Regional differences in acute stroke admission and thrombolysis rates in the German federal state of Hesse

Identifying factors in the provision of intravenous stroke thrombolysis in Malaysia: a multiple case study from the healthcare providers' perspective

BACKGROUND

Translation into clinical practice for use of intravenous thrombolysis (IVT) for the management of ischemic stroke remains a challenge especially across low- and middle-income countries, with regional inconsistencies in its rate. This study aimed at identifying factors that influenced the provision of IVT and the variation in its rates in Malaysia.

METHODS

A multiple case study underpinning the Tailored Implementation for Chronic Diseases framework was carried out in three public hospitals with differing rates of IVT using a multiple method design. Twenty-five in-depth interviews and 12 focus groups discussions were conducted among 89 healthcare providers, along with a survey on hospital resources and a medical records review to identify reasons for not receiving IVT. Qualitative data were analysed using reflective thematic method, before triangulated with quantitative findings.

RESULTS

Of five factors identified, three factors that distinctively influenced the variation of IVT across the hospitals were: 1) leadership through quality stroke champions, 2) team cohesiveness which entailed team dynamics and its degree of alignment and, 3) facilitative work process which included workflow simplification and familiarity with IVT. Two other factors that were consistently identified as barriers in these hospitals included patient factors which largely encompassed delayed presentation, and resource constraints. About 50.0 - 67.6% of ischemic stroke patients missed the opportunity to receive IVT due to delayed presentation.

CONCLUSIONS

In addition to the global effort to explore sustainable measures to improve patients' emergency response for stroke, attempts to improve the provision of IVT for stroke care should also consider the inclusion of interventions targeting on health systems perspectives such as promoting quality leadership, team cohesiveness and workflow optimisation.

Availability of stroke services and hospital facilities at different hospital levels in Thailand: a cross-sectional survey study

BACKGROUND

Stroke has one of the biggest burden of disease in Thailand and all health regions have been tasked to develop their service delivery to achieve the national key performance indicators set out by the Thai service plan strategy 2018-2022. Our aim was to characterise stroke services and hospital facilities by investigating differences in facilities across different hospital levels in Thailand.

METHODS

Self-complete questionnaires were distributed to 119 hospitals in 12 health regions between November-December 2019. Participants were health professionals whose main responsibilities are related to stroke service provision in their hospital. Descriptive statistics were used to report differences of stroke service provision between advanced-level, standard-level and mid-level referral hospitals.

RESULTS

Thirty-eight (32% response rate) completed questionnaires were returned. All advanced-level, standard-level (100%) and 55% of mid-level referral hospitals provided stroke units. Neurologists were available in advanced-level (100%) and standard-level referral hospitals (50%). Standard-level and mid-level referral hospitals only had a quarter of rehabilitation physicians compared to advanced-level referral hospital. Home-based rehabilitation was provided at 100% in mid-level but only at 16% and 50% in advanced-level and standard-level referral hospitals.

CONCLUSIONS

Setting up a stroke unit, as a national goal that was set out in the service plan strategy 2018-2022, was achieved fully (100%) in advanced-level and standard-level referral hospitals including key essential supportive components. However, capacity in hospitals was found to be limited and stroke service delivery needs to be improved especially at mid-level referral hospitals. This should include regular organisational surveys and the use of electronic records to facilitate monitoring of clinical/health outcomes of patients.

Optimising acute stroke care organisation: a simulation study to assess the potential to increase intravenous thrombolysis rates and patient gains

OBJECTIVES

To assess potential increases in intravenous thrombolysis (IVT) rates given particular interventions in the stroke care pathway.

DESIGN

Simulation modelling was used to compare the performance of the current pathway, best practices based on literature review and an optimised model.

SETTING

Four hospitals located in the North of the Netherlands, as part of a centralised organisational model.

PARTICIPANTS

Ischaemic stroke patients prospectively ascertained from February to August 2010.

INTERVENTION

The interventions investigated included efforts aimed at patient response and mode of referral, prehospital triage and intrahospital delays.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was thrombolysis utilisation. Secondary measures were onset-treatment time (OTT) and the proportion of patients with excellent functional outcome (modified Rankin scale (mRS) 0-1) at 90 days.

RESULTS

Of 280 patients with ischaemic stroke, 125 (44.6%) arrived at the hospital within 4.5 hours, and 61 (21.8%) received IVT. The largest improvements in IVT treatment rates, OTT and the proportion of patients with mRS scores of 0-1 can be expected when patient response is limited to 15 min (IVT rate +5.8%; OTT -6 min; excellent mRS scores +0.2%), door-to-needle time to 20 min (IVT rate +4.8%; OTT -28 min; excellent mRS scores+3.2%) and 911 calls are increased to 60% (IVT rate +2.9%; OTT -2 min; excellent mRS scores+0.2%). The combined implementation of all potential best practices could increase IVT rates by 19.7% and reduce OTT by 56 min.

CONCLUSIONS

Improving IVT rates to well above 30% appears possible if all known best practices are implemented.

Notification Strategy and Predictors of Outcome in Stroke Ineligible for Reperfusion Therapies

Background, Objective: At least 70% of all stroke patients are ineligible for recanalization therapy. We identified predictors of outcome among these patients, with special focus on notification of emergency medical services (EMS).

Methods: We prospectively collected data of 250 consecutive patients with acute cerebrovascular diseases ineligible for recanalization therapy. Initial notification strategy and outcome were analyzed by regression models.

Results: EMS notification rate was 55, 41, and 21% in patients with <6, 6–24, and >24 h stroke-to-door time. Atrial fibrillation (AF; OR = 2.66, 95% CI: 1.19–5.96), stroke severity (National Institutes of Health Stroke Scale score, NIHSS; OR = 1.12, 95% CI: 1.02–1.23), history of any psychiatric disease (OR = 2.2, 95% CI: 0.98–4.97), aphasia (OR = 1.99, 95% CI: 0.99–3.98), and residence type were predictors of EMS notification. Disability (modified Rankin Scale score [mRS]) both at discharge and at 1 year was associated with age, admission NIHSS score, type of cerebrovascular disorder, and pre-stroke mRS at discharge and discharge mRS at follow-up. Age (HR = 1.05, 95% CI: 1.02–1.08) and NIHSS (HR = 1.16, 95% CI: 1.12–1.21) had a significant effect on the relative hazard of death.

Conclusions: EMS notification is influenced by AF, stroke severity, psychiatric disease, aphasia, and residence type. Early disability depends on age, the type and severity of the stroke, and pre-stroke mRS. Predictors of disability at 1 year after stroke are age, stoke severity, mRS at discharge, and recurrent ischemic stroke. Higher NIHSS and older age are associated with higher case fatality. In patients ineligible for recanalization, EMS notification had no significant effect on outcome, regarding both disability and survival.

Factors associated with late arrival of acute stroke patients to emergency department in Saudi Arabia

Background

Tissue plasminogen activator within 4.5 h of onset is effective for acute ischemic stroke. However, only small proportion of patients is treated due to delayed presentation. We aimed to examine the factors associated with delays of stroke patients in Riyadh, Saudi Arabia.

Methods

A cross-sectional survey was conducted at King Abdulaziz Medical City, Riyadh, Saudi Arabia, during a 6-month period. An interviewer administered structured questionnaire addressed to the acute stroke patients or their relatives was used to explore the factors associated with delayed arrival.

Results

A total of 227 patients attending the emergency department were interviewed. The mean age was 60.4 ± 15.6 years. Approximately 56.4% presented after 4.5 h of stroke onset. Factors associated with late arrival were being alone during the onset of stroke, not being transported in an ambulance, not knowing that they were experiencing a stroke, and residing outside the city of Riyadh.

Conclusion

More than half of patients missed the golden hours for thrombolysis due to delayed presentation. Reasons include lack of knowledge, underuse of ambulance and difficult access to care. Urgent community-based interventions are needed to address these factors.

Recent advances in the management of acute ischemic stroke

In recent years, several landmark trials have transformed acute ischemic stroke care. The most dramatic results from the field of acute endovascular intervention demonstrate unequivocal benefit for a select group of patients with moderate to severe deficits presenting within 7 hours from onset and with occlusions of proximal arteries in the anterior circulation. In addition, technological advances and workflow efficiencies have facilitated more rapid delivery of acute stroke interventions. This review provides an overview of recent advances in the management of acute ischemic stroke.

Expansion or compression of long-term care in Germany between 2001 and 2009? A small-area decomposition study based on administrative health data

Background

Studies state profound cross-country differences in healthy life years and its time trends, suggesting either the health scenario of expansion or compression of morbidity. A much-discussed question in public health research is whether the health scenarios are heterogeneous or homogeneous on the subnational level as well. Furthermore, the question arises whether the morbidity trends or the mortality trends are the decisive drivers of the care need-free life years (CFLY), the life years with care need (CLY), and, ultimately, the health scenarios.

Methods

This study uses administrative census data of all beneficiaries in Germany from the Statutory Long-Term Care Insurance 2001–2009. We compute the CFLY and CLY at age 65+ for 412 counties. The CFLY and CLY gains are decomposed into the effects of survival and of the prevalence of care need, and we investigate their linkages with the health scenarios by applying multinomial regression models.

Results

We show an overall increase in CFLY, which is higher for men than for women and higher for severe than for any care need. However, spatial variation in CFLY and in CLY has increased. In terms of the health scenarios, a majority of counties show an expansion of any care need but a compression of severe care need. There is high spatial heterogeneity, with expansion-counties surrounding compression-counties and vice versa, which is mainly caused by divergent trends in the prevalence of care need. We show that mortality is responsible for the absolute changes in CFLY and CLY, while morbidity is the decisive driver that determines the health scenario of a county.

Conclusion

Combining regionalized administrative data and advanced statistical methods permits a deeper insight into the complex relationship between health and mortality. Our findings demonstrate a compression of life years with severe care need, which however, depends on the region of residence. To attenuate regional inequalities, more efforts are needed that improve health by medical and infrastructural interventions and by the exchange of insights in the efficiency of small- and large-area policy measures between the vanguard and the rearguard counties. In future research, the underlying latent mechanisms should be investigated in more detail.

Electronic supplementary material

The online version of this article (doi:10.1186/s12963-016-0093-1) contains supplementary material, which is available to authorized users.

Increase in national intravenous thrombolysis rates for ischaemic stroke between 2005 and 2012: is bigger better?

BACKGROUND

Intravenous thrombolytic therapy after ischaemic stroke significantly reduces mortality and morbidity. Actual thrombolysis rates are disappointingly low in many western countries. It has been suggested that higher patient volume is related to shorter door-to-needle-time (DNT) and increased thrombolysis rates. We address a twofold research question: a) What are trends in national thrombolysis rates and door-to-needle times in the Netherlands between 2005-2012? and b) Is there a relationship between stroke patient volume per hospital, thrombolysis rates and DNT?

METHODS

We used data from the Stroke Knowledge Network Netherlands dataset. Information on volume, intravenous thrombolysis rates, and admission characteristics per hospital is acquired through yearly surveys, in up to 65 hospitals between January 2005 and December 2012. We used linear regression to determine a possible relationship between hospital stroke admission volume, hospital thrombolysis rates and mean hospital DNT, adjusted for patient characteristics.

RESULTS

Information on 121.887 stroke admissions was available, ranging from 7.393 admissions in 2005 to 24.067 admissions in 2012. Mean national thrombolysis rate increased from 6.4% in 2005 to 14.6% in 2012. Patient characteristics (mean age, gender, type of stroke) remained stable. Mean DNT decreased from 72.7 min in 2005 to 41.4 min in 2012. Volume of stroke admissions was not an independent predictor for mean thrombolysis rate nor for mean DNT.

CONCLUSION

Intravenous thrombolysis rates in the Netherlands more than doubled between 2005 and 2012, in parallel with a large decline in mean DNT. We found no convincing evidence for a relationship between stroke patient volume per hospital and thrombolysis rate or DNT.

The quality of acute stroke care- an analysis of evidence-based indicators in 260 000 patients

BACKGROUND

Stroke patients should be cared for in accordance with evidence-based guidelines. The extent of implementation of guidelines for the acute care of stroke patients in Germany has been unclear to date.

METHODS

The regional quality assurance projects that cooperate in the framework of the German Stroke Registers Study Group (Arbeitsgemeinschaft Deutscher Schlaganfall-Register, ADSR) collected data on the care of stroke patients in 627 hospitals in 2012. The quality of the acute hospital care of patients with stroke or transient ischemic attack (TIA) was assessed on the basis of 15 standardized, evidence-based quality indicators and compared across the nine participating regional quality assurance projects.

RESULTS

Data were obtained on more than 260 000 patients nationwide. Intravenous thrombolysis was performed in 59.7% of eligible ischemic stroke patients patients (range among participating projects, 49.7-63.6%). Dysphagia screening was documented in 86.2% (range, 74.8-93.1%). For the following indicators, the defined targets were not reached for all of Germany: anti-aggregation within 48 hours, 93.4% (range, 86.6-96.4%); anticoagulation for atrial fibrillation, 77.6% (range, 72.4-80.1%); standardized dysphagia screening, 86.2% (range, 74.8-93.1%); oral and written information of the patients or their relatives, 86.1% (range, 75.4-91.5%). The rate of patients examined or treated by a speech therapist was in the target range.

CONCLUSION

The defined targets were reached for most of the quality indicators. Some indicators, however, varied widely across regional quality assurance projects. This implies that the standardization of care for stroke patients in Germany has not yet been fully achieved.

Baseline characteristics in stroke patients with atrial fibrillation: clinical trials versus clinical practice

Background

When applying information gathered from medical research to the clinical setting, it is imperative that the sample of the investigated patients be representative of the clinical population. Because of this fact, it is necessary to closely examine the sample’s baseline characteristics in clinical trials.

Methods

We analysed baseline data of relevant trials investigating considerable proportions of patients with atrial fibrillation (AF) in the secondary stroke prevention: EAFT, SIFA, Active-W, BAFTA, RE-LY, AVERROES, ARISTOTLE and ROCKET AF. For comparing baseline data stroke patients with AF documented in a statutory stroke registry were considered. In a subgroup of patients (members of a large insurance) data on subsequent prescription for oral anticoagulants (oAK) were available.

Results

In the stroke registry (n = 15,886) the mean age was higher than in the selected clinical trials (mean 77.7 versus 70–72 years). Among insurance members (n = 1,828), those with a prescription for oAK (n = 827) were older than patients recruited in clinical trials (mean 75.1 versus 70–72 years). Results also showed that the male sex was overrepresented in clinical trials (59–63% versus 46%). The distribution of vascular risk factors in recent clinical trials was comparable to proportions in the registry (hypertension: 77–85% versus 80%; diabetes mellitus: 20–26% versus 27%).

Conclusions

The majority of stroke patients with AF in the clinical setting are considerably older than those included in clinical trials. While the distribution of vascular risk factors in clinical trials corresponds to proportions observed in clinical practice, an overrepresentation of the male sex in clinical trials is evident.

Secondary stroke prevention in atrial fibrillation: a challenge in the clinical practice

Background

Despite clear evidence for the effectiveness of oral anticoagulation (OA) in patients with atrial fibrillation (AF), there is evidence for the underutilisation of this therapy in the secondary stroke prevention. We therefore investigate the link between the use of OA in stroke patients with AF and favourable clinical outcome following the acute event.

Methods

The study population was determined by identifying the overlap of two different databases: a stroke registry and claims data of a health insurance company. Baseline data originated from the registry; documented dementia and the prescriptions for OA were derived from the insurance database. Patients with AF, minor physical impairment, and evidence of more than 30 days without further hospitalisation within the subsequent 90 days after the acute event were selected for the analysis.

Results

1828 patients were selected (mean age 77.6 years), 1064 patients (58.2%) were female. 827 patients (45%) received a prescription for OA. The following factors were independently associated with no prescription for oral anticoagulants: increased age (OR: 0.54, CI: 0.46-0.63; P < 0.0001), female sex (OR: 0.77, CI: 0.63-0.94; P < 0.011), worsening disability status at discharge (OR: 0.88, CI: 0.81-0.96; P < 0.006), and documented dementia (OR: 0.54, CI: 0.39-0.73; P < 0.001). Conversely, treatment in a neurological department was associated with prescription for OA (OR: 1.47, CI: 1.19-1.81; P < 0.003).

Conclusions

In more than half of the patients with AF who suffered a stroke OA was not prescribed. The factors associated with reluctance in prescribing anticoagulants are increasing age, female sex, treatment at a non-neurological department, worsening disability, and dementia.

Lessons from everyday stroke care for clinical research and vice versa: comparison of a comprehensive and a research population of young stroke patients

Background

Translating knowledge derived from medical research into the clinical setting is dependent on the representativeness of included patients. Therefore we compared baseline data of patients included in a recent large study addressing young stroke in comparison to a large representative stroke registry.

Methods

We analysed baseline data of 5023 patients (age 18-55 years) with an acute cerebrovascular event included in the sifap1 (Stroke in Young Fabry Patients) study. For comparison 17007 stroke patients (age 18-55 years) documented (2004-2010) in a statutory stroke registry of the Institute of Quality Assurance Hesse of the Federal State of Hesse (GQH), Germany.

Results

Among 17007 juvenile (18-55 years) patients identified in the GQH registry 15997 had an ischaemic stroke or TIA (91%) or an intracranial haemorrhage (9%). In sifap1 5023 subjects were included. Sex distribution was comparable (men: 59% sifap1 versus 60.5% GQH) whereas age differed between the groups: median age was 46 years in sifap1 versus 49 years in GQH. Slightly higher percentages for diabetes mellitus and hypertension in the GQH registry were noted. There were no differences in stroke severity as assessed by NIHSS (median 3) and mRS (median 2). In patients with ischaemic stroke or TIA (n = 4467 sifap1; n = 14522 GQH) higher rates of strokes due to small artery occlusion and atherosclerosis occurred in older age groups; cardioembolism and strokes of other determined cause occurred more frequently in younger patients.

Conclusions

The comparison of baseline characteristics between the sifap1 study and the GQH registry revealed differences mainly determined by age.

[Reality of acute stroke patient care in the metropolitan Ruhr area: status quo and perspectives of a stroke-specific network]

BACKGROUND

Networking structures are constructed to improve daily care of acute stroke patients, in the Ruhr area by the association of 26 neurological departments. Quality of care can be measured by the rate of stroke unit treatment and of thrombolysis. Epidemiological data are mainly derived from registers resulting in sparse insight into incidence and rate of specialized care in daily practice.

METHODS

The study involved data analysis of diagnosis-related groups (DRG) statistics and structured quality reports for 2008 and 2010 for depiction of the quality of routine treatment. Aggregation of the number of cases for incidence, rate of stroke unit treatment and thrombolysis district, province, and nation wide were analyzed.

RESULTS

In 5.2 million inhabitants, the incidence of ischemic stroke (ICD I63) was 296/100,000 in 2010 (district-wise range 244-364) and 56% of patients were treated on a stroke unit (range 18-80%; 2008: 43%, range 10-72%). The rate of thrombolysis (ICD I63) was 6.4% and 9.1% in 2008 and 2010 (2008 range 0-11.2%, 2010 range 3.9-18.0%), respectively, which was significantly above the provincial average in 10 out of 15 districts.

DISCUSSION

Ischemic stroke is a common disease in the area and the quality of care (e.g. stroke unit treatment and thrombolysis rate) is above average. The heterogeneous character of the region allows an exemplary networking aiming for the improvement of routine patient care, e.g. by the implementation of homogeneous standards and structural measures for the implementation of novel therapies. The current analysis allows the identification of the potential for optimization and monitoring of any changes.