herlitz J, Brink P, Wireklint Sundström B. Prehospital assessment of suspected stroke and TIA: An observational study. Acta Neurol Scand 2019; 140:93-99. [PMID: 31009075 DOI: 10.1111/ane.13107] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/06/2019] [Accepted: 04/15/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Symptoms related to stroke diverge and may mimic many other conditions. AIMS To evaluate clinical findings among patients with a clinical suspicion of stroke in a prehospital setting and find independent predictors of a final diagnosis of stroke or transient ischemic attack (TIA). METHODS An observational multicenter study includes nine emergency hospitals in western Sweden. All patients transported to hospital by ambulance and in whom a suspicion of stroke was raised by the emergency medical service clinician before hospital admission during a four-month period were included. RESULTS Of 1081 patients, a diagnosis of stroke was confirmed at hospital in 680 patients (63%), while 69 (6%) were diagnosed as TIA and 332 patients (31%) received other final diagnoses. In a multiple logistic regression analysis, factors independently associated with a final diagnosis of stroke or TIA were increasing age, odds ratio (OR) per year: 1.02, P = 0.007, a history of myocardial infarction (OR: 1.77, P = 0.01), facial droop (OR: 2.81, P < 0.0001), arm weakness (OR: 2.61, P < 0.0001), speech disturbance (OR: 1.92, P < 0.0001), and high systolic blood pressure (OR: 1.50, P = 0.02), while low oxygen saturation was significantly associated with other diagnoses (OR: 0.41, P = 0.007). More than half of all patients among patients with both stroke/TIA and other final diagnoses died during the five-year follow-up. CONCLUSIONS Seven factors including the three symptoms included in the Face Arm Speech Test were significantly associated with a final diagnosis of stroke or TIA in a prehospital assessment of patients with a suspected stroke.
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Affiliation(s)
- Per‐Olof Hansson
- Sahlgrenska University Hospital and Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Magnus Andersson Hagiwara
- Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare University of Borås Borås Sweden
| | - Johan Herlitz
- Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare University of Borås Borås Sweden
| | - Peter Brink
- Intensive Care Unit NU‐Hospital Trollhättan Sweden
| | - Birgitta Wireklint Sundström
- Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare University of Borås Borås Sweden
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Turner GM, Mullis R, Lim L, Kreit L, Mant J. Using a checklist to facilitate management of long-term care needs after stroke: insights from focus groups and a feasibility study. BMC FAMILY PRACTICE 2019; 20:2. [PMID: 30609920 PMCID: PMC6318919 DOI: 10.1186/s12875-018-0894-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 12/20/2018] [Indexed: 12/02/2022]
Abstract
Background Long-term needs of stroke survivors are often not adequately addressed and many patients are dissatisfied with care post-discharge from hospital. Primary care could play an important role in identifying need in people with stroke. Aim We aimed to explore, refine and test the feasibility and acceptability of a post-stroke checklist for stroke reviews in primary care. Design and setting Focus groups (using a generic qualitative approach) and a single-centre feasibility study. Method Five focus groups were conducted; three with healthcare providers and two with stroke survivors/carers. The focus groups discussed acceptability of a checklist approach and the content of an existing checklist. The checklist was then modified and piloted in one general practice surgery in the East of England. Results The qualitative data found the concept of a checklist was considered valuable to standardise stroke reviews and prevent post-stroke problems being missed. Items were identified that were missing from the original checklist: return to work, fatigue, intimate relationships and social activities. Time constraints was the main concern from healthcare professionals and pre-completion of the checklist was suggested to address this. Thirteen stroke survivors were recruited to the feasibility study. The modified checklist was found to be feasible and acceptable to patients and primary care clinicians and resulted in agreed action plans. Conclusion The modified post-stroke checklist is a pragmatic and feasible approach to identify problems post-stroke and facilitate referral to appropriate support services. The checklist is a potentially valuable tool to structure stroke reviews using a patient-centred approach. Electronic supplementary material The online version of this article (10.1186/s12875-018-0894-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Grace M Turner
- Institute for Applied Health Research, University of Birmingham, Birmingham, Edgbaston, B15 2TT, UK.
| | - Ricky Mullis
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Worts' Causeway, Cambridge, CB1 8RN, UK
| | - Lisa Lim
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Worts' Causeway, Cambridge, CB1 8RN, UK
| | - Lizzie Kreit
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Worts' Causeway, Cambridge, CB1 8RN, UK
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Worts' Causeway, Cambridge, CB1 8RN, UK
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Hansson PO, Andersson Hagiwara M, Brink P, Herlitz J, Wireklint Sundström B. Prehospital identification of factors associated with death during one-year follow-up after acute stroke. Brain Behav 2018; 8:e00987. [PMID: 29770601 PMCID: PMC5991565 DOI: 10.1002/brb3.987] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 03/11/2018] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES In acute stroke, the risk of death and neurological sequelae are obvious threats. The aim of the study was to evaluate the association between various clinical factors identified by the emergency medical service (EMS) system before arriving at hospital and the risk of death during the subsequent year among patients with a confirmed stroke. MATERIAL AND METHODS All patients with a diagnosis of stroke as the primary diagnosis admitted to a hospital in western Sweden (1.6 million inhabitants) during a four-month period were included. There were no exclusion criteria. RESULTS In all, 1,028 patients with a confirmed diagnosis of stroke who used the EMS were included in the analyses. Among these patients, 360 (35%) died during the following year. Factors that were independently associated with an increased risk of death were as follows: (1) high age, per year OR 1.07; 95% CI 1.05-1.09; (2) a history of heart failure, OR 2.08; 95% CI 1.26-3.42; (3) an oxygen saturation of <90%, OR 8.05; 95% CI 3.33-22.64; and (4) a decreased level of consciousness, OR 2.19; 95% CI 1.61-3.03. CONCLUSIONS Among patients with a stroke, four factors identified before arrival at hospital were associated with a risk of death during the following year. They were reflected in the patients' age, previous clinical history, respiratory function, and the function of the central nervous system.
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Affiliation(s)
- Per-Olof Hansson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Andersson Hagiwara
- Faculty of Caring Science, Work Life and Social Welfare, Centre for Prehospital Research, University of Borås, Borås, Sweden
| | - Peter Brink
- Department of Health Sciences, Section for nursing - undergraduate level, University West, Trollhättan, Sweden
| | - Johan Herlitz
- Faculty of Caring Science, Work Life and Social Welfare, Centre for Prehospital Research, University of Borås, Borås, Sweden
| | - Birgitta Wireklint Sundström
- Faculty of Caring Science, Work Life and Social Welfare, Centre for Prehospital Research, University of Borås, Borås, Sweden
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Han KT, Kim SJ, Kim SJ, Yoo JW, Park EC. Do Reduced Copayments Affect Mortality after Surgery due to Stroke? An Interrupted Time Series Analysis of a National Cohort Sampled in 2003-2012. J Stroke Cerebrovasc Dis 2018; 27:1502-1510. [PMID: 29467088 DOI: 10.1016/j.jstrokecerebrovasdis.2017.12.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/18/2017] [Accepted: 12/24/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The South Korean government introduced a policy in 2 phases, in September 2005 and in January 2010, for reducing copayments for patients with critical diseases, including stroke, to prevent excessive medical expenditures and to ease economic barriers. Previous studies of the effect of this policy were focused primarily on cancer. Therefore, we investigated the relationship between this policy and 1-year mortality after surgery among patients with stroke. METHODS We used data from the Korean National Health Insurance sampling cohort (n = 2173 in 2003-2012) and performed an interrupted time series analysis. RESULTS Approximately 26% of the patients died within 1 year after surgery. The time trends after reducing copayments from 10% to 5% (phase 2) were inversely associated with risk of 1-year mortality (relative risk = .855, 95% confidence interval: .749-.975; P = .0196). In addition, this inverse association was greater in patients with low incomes, of older ages, and with higher Charlson comorbidity indices. CONCLUSIONS The introduction of a policy for reducing copayments to ease excessive cost burdens for patients with stroke was positively associated with a reduced risk of 1-year mortality after surgical treatment due to stroke. On the basis of our results, health policy makers should make an effort to identify vulnerable populations and to overcome economic barriers for providing effective alternatives to ensure patients receive optimal health care.
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Affiliation(s)
- Kyu-Tae Han
- Research and Analysis Team, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Seung Ju Kim
- Department of Nursing, College of Nursing, Eulji University, Seongnam, Republic of Korea
| | - Sun Jung Kim
- Department of Health Administration and Management, College of Medical Science, Soonchunhyang University, Asan, Republic of Korea
| | - Ji Won Yoo
- Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas, Nevada
| | - Eun-Cheol Park
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Pindus DM, Lim L, Rundell AV, Hobbs V, Aziz NA, Mullis R, Mant J. Primary care interventions and current service innovations in modifying long-term outcomes after stroke: a protocol for a scoping review. BMJ Open 2016; 6:e012840. [PMID: 27798023 PMCID: PMC5093648 DOI: 10.1136/bmjopen-2016-012840] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 08/25/2016] [Accepted: 09/20/2016] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Interventions delivered by primary and/or community care have the potential to reach the majority of stroke survivors and carers and offer ongoing support. However, an integrative account emerging from the reviews of interventions addressing specific long-term outcomes after stroke is lacking. The aims of the proposed scoping review are to provide an overview of: (1) primary care and community healthcare interventions by generalist healthcare professionals to stroke survivors and/or their informal carers to address long-term outcomes after stroke, (2) the scope and characteristics of interventions which were successful in addressing long-term outcomes, and (3) developments in current clinical practice. METHODS AND ANALYSIS Studies that focused on adult community dwelling stroke survivors and informal carers were included. Academic electronic databases will be searched to identify reviews of randomised controlled trials (RCTs) and controlled trials, trials from the past 5 years; reviews of observational studies. Practice exemplars from grey literature will be identified through advanced Google search. Reports, guidelines and other documents of major health organisations, clinical professional bodies, and stroke charities in the UK and internationally will be included. Two reviewers will independently screen titles, abstracts and full texts for inclusion of published literature. One reviewer will screen search results from the grey literature and identify relevant documents for inclusion. Data synthesis will include analysis of the number, type of studies, year and country of publication, a summary of intervention components/service or practice, outcomes addressed, main results (an indicator of effectiveness) and a description of included interventions. ETHICS AND DISSEMINATION The review will help identify components of care and care pathways for primary care services for stroke. By comparing the results with stroke survivors' and carers' needs identified in the literature, the review will highlight potential gaps in research and practice relevant to long-term care after stroke.
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Affiliation(s)
- Dominika M Pindus
- Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Lisa Lim
- Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - A Viona Rundell
- Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Victoria Hobbs
- Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Noorazah Abd Aziz
- Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
- Department of Family Medicine, National University of Malaysia, Bandar Tun Razak Cheras, Kuala Lumpur, Malaysia
| | - Ricky Mullis
- Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Jonathan Mant
- Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
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30-Year Trends in Stroke Rates and Outcome in Auckland, New Zealand (1981-2012): A Multi-Ethnic Population-Based Series of Studies. PLoS One 2015; 10:e0134609. [PMID: 26291829 PMCID: PMC4546383 DOI: 10.1371/journal.pone.0134609] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 07/12/2015] [Indexed: 11/29/2022] Open
Abstract
Background Insufficient data exist on population-based trends in morbidity and mortality to determine the success of prevention strategies and improvements in health care delivery in stroke. The aim of this study was to determine trends in incidence and outcome (1-year mortality, 28-day case-fatality) in relation to management and risk factors for stroke in the multi-ethnic population of Auckland, New Zealand (NZ) over 30-years. Methods Four stroke incidence population-based register studies were undertaken in adult residents (aged ≥15 years) of Auckland NZ in 1981–1982, 1991–1992, 2002–2003 and 2011–2012. All used standard World Health Organization (WHO) diagnostic criteria and multiple overlapping sources of case-ascertainment for hospitalised and non-hospitalised, fatal and non-fatal, new stroke events. Ethnicity was consistently self-identified into four major groups. Crude and age-adjusted (WHO world population standard) annual incidence and mortality with corresponding 95% confidence intervals (CI) were calculated per 100,000 people, assuming a Poisson distribution. Results 5400 new stroke patients were registered in four 12 month recruitment phases over the 30-year study period; 79% were NZ/European, 6% Māori, 8% Pacific people, and 7% were of Asian or other origin. Overall stroke incidence and 1-year mortality decreased by 23% (95% CI 5%-31%) and 62% (95% CI 36%-86%), respectively, from 1981 to 2012. Whilst stroke incidence and mortality declined across all groups in NZ from 1991, Māori and Pacific groups had the slowest rate of decline and continue to experience stroke at a significantly younger age (mean ages 60 and 62 years, respectively) compared with NZ/Europeans (mean age 75 years). There was also a decline in 28-day stroke case fatality (overall by 14%, 95% CI 11%-17%) across all ethnic groups from 1981 to 2012. However, there were significant increases in the frequencies of pre-morbid hypertension, myocardial infarction, and diabetes mellitus, but a reduction in frequency of current smoking among stroke patients. Conclusions In this unique temporal series of studies spanning 30 years, stroke incidence, early case-fatality and 1-year mortality have declined, but ethnic disparities in risk and outcome for stroke persisted suggesting that primary stroke prevention remains crucial to reducing the burden of this disease.
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Lewsey J, Ebueku O, Jhund PS, Gillies M, Chalmers JWT, Redpath A, Briggs A, Walters M, Langhorne P, Capewell S, McMurray JJV, MacIntyre K. Temporal trends and risk factors for readmission for infections, gastrointestinal and immobility complications after an incident hospitalisation for stroke in Scotland between 1997 and 2005. BMC Neurol 2015; 15:3. [PMID: 25591718 PMCID: PMC4320501 DOI: 10.1186/s12883-014-0257-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 12/23/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improvements in stroke management have led to increases in the numbers of stroke survivors over the last decade and there has been a corresponding increase of hospital readmissions after an initial stroke hospitalisation. The aim of this study was to examine the one year risk of having a readmission due to infective, gastrointestinal or immobility (IGI) complications and to identify temporal trends and any risk factors. METHODS Using a cohort of first hospitalised for stroke patients who were discharged alive, time to first event (readmission for IGI complications or death) within 1 year was analysed in a competing risks framework using cumulative incidence methods. Regression on the cumulative incidence function was used to model the risks of having an outcome using the covariates age, sex, socioeconomic status, comorbidity, discharge destination and length of hospital stay. RESULTS There were a total of 51,182 patients discharged alive after an incident stroke hospitalisation in Scotland between 1997-2005, and 7,747 (15.1%) were readmitted for IGI complications within a year of the discharge. Comparing incident stroke hospitalisations in 2005 with 1997, the adjusted risk of IGI readmission did not increase (HR = 1.00 95% CI (0.90, 1.11). However, there was a higher risk of IGI readmission with increasing levels of deprivation (most deprived fifth vs. least deprived fifth HR = 1.16 (1.08, 1.26). CONCLUSIONS Approximately 15 in 100 patients discharged alive after an incident hospitalisation for stroke in Scotland between 1997 and 2005 went on to have an IGI readmission within one year. The proportion of readmissions did not change over the study period but those living in deprived areas had an increased risk.
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Affiliation(s)
- James Lewsey
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK.
| | - Osaretin Ebueku
- Public Health, Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK.
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
| | - Michelle Gillies
- Public Health, Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK.
| | - Jim W T Chalmers
- Information Services Division, NHS National Services Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh, EH12 9 EB, UK.
| | - Adam Redpath
- Information Services Division, NHS National Services Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh, EH12 9 EB, UK.
| | - Andrew Briggs
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK.
| | - Matthew Walters
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Gardiner Institute, Western Infirmary, Glasgow, G11 6NT, UK.
| | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Gardiner Institute, Western Infirmary, Glasgow, G11 6NT, UK.
| | - Simon Capewell
- Public Health, University of Liverpool, Whelan Building, Quadrangle, Liverpool, L69 3GB, UK.
| | - John J V McMurray
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
| | - Kate MacIntyre
- School of Medicine, University of Tasmania, 17 Liverpool Street, Hobart, Australia.
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Dregan A, Charlton J, Wolfe CDA, Gulliford MC, Markus HS. Is sodium valproate, an HDAC inhibitor, associated with reduced risk of stroke and myocardial infarction? A nested case-control study. Pharmacoepidemiol Drug Saf 2014; 23:759-67. [PMID: 24890032 PMCID: PMC4312949 DOI: 10.1002/pds.3651] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 04/08/2014] [Accepted: 04/28/2014] [Indexed: 01/18/2023]
Abstract
Background This study aimed to evaluate whether treatment with sodium valproate (SV) was associated with reduced risk of stroke or myocardial infarction (MI). Methods Electronic health records data were extracted from Clinical Practice Research Database for participants ever diagnosed with epilepsy and prescribed antiepileptic drugs. A nested case–control study was implemented with cases diagnosed with incident non-haemorrhagic stroke and controls matched for sex, year of birth, and study start date (ratio of 1:6). A second nested study was implemented with MI as outcome. The main exposure variable was SV therapy assessed as: ever prescribed, pre-stroke year treatment, number of SV prescriptions, and cumulative time on SV drug therapy. Odds ratios were estimated using conditional logistic regression. Results Data were analysed for 2002 stroke cases and 13 098 controls. MI analyses included 1153 cases and 7109 controls. Pre-year stroke SV treatment (28%) was associated with increased stroke risk (odds ratio 1.22, 95% confidence interval (CI): 1.09 to 1.38, p < 0.001). No association was observed between ever being prescribed SV with ischemic stroke (OR = 1.01, 95% CI: 0.91 to 1.12, p = 0.875). A significant association was observed between ever being prescribed SV with MI (OR = 0.78, 95% CI: 0.67 to 0.90, p < 0.001). Patients in the highest quarter of SV treatment duration had lower odds of ischemic stroke (OR = 0.57, 95% CI: 0.44 to 0.72, p < 0.001) and MI (OR = 0.29, 95% CI: 0.20 to 0.44, p < 0.001). Conclusion Sodium valproate exposure was associated with the risk of MI, but not ischemic stroke. However, longer exposure to SV was associated with lower odds of stroke, but this might be explained by survivor bias.
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Affiliation(s)
- Alex Dregan
- Department of Primary Care and Public Health Sciences, King's College London, London, UK; NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
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Wolfe CDA, Rudd AG, McKevitt C. Modelling, evaluating and implementing cost-effective services to reduce the impact of stroke. PROGRAMME GRANTS FOR APPLIED RESEARCH 2014. [DOI: 10.3310/pgfar02020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BackgroundStroke is a leading cause of death and disability but there is little information on the longer-term needs of patients and those of different ethnic groups.ObjectivesTo estimate risk of stroke, longer-term needs and outcomes, risk of recurrence, trends and predictors of effective care, to model cost-effective configurations of care, to understand stakeholders’ perspectives of services and to develop proposals to underpin policy.DesignPopulation-based stroke register, univariate and multivariate analyses, Markov and discrete event simulation, and qualitative methods for stakeholder perspectives of care and outcome.SettingSouth London, UK, with modelling for estimates of cost-effectiveness.ParticipantsInner-city population of 271,817 with first stroke in lifetime between 1995 and 2012.Outcome measuresStroke incidence rates and trends, recurrence, survival, activities of daily living, anxiety, depression, quality of life, appropriateness and cost-effectiveness of care, and qualitative narratives of perspectives.Data sourcesSouth London Stroke Register (SLSR), qualitative data, group discussions.ResultsStroke incidence has decreased since 1995, particularly in the white population, but with a higher stroke risk in black groups. There are variations in risk factors and types of stroke between ethnic groups and a large number of strokes occurred in people with untreated risk factors with no improvement in detection observed over time. A total of 30% of survivors have a poor range of outcomes up to 10 years after stroke with differences in outcomes by sociodemographic group. Depression affects over half of all stroke patients and the prevalence of cognitive impairment remains 22%. Survival has improved significantly, particularly in the older black groups, and the cumulative risk of recurrence at 10 years is 24.5%. The proportion of patients receiving effective acute stroke care has significantly improved, yet inequalities of provision remain. Using register data, the National Audit Office (NAO) compared the levels of stroke care in the UK in 2010 with previous provision levels and demonstrated that improvements have been cost-effective. The treatment of, and productivity loss arising from, stroke results in total societal costs of £8.9B a year and 5% of UK NHS costs. Stroke unit care followed by early supported discharge is a cost-effective strategy, with the main gain being years of life saved. Half of stroke survivors report unmet long-term needs. Needs change over time, but may not be stroke specific. Analysis of patient journeys suggests that provision of care is also influenced by structural, social and personal characteristics.Conclusions/recommendationsThe SLSR has been a platform for a range of health services research activities of international relevance. The programme has produced data to inform policy and practice with estimates of need for stroke prevention and care services, identification of persistent sociodemographic inequalities in risk and care despite a reduction in stroke risk, quantification of the effectiveness and cost-effectiveness of care and development of models to simulate configurations of care. Stroke is a long-term condition with significant social impact and the data on need and economic modelling have been utilised by the Department of Health, the NAO and Healthcare for London to assess need and model cost-effective options for stroke care. Novel approaches are now required to ensure that such information is used effectively to improve population and patient outcomes.FundingThe National Institute for Health Research Programme Grants for Applied Research programme and the Department of Health via the National Institute for Health Research Biomedical Research Centre award to Guy’s and St Thomas’ NHS Foundation Trust in partnership with King’s College London.
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Affiliation(s)
- Charles DA Wolfe
- Department of Primary Care and Public Health Sciences, Division of Health and Social Care Research, School of Medicine, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, UK
| | - Anthony G Rudd
- Department of Primary Care and Public Health Sciences, Division of Health and Social Care Research, School of Medicine, King’s College London, London, UK
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Christopher McKevitt
- Department of Primary Care and Public Health Sciences, Division of Health and Social Care Research, School of Medicine, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, UK
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Gnonlonfoun DD, Adjien C, Ossou-Nguiet PM, Avlessi I, Goudjinou G, Houannou O, Acakpo J, Houinato D, Avode GD. Stroke: Medium and long-term mortality and associated factors in French-speaking West Africa, case of Benin. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/wjns.2014.41008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Félix-Redondo F, Consuegra-Sánchez L, Ramírez-Moreno J, Lozano L, Escudero V, Fernández-Bergés D. Ischemic stroke mortality tendency (2000–2009) and prognostic factors. ICTUS Study-Extremadura (Spain). Rev Clin Esp 2013. [DOI: 10.1016/j.rceng.2013.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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20
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Félix-Redondo F, Consuegra-Sánchez L, Ramírez-Moreno J, Lozano L, Escudero V, Fernández-Bergés D. Tendencia de la mortalidad por ictus isquémico (2000-2009) y factores pronósticos. Estudio ICTUS-Extremadura. Rev Clin Esp 2013; 213:177-85. [DOI: 10.1016/j.rce.2013.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Revised: 01/26/2013] [Accepted: 01/28/2013] [Indexed: 10/27/2022]
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Vaartjes I, O'Flaherty M, Capewell S, Kappelle J, Bots M. Remarkable decline in ischemic stroke mortality is not matched by changes in incidence. Stroke 2012; 44:591-7. [PMID: 23212165 DOI: 10.1161/strokeaha.112.677724] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE In Western Europe, mortality from ischemic stroke (IS) has declined over several decades. Age-sex-specific IS mortality, IS incidence, 30-day case fatality, and 1-year mortality after hospital admission are essential for explaining recent trends in IS mortality in the new millennium. METHODS Data for all IS deaths (1980-2010) in the Netherlands were grouped by year, sex, and age. A joinpoint regression was fitted to detect points in time at which significant changes in the trends occur. By linking nationwide registers, a cohort of patients first admitted for IS between 1997 and 2005 was constructed and age-sex-specific 30-day case fatality and 1-year mortality were computed. IS incidence (admitted IS patients and out-of-hospital IS deaths) was computed by age and sex. Mann-Kendall tests were used for trend evaluation. RESULTS IS mortality declined continuously between 1980 and 2000 with an attenuation of decline in the 1990s in some of the age-sex groups. A remarkable decline in IS mortality after 2000 was observed in all age-sex groups, except for young men. An improved decline in 30-day case fatality and in 1-year mortality was also observed in almost all age-sex groups. In contrast, IS incidence remained stable between 1997 and 2005 or even increased slightly. CONCLUSIONS The recent remarkable decline in IS mortality was not matched by a decline in the number of incident nonfatal IS events. This is worrying, because IS is already a leading cause of adult disability, claiming a heavy human and economic burden. Prevention of IS is therefore now of the greatest importance.
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Affiliation(s)
- Ilonca Vaartjes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
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Chang KC, Lee HC, Huang YC, Hung JW, Chiu HE, Chen JJ, Lee TH. Cost-effectiveness analysis of stroke management under a universal health insurance system. J Neurol Sci 2012; 323:205-15. [PMID: 23046751 DOI: 10.1016/j.jns.2012.09.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 08/21/2012] [Accepted: 09/17/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Cost-effectiveness analysis (CEA) of stroke management was evaluated in three care models: Neurology/Rehabilitation wards (NW), Neurosurgery wards (NS), and General/miscellaneous wards (GW) under a universal health insurance system. METHODS From 1997 to 2002, subjects with first-ever acute stroke were sampled from claims data of a nationally representative cohort in Taiwan, categorized as hemorrhage stroke (HS) including subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH); or, ischemic stroke (IS), including cerebral infarction (CI), transient ischemic attack/ unspecified stroke (TIA/unspecified); with mild-moderate and severe severity. All-cause readmissions or mortality (AE) and direct medical cost during first-year (FYMC) after stroke were explored. CEA was performed by incremental cost-effectiveness ratios. RESULTS 2368 first-ever stroke subjects including SAH 3.3%, ICH 17.9%, CI 49.8%, and TIA/unspecified 29.0% were identified with AE 59.0%, 63.0%, 48.6%, 46.8%, respectively. There were 50.8%, 13.5%, 35.6% of stroke patients served by NW, NS and GW with AE 44.9%, 60.6%, 56.0%, and medical costs of US$ 5,031, US$ 8,235, US$ 4,350, respectively. NW was cost-effective for both mild-moderate and severe IS. NS was the dominant care model in mild-moderate HS, while NW appeared to be a cost-minimization model for severe HS. CONCLUSIONS TIA/unspecified stroke carried substantial risk of AE. NS performed better in serving mild-moderate HS, whereas NW was the optimal care model in management of IS.
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Affiliation(s)
- Ku-Chou Chang
- Department of Neurology, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Lund A, Michelet M, Sandvik L, Wyller T, Sveen U. A lifestyle intervention as supplement to a physical activity programme in rehabilitation after stroke: a randomized controlled trial. Clin Rehabil 2011; 26:502-12. [PMID: 22169830 DOI: 10.1177/0269215511429473] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of lifestyle group intervention on well-being, occupation and social participation. DESIGN A randomized controlled trial. SETTING Senior centres in the community. SUBJECTS Of 204 stroke survivors screened, 99 (49%) were randomized three months after stroke whereby 86 (87%) participants (mean (SD) age 77.0 (7.1) years) completed all assessments (39 in the intervention group and 47 in the control group). INTERVENTION A lifestyle course in combination with physical activity (intervention group) compared with physical activity alone (control group). Both programmes were held once a week for nine months. MAIN OUTCOME MEASURE The Short Form Questionnaire (SF-36), addressing well-being and social participation. Assessments were performed at baseline and at nine months follow-up. RESULTS We found no statistically significant differences between the groups at the nine months follow-up in the SF-36. Adjusted mean differences in change scores in the eight subscales of SF-36 were; 'mental health' (+1.8, 95% confidence interval (CI) -4.0, +7.6), 'vitality' (-3.0, 95% CI -9.6, +3.6), 'bodily pain' (+3.3, 95% CI -7.8, +14.4), 'general health' (-1.6, 95% CI -8.4, +5.1), 'social functioning' (-2.5, 95% CI -12.8, +7.8), 'physical functioning' (+1.0, 95% CI -6.7, +8.6), 'role physical' (-7.1, 95% CI -22.7, +8.4), 'role emotional' (+11.8, 95% CI -4.4, +28.0). CONCLUSIONS Improvements were seen in both groups, but no statistically significant differences were found in the intervention group compared to controls. An intervention comprising regular group-based activity with peers may be sufficient in the long-term rehabilitation after stroke.
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Affiliation(s)
- A Lund
- Oslo University Hospital, Geriatric Medicine, Oslo, Norway.
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[Development of mortality and morbidity of vascular diseases: variations between coronary heart disease and stroke]. DER NERVENARZT 2011; 82:145-6, 148-50, 152. [PMID: 21286677 DOI: 10.1007/s00115-010-3110-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Cardiovascular diseases represent a central challenge for our health care system because of their individual and societal consequences. The manuscript compares the current development of mortality and morbidity of coronary heart disease and stroke in Germany. RESULTS Coronary heart diseases are one of the leading causes of death and one of the major causes for adult disability. In Germany the average life expectancy has increased by more then 2 years per decade within recent years. The greatest contribution to the increase in life expectancy between 1980 and 2002 in Germany was attributed in previous studies to the decline in mortality rates of cardiovascular diseases; for example in Germany 134,648 persons died in 2008 from coronary heart disease (ICD-10 I20-I25) and 63,060 persons from stroke (ICD-10 I60-I64) compared to 178,759 persons and 90,241 persons in 1998, respectively. Statistical models from other countries estimated that the decrease in coronary heart disease mortality is attributed by about 40% to better treatment and by about 60% to changes in risk factors in the population. Comparable data for stroke are lacking. CONCLUSION Despite the substantial knowledge on cardiovascular diseases in Germany a continuous and timely documentation of their determinants, time trends of risk factors and impact regarding mortality and morbidity is compulsory to assess the effectiveness of initiated population health measures and to identify future options for improving prevention and treatment of cardiovascular diseases in Germany.
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Dregan A, Toschke MA, Wolfe CD, Rudd A, Ashworth M, Gulliford MC. Utility of electronic patient records in primary care for stroke secondary prevention trials. BMC Public Health 2011; 11:86. [PMID: 21299872 PMCID: PMC3041663 DOI: 10.1186/1471-2458-11-86] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Accepted: 02/07/2011] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND This study aimed to inform the design of a pragmatic trial of stroke prevention in primary care by evaluating data recorded in electronic patient records (EPRs) as potential outcome measures. The study also evaluated achievement of recommended standards of care; variation between family practices; and changes in risk factor values from before to after stroke. METHODS Data from the UK General Practice Research Database (GPRD) were analysed for 22,730 participants with an index first stroke between 2003 and 2006 from 414 family practices. For each subject, the EPR was evaluated for the 12 months before and after stroke. Measures relevant to stroke secondary prevention were analysed including blood pressure (BP), cholesterol, smoking, alcohol use, body mass index (BMI), atrial fibrillation, utilisation of antihypertensive, antiplatelet and cholesterol lowering drugs. Intraclass correlation coefficients (ICC) were estimated by family practice. Random effects models were fitted to evaluate changes in risk factor values over time. RESULTS In the 12 months following stroke, BP was recorded for 90%, cholesterol for 70% and body mass index (BMI) for 47%. ICCs by family practice ranged from 0.02 for BP and BMI to 0.05 for LDL and HDL cholesterol. For subjects with records available both before and after stroke, the mean reductions from before to after stroke were: mean systolic BP, 6.02 mm Hg; diastolic BP, 2.78 mm Hg; total cholesterol, 0.60 mmol/l; BMI, 0.34 Kg/m2. There was an absolute reduction in smokers of 5% and heavy drinkers of 4%. The proportion of stroke patients within the recommended guidelines varied from less than a third (29%) for systolic BP, just over half for BMI (54%), and over 90% (92%) on alcohol consumption. CONCLUSIONS Electronic patient records have potential for evaluation of outcomes in pragmatic trials of stroke secondary prevention. Stroke prevention interventions in primary care remain suboptimal but important reductions in vascular risk factor values were observed following stroke. Better recording of lifestyle factors in the GPRD has the potential to expand the scope of the GPRD for health care research and practice.
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Affiliation(s)
- Alex Dregan
- Division of Health and Social Care Research, King's College London, Capital House, Weston Street, London, UK.
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