Centralising acute stroke care and moving care to the community in a Danish health region: Challenges in implementing a stroke care reform

In May 2012, one of Denmark's five health care regions mandated a reform of stroke care. The purpose of the reform was to save costs, while at the same time improving quality of care. It included (1) centralisation of acute stroke treatment at specialised hospitals, (2) a reduced length of hospital stay, and (3) a shift from inpatient rehabilitation programmes to community-based rehabilitation programmes. Patients would benefit from a more integrated care pathway between hospital and municipality, being supported by early discharge teams at hospitals.A formal policy tool, consisting of a health care agreement between the region and municipalities, was used to implement the changes. The implementation was carried out in a top-down manner by a committee, in which the hospital sector – organised by regions – was better represented than the primary care sector—organised by municipalities. The idea of centralisation of acute care was supported by all stakeholders, but municipalities opposed the hospital-based early discharge teams as they perceived this to be interfering with their core tasks. Municipalities would have liked more influence on the design of the reform.Preliminary data suggest good quality of acute care. Cost savings have been achieved in the region by means of closure of beds and a reduction of hospital length of stay. The realisation of the objective of achieving integrated rehabilitation care between hospitals and municipalities has been less successful. It is likely that greater involvement of municipalities in the design phase and better representation of health care professionals in all phases would have led to more successful implementation of the reform.     

Telemedicine for eye care

Tele-ophthalmology has been employed mainly for patients in under-served rural areas in need of specialty care, but other applications such as telementoring have also been used. In certain populations, cost containment is a significant issue and telemedicine is a solution. Tele-ophthalmology can be performed in realtime, by store-and-forward mode, or by hybrid techniques. After appropriate modification, a range of peripherals may be used for tele-ophthalmology, including the direct ophthalmoscope, indirect ophthalmoscope, slit lamp or retinal camera. Tele-ophthalmology applications include: detecting, screening and diagnosing diabetic retinopathy; anterior segment imaging; glaucoma screening; low vision consultation; telementoring. Tele-ophthalmology shows great promise for improving patient care and increasing access to specialty care not available in under-served areas. In developing countries tele-ophthalmology may be a cost-effective method by which richer countries can assist them.     

Telemedicine: an emerging health care technology

Telemedicine uses advanced telecommunication technologies to exchange health information and provide health care services across geographic, time, social, and cultural barriers. All telemedicine applications require the use of the electronic transfer of information. Telemedicine encompasses computer technologies using narrow and high bandwidths for specific types of information transmission, broadcast video, compressed video, full motion video, and even virtual reality. There are many types of common medical devices that have been adapted for use with telemedicine technology, and many clinical services can be provided via telemedicine to patients who live in physician shortage areas. The greatest challenges for telemedicine in the twenty-first century are financing, safety standards, security, and infrastructure.     

Optimal patient protocols in regional acute stroke care

Health Care Management Science - In acute stroke care two proven reperfusion treatments exist: (1) a blood thinner and (2) an interventional procedure. The interventional procedure can only be...     

Management of stroke: acute, rehabilitation and long-term care

Stroke is the major cause of disability in adults, resulting in much morbidity and mortality in the west. Each year 120,000 people will suffer their first stroke with a further 40,000 suffering a recurrent stroke and 40,000 a transient ischaemic attack. The prevalence rises from 2/1000 population to 2/100 in those over 85 years of age. Consequently stroke is seen as a problem of the elderly.     

Facilities for acute stroke patients care in the Czech Republic: nationwide epidemiological study

Background and purpose: Stroke is the third most common cause of death in the Czech Republic (CR). Specialized in-patient stroke unit care improves the outcome of stroke patients. The aim of the study was to chart and improve the current facilities. Methods: Neurological in-patient departments exist in 75% of the districts in the CR, and in the capital Prague. Questionnaires were sent to all 79 neurological in-patient departments. A ² test was used for the evaluation of statistical significance. Results: There is better access to intensive/intermediary care beds (statistically not significant) and to angiography (statistically significant) in the districts with a population density of over 151 inhabitants per km² than in districts with a lower population density (p = 0.09 and p = 0.008). Stroke patients have access within 1 hour to computed tomography of the brain in all but one, and to laboratory tests in all districts with a neurological in-patient department(s). There is no statistically significant difference in the availability of ultrasound examination of extracranial brain arteries between the sparse, and more populated districts (p = 0.715). Conclusions: Facilities for the establishment of stroke units are quite good in the majority of highly populated areas; however, they are worse in some of the larger towns. The results of the study must be used to further improve the development of stroke care in the CR.     

Telemedicine for acute burn treatment: the time has come

This brief paper sets out the arguments for the routine use of telemedicine in the evaluation of burns. Two cases are reported from the author's practice that show the need for it.     

The weekend effect in stroke mortality: evidence from Austrian acute care hospitals

International Journal of Health Economics and Management - Many studies provide evidence for the so-called weekend effect by demonstrating that patients admitted to hospital during weekends show...     

Evaluating integrative medicine acute stroke inpatient care in South Korea

High demand for traditional Korean medicine led to a policy change in 2010 allowing hospitals to provide Integrative medicine care that combines Western medicine and Korean medicine. This study evaluated the effects of Integrative medicine compared to Western medicine-only for managing acute stroke in South Korean hospitals.A retrospective matched case-control observational study was conducted for acute stroke patients admitted nationwide in 2012 and 2013. Propensity score matching was used to adjust for the likelihood of selecting Integrative medicine. Hierarchical generalized linear models were used to control for patient characteristics at the episode of care (level 1) and cluster effects from the hospitals (level 2).A total of 1182 patients and 65 hospitals were matched and analyzed. Receiving Integrative medicine significantly increased the average length of stay (OR 1.27; 95% CI 1.13–1.42), total cost of inpatient care (OR 1.93; 95% CI 1.62–2.31), and per-day cost (OR 1.34; 95% CI 1.21–1.47). Receiving Integrative medicine did not affect all-cause 3-month emergency readmissions (OR 1.36; 95% CI 0.92–2.02). However, Integrative medicine was associated with a reduced risk of all-cause mortality at 3 months (OR 0.36; 90% CI 0.13–0.99) and 12 months (OR 0.34; 95% CI 0.15–0.75) after admission.Receiving Integrative medicine was associated with improved 3-month and 12-month survival, greater healthcare utilization and higher costs. Further economic evaluations are needed to guide policy for efficient integration of Korean medicine and Western medicine.     

Prehospital and emergency department capacity for acute stroke care in Minnesota

Introduction

Stroke is the third leading cause of death in Minnesota. One strategy to reduce the burden of stroke is to implement systems-level improvements in the prehospital and acute care settings. Two surveys conducted in 2006 obtained information about current practices and capacities of emergency medical services and emergency departments in Minnesota.

Methods

In 2006, the Minnesota Department of Health and the Minnesota Stroke Partnership (the statewide stroke collaborative group) conducted two surveys. The survey for emergency medical services organizations, mailed to every licensed ambulance service in Minnesota, asked about transportation policies and training needs. The survey for hospitals, mailed to every hospital in the state, asked about capacity to treat acute stroke. Results were calculated using simple frequency analyses.

Results

Of 257 surveys mailed to ambulance services, 199 (77%) were returned. Ambulance services generally considered stroke an emergency. Training on stroke was reported most effective in person annually or semiannually. Of 133 surveys mailed to hospitals, 120 (90%) were returned. Stroke capacity differed markedly between hospitals in rural areas and hospitals in the large Minneapolis–St. Paul metropolitan area. Many hospitals, particularly small hospitals, reported lacking stroke protocols. Training for stroke is needed overall but particularly in small hospitals.

Conclusion

Transport and treatment of people with acute stroke in Minnesota vary by hospital size and location. Standardization of transport and protocols for acute treatment may increase efficiency and overall care for stroke patients. In addition, the need to train ambulance personnel and emergency departments about stroke remains high.     

Education in stroke: strategies to improve stroke patient care

'Stroke units save lives', but organized care requires expert staff and regular training to be effective. However, the quality of inpatient care for stroke remains poor, and stroke education is often fragmented between the health-care professions. This review describes some national and local strategies aimed at ensuring that all patients are cared for by expert staff.     

The Arizona Telemedicine Program business model

The Arizona Telemedicine Program (ATP) was established in 1996 when state funding was provided to implement eight telemedicine sites. Since then the ATP has expanded to connect 55 health-care organizations through a membership programme formalized through legal contracts. The ATP's membership model is based on an application service provider (ASP) concept, whereby organizations can share services at lower cost; that is, the ATP acts as a broker for services. The membership fee schedule is flexible, allowing clients to purchase only those services desired. An annual membership fee is paid by every user, based on the services requested. The membership programme income has provided a steady revenue stream for the ATP. The membership-derived revenue represented 30% of the ATP's 2.6 million dollars total income during fiscal year 2003/04.     

Telemedicine for delivery of health care in Parkinson's disease

We have used telemedicine at the Seattle Veterans Administration Medical Center to deliver follow-up care to patients with Parkinson's disease (PD). Patients were located at eight facilities which were 67-2400 km from the medical centre. Each facility had videoconferencing equipment (connected by Internet Protocol at 384 kbit/s), and computer terminals that could access the patient's electronic medical record. Over a three-year period, we used telemedicine for 100 follow-up visits on 34 PD patients. Visits lasted 30-60 min. Patients and providers were satisfied with the use of the technology. Savings amounted to approximately 1500 attendant travel hours, 100,000 travel kilometres, and US 37,000 dollars in travel and lodging costs. For the first 82 telemedicine visits, the video quality was inadequate for scoring all components of the motor Unified Parkinson Disease Rating Scale (UPDRS). For the last 18 visits, a different videoconferencing unit produced better video quality, which was satisfactory for motor UPDRS measurements, except for components that required physical contact with the patient (rigidity and retropulsion testing). Our experience shows that telemedicine can be used effectively for follow-up visits with selected PD patients who are unable to travel.