Establishment of Government-Initiated Comprehensive Stroke Centers for Acute Ischemic Stroke Management in South Korea

Kim, Jei; Hwang, Younghun; Kim, Joon‐Tae; Choi, Nack-Cheon; Kang, Sa-Yoon; Cha, Jae‐Kwan; Ha, Yeon Soo; Shin, Dong‐Ick; Kim, Seongheon; Lim, Byeong Hoon

doi:10.1161/strokeaha.114.006134

Cited by 40 publications

(29 citation statements)

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“…3,4 Worldwide, stroke physicians have implemented continuous quality improvement programs to accelerate delivery of tPA, steadily reducing door-to-needle (DTN) times. [5][6][7] To guide further improvement of tPA delivery, it would be helpful to clarify 2 aspects of the time dependence of tPA benefit: (1) the additional benefit associated with hyperacute treatment in the first 60 minutes after last known well time, and (2) the shape of the time-benefit curve of tPA through 4.5 hours.…”

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confidence: 99%

Treatment With Tissue Plasminogen Activator in the Golden Hour and the Shape of the 4.5-Hour Time-Benefit Curve in the National United States Get With The Guidelines-Stroke Population

et al. 2017

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Background: Earlier tissue plasminogen activator treatment improves ischemic stroke outcome, but aspects of the time-benefit relationship still not well delineated are: (1) the degree of additional benefit accrued with treatment in the first 60 minutes after onset, and (2) the shape of the time-benefit curve through 4.5 hours. Methods: We analyzed patients who had acute ischemic stroke treated with intravenous tissue plasminogen activator within 4.5 hours of onset from the Get With The Guidelines-Stroke US national program. Onset-to-treatment time was analyzed as a continuous, potentially nonlinear variable and as a categorical variable comparing patients treated within 60 minutes of onset with later epochs. Results: Among 65 384 tissue plasminogen activator–treated patients, the median onset-to-treatment time was 141 minutes (interquartile range, 110–173) and 878 patients (1.3%) were treated within the first 60 minutes. Treatment within 60 minutes, compared with treatment within 61 to 270 minutes, was associated with increased odds of discharge to home (adjusted odds ratio, 1.25; 95% confidence interval, 1.07–1.45), independent ambulation at discharge (adjusted odds ratio, 1.22; 95% confidence interval, 1.03–1.45), and freedom from disability (modified Rankin Scale 0–1) at discharge (adjusted odds ratio, 1.72; 95% confidence interval, 1.21–2.46), without increased hemorrhagic complications or in-hospital mortality. The pace of decline in benefit of tissue plasminogen activator from onset-to-treatment times of 20 through 270 minutes was mildly nonlinear for discharge to home, with more rapid benefit loss in the first 170 minutes than later, and linear for independent ambulation and in-hospital mortality. Conclusions: Thrombolysis started within the first 60 minutes after onset is associated with best outcomes for patients with acute ischemic stroke, and benefit declined more rapidly early after onset for the ability to be discharged home. These findings support intensive efforts to organize stroke systems of care to improve the timeliness of thrombolytic therapy in acute ischemic stroke.

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Treatment With Tissue Plasminogen Activator in the Golden Hour and the Shape of the 4.5-Hour Time-Benefit Curve in the National United States Get With The Guidelines-Stroke Population

et al. 2017

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“…Even though the US and several European countries have established such centers (Gorelick, 2013; Leys, Ringelstein, Kaste, & Hacke, 2007), other countries face economic and expertise‐related limitations. Governments, including that of South Korea, should rapidly establish comprehensive stroke centers (Kim et al., 2014). …”

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Cost benefits of rapid recanalization using intraarterial thrombectomy

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ObjectivesThrombolytic therapy is associated with favorable clinical outcomes after successful and rapid recanalization in patients with acute ischemic stroke. This study aimed to evaluate the cost benefits and clinical outcomes at 1 year after intraarterial thrombectomy (IAT) by the rapidity of the successful recanalization.Materials & MethodsClinical outcomes of and medical costs incurred by 230 patients with acute ischemic stroke who underwent IAT were compared by the rapidity from symptom onset to successful recanalization (2b/3 thrombolysis in cerebral infarction grade): ≤6‐hr (n = 143), >6‐hr (n = 31), and no‐recanalization (n = 56). Clinical outcomes including functional independence (0–2 modified Rankin Score), mortality, and home‐discharge checked at 1 year post‐IAT were compared among the three groups. Cost utility was calculated using quality‐adjusted life years (QALY) estimated using the EuroQol‐5 dimensions‐3 levels questionnaire and the fees paid for institutional rehabilitation during the year post‐IAT, and, was compared among the groups.ResultsPatients in the ≤6‐hr group showed higher functional independence (≤6‐hr, 70%; >6‐hr, 40%; no‐recanalization, 6%, p < .001) and home‐discharge rate (73%, 52%, 21%, and respectively, p < .001), and lower mortality (10%, 16%, and 43%, respectively, p < .001) at 1 year after IAT than other two groups. The cost utility of the ≤6‐hr group was $35,557/QALY higher than that of the >6‐hr group, and $27.829/QALY higher than no‐recanalization group.ConclusionsRapid and successful recanalization of the occluded intracranial vessels within 6 hr after the onset of symptoms resulted in markedly higher cost utility and functional independence at 1 year post‐IAT.

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“…Dünya genelinde geçerli olan bu durumun çözümü için bazı stratejiler geliştirilmiştir. Özellikle kırsal kesimde mevcut olan bu sorunları çözmeye yönelik olarak devlet kontrolünde inme merkezlerinin sayısı arttırılmış, tele-tıp ağları kurulmuş, kimi yerlerde de "başla ve yönlendir" stratejisi uygulanmaya başlanmıştır (11,12,13,14,15,16). Son yıllarda yaygınlaşarak kullanılmaya başlanan bu stratejiler sayesinde ilgili bölgelerde trombolitik tedavi verilme oranları artmış, prognostik verilerde de iyileşme sağlanmıştır.…”

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“…İnme merkezleri, yalnızca zorlu inme olgularının bakımı için önemli olmakla kalmayıp, asistan eğitiminde inme pratiğinin etkili bir biçimde verilebilmesi için gereklidir ve trombolitik tedavi uygulanması için koordinasyonu sağlayan merkezler konumundadırlar. Sayılarının ülke genelinde arttırılması inme tanı ve tedavisi açısından kritik önem taşıyan noktalardan biridir (15).…”

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Acute Stroke Through the Perspective of a County Hospital: Problems and Opportunities

Vural¹

2016

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Amaç: İnme dünya çapında en önemli halk sağlığı problemlerinden biri olup, ülkemizdeki mortalite sebepleri arasında ikinci sırada yer alır. İnme sonrası prognozun ve sağkalımın iyileştirilmesi amacıyla kullanılan en önemli yöntemlerden biri, ülkelerin kendi inme istatistiklerini düzenli olarak takip etmeleri ve eksik noktalarını tespit ederek gerekli önlemleri almalarıdır. Bunun için, sağlık hizmetlerinin çeşitli basamaklarında gerçekleştirilmiş istatistiksel çalışmalara ihtiyaç vardır. Bu tarz çalışmalar genellikle üçüncü basamak araştırma hastanelerinde gerçekleştirilebilmektedir. Nüfusun önemli bir kısmının tedavi edildiği ikinci basamaktaki durum ise bilinmemektedir. Bu çalışmanın amacı, bir ilçe hastanesine bir yıl boyunca başvuran tüm akut inmeli hastaları inceleyerek, konuyla ilgili veri sağlamak, eksiklikleri tartışmak ve çözüm önerileri sunmaktır. Gereç ve Yöntem: Temmuz 2013-Temmuz 2014 tarihleri arasında akut iskemik inme tanısı konulan tüm hastalar çalışmaya dahil edilmiştir. Hastaların demografik, klinik, radyolojik verileri ile başvuru süre ve Ulusal İnme Sağlık Ölçeği Skalası 'National Institutes of Health Stroke Scale' (NIHSS) skorları retrospektif olarak toplanmış, inme sınıflandırmaları yapılmıştır. Tüm hastalar inme sonrası en az bir yıl süreyle takip edilmiştir ve kümülatif sağkalım oranları Kaplan-Meier analiziyle hesaplanmıştır. Bulgular: Akut inme tanısı konulan 49 hastadan dördünde hemorajik inme saptanmış, iskemik inme tanısı alan 45 hasta çalışmaya dahil edilmiştir. Bu hastaların %44,4'ü (n=20) belirtilerin başlangıcını takiben ilk üç saatte, %4,4'ü (n=2) 3.-4,5. saatler arasında hastaneye başvurmuştur. İlk üç saatte başvuran hastaların %50'sinde (n=10) NIHSS 1-4 arası (hafif inme), diğer %50'sinde (n=10) NIHSS >=5 (orta veya ağır inme) tespit edilmiştir. Hastaların %37,1'inde (n=13) embolik, %20'sinde (n=7) büyük damar aterosklerozu, %8,6'sında (n=3) küçük damar hastalığı, %2,9'unda (n=1) arterial diseksiyon saptanırken, geri kalan %31,4'ünde (n=11) sebep bulunamamıştır. Hastaların 21'inde takipte ölüm (exitus) gelişmiştir. Bir, üç ve on iki aylık sağkalım oranları sırası ile %82,2, %57,8 ve %53,3 olarak hesaplanmıştır. Sonuç: Akut iskemik inmeli hastaların ikinci basamakta tedavisi üçüncü basamağa göre daha zor şartlarda gerçekleştirilmektedir. İnme sonrası prognozun ülke genelinde iyileştirilebilmesi için gelişmiş ülkelerdekine benzer önlemlerin ülkemiz şartlarına uyarlanarak uygulanması gerekmektedir. Anahtar Kelimeler: İnme, halk sağlığı, sağkalım Objective: Stroke is one of the most important public health issues worldwide, and ranks as the second highest cause of mortality in our country. Regular follow-up of stroke statistics and taking necessary precautions upon determining deficits by countries themselves constitute the most important way of improving prognosis and survival after stroke incidents. To achieve this goal, statistical studies should be performed at various levels of healthcare services. Tertiary care hospitals are the most suitable centers to perform these studies...

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Establishment of Government-Initiated Comprehensive Stroke Centers for Acute Ischemic Stroke Management in South Korea

Cited by 40 publications

References 17 publications

Treatment With Tissue Plasminogen Activator in the Golden Hour and the Shape of the 4.5-Hour Time-Benefit Curve in the National United States Get With The Guidelines-Stroke Population

Treatment With Tissue Plasminogen Activator in the Golden Hour and the Shape of the 4.5-Hour Time-Benefit Curve in the National United States Get With The Guidelines-Stroke Population

Cost benefits of rapid recanalization using intraarterial thrombectomy

Acute Stroke Through the Perspective of a County Hospital: Problems and Opportunities

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