Centralisation of acute stroke services in London: Impact evaluation using two treatment groups

The bundling of clinical expertise in centralised treatment centres is considered an effective intervention to improve quality and efficiency of acute stroke care. In 2010, 8 London Trusts were converted into Hyper Acute Stroke Units. The intention was to discontinue acute stroke services in 22 London hospitals. However, in reality, provision of services declined only gradually, and 2 years later, 15% of all patients were still treated in Trusts without a Hyper Acute Stroke Unit. This study evaluates the impact of centralising London's stroke care on 7 process and outcome indicators using a difference‐in‐difference analysis with two treatment groups, Hyper Acute and discontinued London Trusts, and data on all stroke patients recorded in the hospital episode statistics database from April 2006 to April 2014. The policy resulted in improved thrombolysis treatment and lower rates of pneumonia in acute units. However, 6 indicators worsened in the Trusts that were meant to discontinue services, including deaths within 7 and 30 days, readmissions, brain scan rates, and thrombolysis treatment. The reasons for these results are difficult to uncover and could be related to differences in patient complexity, data recording, or quality of care. The findings highlight that actual implementation of centralisation policies needs careful monitoring and evaluation.     

Calculation of prevalence with Markov models: budget impact analysis of thrombolysis for stroke.

OBJECTIVES: The objective is to develop a method for calculating the prevalence of stroke based on Markov models and to apply it to the assessment of the budget impact analysis of thrombolytic treatment. METHODS: A Markov model was used to reproduce the natural history of stroke. The first step was to run the model to build the sojourn matrix from the initial population vector. The second step was to ascertain the number of individuals in the origin of each annual cohort. Finally, prevalence figures were obtained, validated, and used to calculate the impact of treatment with thrombolysis in 10% of patients with stroke in the Basque Country as if thrombolysis had begun in 2000 and would continue to 2015. RESULTS: Stroke prevalence rates per 100,000 for the entire population are 898 for men and 686 for women, with a combined rate of 774 for men and women. Rates for stroke-related disability are 358 per 100,000 for men, 275 for women, and 309 for men and women combined. If 10% of the stroke patients would have received thrombolytic treatment from 2000 to 2015, the number of disabled in 2015 would be reduced by 328, and the net savings for the Basque society (2,100,000 inhabitants) would be 1.7 million euro. CONCLUSIONS: The budget impact analysis of thrombolysis for stroke starting in 2000 shows a positive impact on the health budget because it saves costs after 2006 and produces a net benefit in health from the beginning of treatment.     

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.     

Thrombolysis of acute ischaemic stroke in a district general hospital: are we doing enough?

Thrombolysis of acute ischaemic stroke is safe, efficacious and licensed for use in the UK. To date, few studies have looked at the rates of thrombolysis within a district general hospital setting. The aim of the study was to identify whether local thrombolysis protocols for stroke are adhered to; the rate of thrombolysis and strategies for implementation focused at improving the provision of thrombolysis of patients with acute ischaemic stroke. The methodology involved in this was a retrospective study within a district general hospital in the South of England. Data on patients admitted between 15 April 2008 and 14 April 2009 including demographics, use of the local thrombolysis protocol and reasons for non-thrombolysis were collected and analysed. Out of a total of 599 patients with a primary presentation of acute stroke, 18 were considered for thrombolysis. Six patients out of these 18 were thrombolysed without complications. Four out of these six patients had an improved National Institutes of Health Stroke Scale (NIHSS) post-thrombolysis and one eventually died due to the extensiveness of the stroke sustained, despite a slightly improved NIHSS. The rate of thrombolysis of acute ischaemic stroke is low in this hospital (1.001%). Various measures will need to be considered for implementation in order to improve the provision of this service.     

Impact of systems of care and blood pressure management on stroke outcomes

Stroke is the third leading cause of death in the United States and the leading cause of disability. Stroke patients' outcomes are strongly determined by how long they remain untreated ("time is brain"). The Joint Commission's adoption of stroke performance improvement measures combined with the Centers for Medicare and Medicaid's more recent adoption in October 2009 make a systems approach to improving stroke outcomes a higher priority. As hospitals establish local and regional stroke care systems to meet these performance measures, treatment of emergent high blood pressure (BP) is a major consideration to improve rapid triage and management of acute stroke patients. Intravenous thrombolysis with tissue plasminogen activator (tPA) is a critical quality of care component for acute ischemic stroke (AIS) treatment, but its administration is contingent on BP management. For patients with AIS who are potentially eligible for tPA and patients with intracerebral hemorrhage, timely, controlled BP may improve patient outcomes. Appropriate BP management, however, is still controversial given the heterogeneity of stroke subtypes, the varying attributes of candidate antihypertensive agents, and both local and central hemodynamics. Additionally, organizational delivery system factors may be suboptimal at some hospitals. Under current hospital stroke performance measures, payment mechanisms, and emergency department throughput measures, the impact of BP management may become transparent to patients and payers, and have important consequences for hospital-derived stroke outcomes.     

Longitudinal epidemiology of leptospirosis in the Czech Republic (1963-2003)

After higher rates of occupational or leisure diseases recorded in the Czech Republic in the second half of the last century it was found that the last climatic changes and catastrophic floods of 1997 and 2002 were followed by outbreaks of leptospirosis as the only re-emerging postflood infection. While in tropics and subtropics the monsoon season is typically followed by highly increased rates of leptospirosis in humans, even, with fatal outcomes, this phenomenon remained unknown under the climatic conditions of the Czech Republic where human leptospirosis has been reported rather sporadically, mostly in natural foci of infection, and its incidence rate is usually about 0.3% per 100,000 population. Nevertheless, after the unexpected vast floods of 1997 and 2002 that also afflicted natural foci of leptospirosis, the rates of reported and serologically confirmed cases of leptospirosis in the Czech Republic were three times as high as usual with the specific morbidity reaching 0.9 case per 100,000 population. In 1997, as many as 7156 persons were tested for leptospirosis in the Czech Republic: the disease was diagnosed and reported in 94 patients and in 2002, 92 out of 4999 persons tested were diagnosed with leptospirosis. Two thirds of these cases were from inundation areas, half of them being directly associated with floods (exposure to residual water, flood mud in cellars, etc.). Four case of Weil disease reported in 1997 were fatal. As many as 41 deaths from Weil disease have been reported in the Czech Republic since 1963 when the disease became reportable.     

Neonatal mortality in the Czech Republic during the transition

OBJECTIVES: To identify factors underlying the reduction in neonatal mortality in the Czech Republic during the 1990s and to identify scope for further improvements. DESIGN: Examination of trends in birth weight and birth weight specific neonatal mortality in the Czech Republic and comparison with figures from Sweden, which has one of the lowest neonatal mortality rates in Europe. SETTING: The Czech Republic. SUBJECTS: All singleton births occurring in the Czech Republic in 1989-1991 and 1994-1995, with a comparison group of all singleton births in Sweden in 1989-1991. MAIN OUTCOME MEASURES: Neonatal mortality rate. RESULTS: Despite a slight worsening in the birth weight distribution, the neonatal mortality rate in the Czech Republic fell from 5.6 to 3.8 per thousand live births. This was due to an improvement in the survival of infants at all birth weights but especially amongst the lightest. Eighty percent of the overall improvement was due to greater survival among those under 2500 g. Comparison with Swedish birth weight specific rates indicates that, for the country as a whole, only small additional gains are likely as a result of improved survival at a given birth weight but, instead, a reduction in the proportion of low birth weight babies would have a much greater effect. Regional analysis indicates that the improvements have been much greater in Prague than in the rest of the country. CONCLUSIONS: An effective strategy to reduce neonatal mortality in the Czech Republic should have two elements. The first is to address the socio-economic determinants of low birth weight. The second is to reduce regional inequalities in the quality of neonatal care. This should, however, be supplemented by more detailed investigation to identify specific amenable factors.     

Evaluation of local accessibility of homes for seniors using multi-criteria approach – Evidence from the Czech Republic

The availability of public services has been perceived as one of the parameters for evaluating the quality of services and a basic component of the effectiveness of the system. Social services have been understood as public services in the countries of the European Union. The state has the primary responsibility for ensuring the availability of social services and should have established powers in the areas of planning, coordination and evaluation. The aim of this paper is to comprehensively evaluate the availability of homes for seniors aggregated into individual districts of the Czech Republic. The method of multi-criteria decision-making was chosen for the evaluation, specifically the Technique for Order of Preference by Similarity to Ideal Solution in combination with the Coefficient of Variance method, as a method for the objective determination of the weights of input indicators. The evaluation in 2017 included 77 districts of the Czech Republic and 519 homes for seniors, which are registered providers of social services for persons who, due to age and reduced self-sufficiency, cannot take care of themselves and are users of residential social services. Based on 14 defined indicators, the local accessibility within individual districts of the Czech Republic was evaluated, focusing on five research questions. The indicators were defined in such a way as to reflect the nature of the problems and to define the need for this service in the territory. Based on the results, a significant relationship was demonstrated between the amount of subsidy per bed, per month, granted to homes for seniors in individual districts of the Czech Republic and service availability, i.e. districts in which homes for seniors with higher subsidies per bed show better availability.     

Acute Stroke Care at Rural Hospitals in Idaho: Challenges in Expediting Stroke Care

CONTEXT: Thrombolytics are currently the most effective treatment for stroke. However, the National Institute for Neurological Disorders and Stroke criteria for initiation of thrombolytic therapy, most notably the 3-hour time limit from symptom onset, have proven challenging for many rural hospitals to achieve. PURPOSE: To provide a snapshot of stroke care at rural hospitals in Idaho and to investigate the experiences of these hospitals in expediting stroke care. METHODS: Using a standard questionnaire, a telephone survey of hospital staff at 21 rural hospitals in Idaho was performed. The survey focused on acute stroke care practices and strategies to expedite stroke care. FINDINGS: The median number of stroke patients treated per year was 23.3. Patient delays were reported by 77.8% of hospitals, transport delays by 66.7%, in-hospital delays by 61.1%, equipment delays by 22.2%, and ancillary services delays by 61.1%. Approximately 67% of hospitals had implemented a clinical pathway for stroke and 80.0% had provided staff with stroke-specific training. No hospitals surveyed had a designated stroke team, and only 33.3% reported engaging in quality improvement efforts to expedite stroke care. Thrombolytics (tPA) were available and indicated for stroke at 55.6% of the hospitals surveyed. CONCLUSIONS: Rural hospitals in Idaho face many difficult challenges as they endeavor to meet the 3-hour deadline for thrombolytic therapy, including limited resources and experience in acute stroke care, and many different types of prehospital and in-hospital delays.     

Cost of informal care for stroke victims in a non-institutionalized general population

BACKGROUND: Stroke has a strong social impact since it causes disability, leading to dependency and the need for informal care. Although awareness of the importance of dependency is increasing, registries of the cost of informal care are lacking and consequently the real value of this activity to society is still unknown. OBJECTIVES: To calculate the cost of informal care of stroke victims in a general population, evaluate these costs according to patients' degree of dependency, and perform a one-way sensitivity analysis with variable unit costs from diverse sources. MATERIAL AND METHODS: Of all the patients with stroke diagnosed at 12-31-2004 (n = 95) among the population within a district health service of Navarre (Spain), 40 (44.4%) required informal care. Dependency for activities of daily life was evaluated by means of the Barthel (basic activities of daily life [BADL]) and Lawton-Brody indices (instrumental activities of daily life [IADL]). Time of informal care was evaluated following a bottom-up approach and diary survey method. RESULTS: The cost of the informal care of patients with stroke was 21,551.28 euros per year. According to the sensitivity analysis the range varied from 6,490.80 to 31,436.72 euros per year. Statistically significant differences in the cost of informal care were found according to patients' degree of dependency (BADL: 24,865.2 euros per year; IADL: 10,442.9 euros per year). CONCLUSIONS: The cost of informal care in ictus is high and is directly related to the degree of dependency.     

A review and commentary of the social factors which influence stroke care: issues of inequality in qualitative literature

Stroke is the third most common cause of death in the UK and a major cause of adult disability. Stroke services have long been criticised for being deficient and there is evidence that some aspects of care provision vary across different population groups. While there is information about the patterns of service provision, questions remain about processes which might underlie these variations. The present paper sought to assess how well the processes which might lead to inequity in the delivery and uptake of stroke services are currently understood by reviewing the qualitative literature in the area. The review was carried out by systematically searching online literature databases, using keyword and bibliographical searches, within a particular time frame. In total, 55 articles were reviewed, including studies related to primary and secondary clinical care, as well as social care. Articles focused on both professionals' and patients' perspectives. The review reports the cultural factors and processes which have been identified as possible causes of barriers to professionals' delivering stroke services, as well as issues which influence patients' uptake of services. Issues identified in the literature were categorised into four broad thematic areas: conceptualisations of stroke illness and ageing, socio-economic factors, resource allocation and information provision. These themes are then revisited through the hypothesis that the concept of social and personal identity could cast new light on our understanding of how inequity in stroke care provision might arise. It is argued that the ways in which professionals and patients view themselves and each other influences their interaction, and in turn, the delivery and demand for services. Finally, the authors suggest areas where further research is warranted.     

Determinants of outcome in patients eligible for thrombolysis for ischemic stroke

Objectives

Eligibility criteria for thrombolysis in ischemic stroke have been clearly defined. However, not all eligible patients benefit from this treatment. This study aimed to assess the determinants for clinical outcome in consecutive, eligible patients with ischemic stroke treated with thrombolysis in a single-center study.

Methods

Consecutive patients with ischemic stroke were treated with tissue plasminogen activator (t-PA) following the established eligibility National Institute of Neurological Disorders and Stroke (NINDS) and European Stroke Initiative (EUSI) criteria. Risk factors including blood pressure and pre-treatment glycemia were properly managed. Death and disability at 3 months were the study outcomes. Disability was evaluated by the Rankin-scale. Favorable outcome was defined as 0–2 and adverse outcome as 3–6 including death.

Results

Seventy-eight patients were included in the study in a single stroke unit. The mean age was 70.9 ± 13.2 years (range 36–94). Follow-up at 3 months was completed in 73 patients. A favorable outcome was observed in 37 patients (50%) and adverse outcome in 36 (36%). Nine patients (12.3%) died within 3 months. The presence of an occluded carotid artery was a strong predictor for adverse outcome (p < 0.0001). A low NIH Stroke Scale-Score (NIHSS) at admission was a associated with a favorable outcome, while history of diabetes mellitus led to an unfavorable outcome.

Conclusion

Among patients eligible for thrombolysis, many do not benefit from this treatment. These include patients with carotid occlusion and diabetes.     

Occupational diseases in the Czech Republic in the year 1998. The need for unifying European standards/criteria for all occupational diseases

In the Czech Republic, the Clinics and Departments for Occupational Medicine according to the legislation have the right to recognise occupational diseases. The diagnosis must correspond to the Czech list of occupational diseases, which is similar to the European list of occupational diseases. The exposure, sufficient enough to cause certain occupational disease, must be confirmed by regional industrial hygienists, responsible for hygienic control of the workplace. It is evident that the number of diseases is very much dependent upon the standards/criteria used to recognise occupational diseases. In the Czech Republic, the patients suffering from occupational diseases are given considerable financial compensations, which creates a great motivation for them to apply for occupational diseases. The article presents the overview of occupational diseases in the Czech Republic in the year 1998. The total number of diseases was 2111, the incidence per 100,000 employees was 45.8. It is necessary to present and discuss unifying criteria for occupational diseases in European countries, as well as the minimum level of the damage, that could be called an occupational disease. The criteria should be co-ordinated, because in a unified Europe, there will be many more possibilities for change in the workplace.     

Ein Ansatz zur bevölkerungsbezogenen Auswertung der deutschen Influenza-Sentineldaten

The influenza surveillance in many countries is based on the registration of consultations in primary care facilities. Partly as a result of differences in the health care systems, the definitions used for the numerator and denominator when calculating morbidity rates are different. In Germany the number of persons each physician cares for is unknown because the patients can choose the GP to be contacted for each consultation. Hence population cannot directly be used as denominator. Population based figures are useful to estimate the burden of disease and support the comparability with data from other countries. The following article describes an approach to calculate population based consultation incidences for different age groups from the German sentinel data. The total number of GPs active in primary care is used as linkage to population. The care for the younger age groups is split between pediatricians and GPs. As a consequence the calculation of the consultation incidence in the younger age groups considers both professional groups separately. The part of both groups regarding the care for a particular age group is estimated. The results for the season 1999/2000 indicate a decrease of the consultation incidence due to ARE with increasing age. In opposition the relative elevation of the ARE during influenza waves increases with age due to the smaller background morbidity. The estimated consultation incidence for the whole population is in reasonable accordance to the data from the Czech Republic where ARE per population are recorded.     

Nutritional management of stroke: from current evidence to conjecture

Summary   Stroke is a leading cause of death and adult disability in the Western world. Diet is an important consideration as there is evidence that around half of stroke patients are undernourished on admission to hospital and their nutritional status often declines during the hospital stay. Undernutrition is associated with both increased morbidity and mortality. There have been many studies that have looked at various aspects of feeding in stroke patients, and guidelines are available for clinicians and healthcare workers involved in the care of stroke patients. The present paper aims to review current evidence underpinning guidelines on nutritional management of stroke patients, identify potential barriers to implementation and highlight areas for future research.     

The FINMONICA Stroke Register. Community-based stroke registration and analysis of stroke incidence in Finland, 1983-1985.

In the early 1980s, a standardized community-based stroke register was started in three geographic areas in Finland: North Karelia and Kuopio in eastern Finland and Turku/Loimaa in southwestern Finland. The results from the first 3 years, 1983-1985, confirmed the high incidence of stroke in Finland. The incidence of stroke was higher in eastern Finland than in the southwestern part of the country. The age-standardized annual incidence among men aged 25-74 years varied from 206 per 100,000 population in southwestern Finland to 322 per 100,000 population in the province of Kuopio in eastern Finland. Among women aged 25-74, incidence was 119 and 187 per 100,000 population in these two areas, respectively. The age-standardized male:female ratio in incidence was 1.7, slightly higher than that previously reported in Finland. Out of 3,574 stroke events registered, 78% were first events without a history of previous stroke. People aged 65-74 years accounted for 45% of all events among men and 62% of all events among women. The authors' experience shows that the geographic variation in stroke incidence and attack rates is difficult to assess even within a country with a relatively uniform health care system. Rigorous standardization and quality control is needed for the assessment of long-term trends; this is the primary goal of the FINMONICA Stroke Register. The findings of this study suggest that the incidence of stroke is still high in Finland, although mortality from stroke has steeply declined during the past 15-20 years. The number of stroke survivors in Finland may actually be increasing. Since the occurrence of stroke is high in Finland as compared with other countries, intensified primary and secondary prevention measures are needed to reduce it.     

Thrombolysis and its implications in the management of stroke in the accident and emergency department

OBJECTIVES: Examination of initial management of stroke patients in the emergency setting to assess feasibility of thrombolysis for acute ischaemic stroke. METHODS: Retrospective analysis of all patients presenting with a clinical diagnosis of stroke over a two month period. Exclusion criteria for thrombolysis were applied to assess the number of patients that would potentially have been eligible for thrombolysis. RESULTS: Of 94 patients identified with clinical stroke, only 57 (60.6%) had a CT scan; 23 (24.4%) were confirmed as having had an acute ischaemic stroke. Mean delay in scanning was 2.2 days (range 0-15 days). Even if all patients had presented and been scanned within three hours (as required for thrombolysis), only six (6.4%) patients would have been eligible for thrombolysis. CONCLUSIONS: The great majority of patients presenting with clinical stroke do not fulfill the criteria for thrombolysis. Current practice involves significant delays in CT scanning, which has implications for resource structuring should thrombolysis become widely available.     

Volunteering and mutual aid in health and social care in the Czech Republic as an example of active citizenship

This article informs about recent research findings on voluntary and mutual aid in the Czech Republic with a special attention paid to formal volunteering in health and social care. The data suggest that public involvement is comparable to middle-frequency experienced in European countries. In this respect, volunteering is higher in the Czech Republic than in other former Eastern European countries and is an evidence of a successful and rapid restoration of the civic sector. New patterns of volunteering featured by planning, coordination, and contracting have spread out being strongly supported by national and EU policy measures. Managerial patterns of volunteering are dominating in health and social care institutions. Volunteering in health and social care is firmly motivated by emotional altruism; however, reciprocal (instrumental) and normative motivations are also present, though to a lesser extent compared to other sectors of volunteer activities. In the managerial pattern of volunteering altruism is balanced with personal gains and benefits for those who volunteer. Volunteering is deeply embedded in a civic, humanitarian paradigm instead of a religious faith and duty.