Statewide Efforts to Narrow the Rural–Urban Gap in Acute Stroke Care

Okon, Nicholas J; Fogle, Crystelle C.; McNamara, Michael J.; Oser, Carrie S.; Dietrich, Dennis W.; Gohdes, Dorothy; Harwell, Todd S.; Rodriguez, Daniel; Helgerson, Steven D.

doi:10.1016/j.amepre.2010.05.019

Cited by 13 publications

(10 citation statements)

References 24 publications

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“…Previous studies used to examine the effectiveness of programs to improve rural stroke care using audit or self-reported surveys 18,19 have shown similar improvements in adherence to clinical process indicators consistent with our study. Strengths of the current study are that we included detailed patient characteristics for case-mix adjustment in multivariable models, a large range of clinical process indicators that have reliably been collected and a range of important patient outcomes after hospitalization for stroke.…”

Section: Discussionsupporting

confidence: 80%

“…1,17 Even considering the potential lack of resources, infrastructure, and specialist personnel in rural settings, there is some suggestive evidence that implementing service improvement initiatives, such as peer support and use of protocols, in rural areas can improve the quality of stroke care. 18,19 However, it is still unclear whether introducing elements of organized stroke care, such as clinical coordinators and SUs, within rural settings can reduce evidence-practice gaps as found with metropolitan hospitals. 8 As part of this Implementation of hub-and-spoke system of care …”

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confidence: 99%

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Evaluation of Rural Stroke Services

Cadilhac

Purvis

Kilkenny

et al. 2013

Stroke

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Furthermore, only 4% to 5% of the 91 rural hospitals that responded to a national survey had an SU or access to neurologists, <50% used a care pathway, and only 32% had a clinical nurse specialist for stroke.3 With ≈7 million residents, New South Wales (NSW) is the most populated state in Australia, 9 and almost a third of this population live in rural areas.11 Similar to many locations, variability in the provisionBackground and Purpose-The quality of hospital care for stroke varies, particularly in rural areas. In 2007, funding to improve stroke care became available as part of the Rural Stroke Project (RSP) in New South Wales (Australia). The RSP included the employment of clinical coordinators to establish stroke units or pathways and protocols, and more clinical staff. We aimed to describe the effectiveness of RSP in improving stroke care and patient outcomes. Methods-A historical control cohort design was used. Clinical practice and outcomes at 8 hospitals were compared using 2 medical record reviews of 100 consecutive ischemic or intracerebral hemorrhage patients ≥12 months before RSP and 3 to 6 months after RSP was implemented. Descriptive statistics and multivariable analyses of patient outcomes are presented. Results-Sample: pre-RSP n=750; mean age 74 (SD, 13) years; women 50% and post-RSP n=730; mean age 74 (SD,13) years; women 46%. Many improvements in stroke care were found after RSP: access to stroke units (pre 0%; post 58%, P<0.001); use of aspirin within 24 hours of ischemic stroke (pre 59%; post 71%, P<0.001); use of care plans (pre 15%; post 63%, P<0.001); and allied health assessments within 48 hours (pre 65%; post 82% P<0.001). After implementation of the RSP, patients directly admitted to an RSP hospital were 89% more likely to be discharged home (adjusted odds ratio, 1.89; 95% confidence interval, 1.34-2.66). Conclusions-Investment in clinical coordinators who implemented organizational change, together with increased clinician resources, effectively improved stroke care in rural hospitals, resulting in more patients being discharged home.

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Section: Discussionsupporting

confidence: 80%

mentioning

confidence: 99%

Evaluation of Rural Stroke Services

Cadilhac

Purvis

Kilkenny

et al. 2013

Stroke

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“…In those cases, rather than mandating a location, a MCM could be used by a state institution to decide how many additional centers are needed and in which hospitals they should concentrate educational efforts and incentives to promote PSC certification. 17 A MCM would be the basis for a rational justification by location that can be used to incentivize the process in smaller institutions. This approach might also be useful for other acute stroke care applications such as to find the best locations for remote centers for telemedicine networks by identifying recombinant tissuetype plasminogen activator-ready hospitals as key steps in the regionalization process, 18 or identifying the best centers for a spoke-and-hub comprehensive stroke center network.…”

Section: Discussionmentioning

confidence: 99%

Primary Stroke Centers Should Be Located Using Maximal Coverage Models for Optimal Access

Leira¹,

Fairchild²,

Segre³

et al. 2012

Stroke

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Background and Purpose-The current self-initiated approach by which hospitals acquire Primary Stroke Center (PSC) certification provides insufficient coverage for large areas of the United States. An alternative, directed, algorithmic approach to determine near optimal locations of PSCs would be justified if it significantly improves coverage. Methods-Using geographic location-allocation modeling techniques, we developed a universal web-based calculator for selecting near optimal PSC locations designed to maximize the population coverage in any state. We analyzed the current PSC network population coverage in Iowa and compared it with the coverage that would exist if a maximal coverage model had instead been used to place those centers. We then estimated the expected gains in population coverage if additional PSCs follow the current self-initiated model and compared it against the more efficient coverage expected by use of a maximal coverage model to select additional locations. Results-The existing 12 self-initiated PSCs in Iowa cover 37% of the population, assuming a time-distance radius of 30 minutes. The current population coverage would have been 47.5% if those 12 PSCs had been located using a maximal coverage model. With the current self-initiated approach, 54 additional PSCs on average will be needed to improve coverage to 75% of the population. Conversely, only 31 additional PSCs would be needed to achieve the same degree of population coverage if a maximal coverage model is used. Conclusion-Given the substantial gain in population access to adequate acute stroke care, it appears justified to direct the location of additional PSCs or recombinant tissue-type plasminogen activator-capable hospitals through a maximal coverage model algorithmic approach. (Stroke. 2012;43:2417-2422.)

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“…Bu sorunlar ve çözüm önerileri literatürdeki veriler ışığında, ülkemizdeki özel koşullar da eklenerek Tablo 2'de özetlenmiştir (25,26,27,28). Gerekli düzenlemeler yapıldığı takdirde inme hastalarına bakım daha iyi bir seviyeye çıkarılabilecektir.…”

Section: Sonuçunclassified

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

Vural¹

2016

tnd

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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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Statewide Efforts to Narrow the Rural–Urban Gap in Acute Stroke Care

Cited by 13 publications

References 24 publications

Evaluation of Rural Stroke Services

Evaluation of Rural Stroke Services

Primary Stroke Centers Should Be Located Using Maximal Coverage Models for Optimal Access

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

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