Impact on Clinical and Cost Outcomes of a Centralized Approach to Acute Stroke Care in London: A Comparative Effectiveness Before and After Model

Hunter, Rachael; Davie, Charlie; Rudd, Anthony; Thompson, Alan; Walker, Hilary; Thomson, Neil C.; Mountford, James; Schwamm, Lee H.; Deanfield, John; Thompson, Kim M.; Dewan, Bikash; Mistry, Manesh V.; Quoraishi, Sadik; Morris, Stephen

doi:10.1371/journal.pone.0070420

Cited by 86 publications

(86 citation statements)

References 9 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Some of these, such as the apparent fall in mortality rates after the reorganisation of acute stroke services in London, have been widely publicised 5 and could have important implications nationwide. Differences among centres participating in cluster-randomised trials, in the proportion of stroke admissions included, could also seriously affect the interpretation of results.…”

Section: Discussionmentioning

confidence: 99%

Effects of diagnostic uncertainty and misclassification on hospital performance indicators for acute stroke care

Barer

Cassidy

2014

Clinical Medicine

View full text Add to dashboard Cite

Effects of diagnostic uncertainty and misclassifi cation on hospital performance indicators for acute stroke careThe Stroke Improvement National Audit Programme (SINAP), now replaced by the Sentinel Stroke National Audit Programme, was established to provide comparative data on hospital performance indicators for stroke, but comparisons are only valid if case ascertainment is complete. In Gateshead we compared initial results from SINAP with those from a pre-existing hospital stroke register, which ran independently for 11 months after SINAP's introduction in 2010, as well as with Hospital Episode Statistics (HES) data. Of 315 confi rmed acute stroke cases identifi ed from the three combined data sources, 96 (30%) were omitted from SINAP and 51 (16%) were missed by HES. Of 478 suspected strokes in the combined datasets, 214 were either misclassifi ed by HES or remained with uncertain diagnosis. These patients had much lower mortality and shorter hospital stays than those with confi rmed stroke. This diagnostic uncertainty could be an important source of uncontrolled variation in, or even a potential target for manipulation of, hospital performance indicators for stroke.

show abstract

Section: Discussionmentioning

confidence: 99%

Effects of diagnostic uncertainty and misclassification on hospital performance indicators for acute stroke care

Barer

Cassidy

2014

Clinical Medicine

View full text Add to dashboard Cite

show abstract

“…One study of A&E centralisation in Sheffield 15 found that the centralised model was more costly. A more recent study of the centralisation of stroke services in London 16 was more positive in its findings.…”

Section: Reconfiguration and The Evidence To Support Itmentioning

confidence: 95%

“…The new model has been formally evaluated. 16 The conclusion of this before-and-after study was that London's centralised model for acute stroke care had reduced mortality for a reduced cost per patient, predominantly as a result of reduced hospital length of stay. However, the authors recognise the limitations of a before-and-after study versus a randomised control trial and noted that further research would be required to assess whether or not the London model is viable in other geographical and clinical settings.…”

Section: Professional Guidance and Evidence From The Literaturementioning

confidence: 99%

Insights from the clinical assurance of service reconfiguration in the NHS: the drivers of reconfiguration and the evidence that underpins it – a mixed-methods study

Imison

Sonola

Honeyman

et al. 2015

Health Services and Delivery Research

View full text Add to dashboard Cite

BackgroundOver the life of the NHS, hospital services have been subject to continued reconfiguration. Yet it is rare for the reconfiguration of clinical services to be evaluated, leaving a deficit in the evidence to guide local reconfiguration of services.ObjectivesThe objectives of this research are to determine the current pressures for reconfiguration within the NHS in England and the solutions proposed. We also investigate the quality of evidence used in making the case for change, any key evidence gaps, and the opportunities to strengthen the clinical case for change and how it is made.MethodsWe have drawn on two key sources of evidence. First, we reviewed the reports produced by the National Clinical Advisory Team (NCAT) documenting its reviews of reconfiguration proposals. An in-depth multilevel qualitative analysis was conducted of 123 NCAT reviews published between 2007 and 2012. Second, we carried out a search and synthesis of the literature to identify the key evidence available to support reconfiguration decisions. The findings from this literature search were integrated with the analysis of the reviews to develop a narrative for each specialty and the process of reconfiguration as a whole.ResultsThe evidence from the NCAT reviews shows significant pressure to reconfigure services within the NHS in England. We found that the majority of reconfiguration proposals are driving an increasing concentration of hospital services, with some accompanying decentralisation and, for some specialist services, the development of supporting clinical networks. The primary drivers of reconfiguration have been workforce (in particular the medical workforce) and finance. Improving outcomes and safety issues have been subsidiary drivers, though many make the link between staffing and clinical safety. Policy has also been a notable driver. Access has been notable by its absence as a driver. Despite significant pressures to reconfigure services, many proposals fail to be implemented owing to public and/or clinical opposition. We found strong evidence that some specialist service reconfiguration including vascular surgery and major trauma can significantly improve clinical outcomes. However, there are notable evidence gaps. The most significant is the absence of evidence that service reconfiguration can deliver significant savings. There is also an absence of evidence about safe staffing models and the interplay between staff numbers, skill mix and outcomes. We found that the advice provided by the NCAT reflects the current evidence, but one of the NCAT’s most valuable contributions has been to encourage greater clinical engagement in service change.ConclusionsThe NHS is continuing to concentrate many district general hospital services to resolve financial and workforce pressures. However, many proposals are not implemented owing to public opposition. We also found no evidence to suggest that this will deliver the savings anticipated. There is a significant gap in the evidence about safe staffing models and the appropriate balance of junior and senior medical as well as other clinical staff. There is an urgent need to carry out research that will help to fill the current evidence gap. There is also a need to retain some national clinical expertise to work alongside Clinical Senates in supporting local service reconfiguration.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

show abstract

“…Telestroke networks are important tools for diagnostic and treatment support of acute stroke patients for less well-resourced hospitals and also for the referral of selected patients to more qualified institutions. Telestroke has been proved to be a safe, efficient and cost-effective strategy for stroke care 30 .…”

Section: Trained Specialists and Telemedicinementioning

confidence: 99%

Endovascular thrombectomy for the treatment of acute ischemic stroke

Ferri

Buehler

Flato

et al. 2015

Arq. Neuro-Psiquiatr.

View full text Add to dashboard Cite

Few patients benefit from the current standard treatment for acute ischemic stroke (AIS), encouraging the development of new treatments. Objective To systematically review the literature on the efficacy and/or safety of endovascular thrombectomy in AIS compared to standard treatment and to identify ongoing randomized controlled trials (RCTs). Method Searches for RCTs were performed in Medline/Embase, and for ongoing trials: International Clinical Trial Registry Platform, Clinicaltrials.gov and ISRCTN registry (to June 15th, 2015). Results From the eight published RCTs, five showed the superiority of treatment that includes thrombectomy compared to standard care alone. From the 13 ongoing RCTs, 3 have been halted, one has not started, one has unknown status and eight will end between 2016 - 2020. Conclusion Evidence favours a combination of the standard therapy with endovascular thrombectomy. The selection criteria however limit the number of people who can benefit. Further studies are needed to prove its cost-effectiveness.

show abstract

Impact on Clinical and Cost Outcomes of a Centralized Approach to Acute Stroke Care in London: A Comparative Effectiveness Before and After Model

Cited by 86 publications

References 9 publications

Effects of diagnostic uncertainty and misclassification on hospital performance indicators for acute stroke care

Effects of diagnostic uncertainty and misclassification on hospital performance indicators for acute stroke care

Insights from the clinical assurance of service reconfiguration in the NHS: the drivers of reconfiguration and the evidence that underpins it – a mixed-methods study

Endovascular thrombectomy for the treatment of acute ischemic stroke

Contact Info

Product

Resources

About