Continuum Of Stroke Care Research Articles

Toward a more effective approach to stroke: Canadian Best Practice Recommendations for Stroke Care

Each year more than 50,000 Canadians experience a stroke and more than 300,000 currently live with its effects. Despite the evidence supporting best practices in stroke care, significant gaps in translating this knowledge into action remains in Canada. An interdisciplinary working group of the Canadian Stroke Strategy was formed to develop best-practice recommendations relevant to Canadian health care. The working group used a rigorous process to develop the guidelines, which included reviewing existing stroke recommendations and research literature, and consulting a national interprofessional consensus panel. The Canadian Best Practice Recommendations for Stroke Care consist of 24 recommendations based on the strongest evidence and address topics that span the full continuum of stroke care. Implementation and dissemination of these recommendations is in progress. Bringing about change will require political will and collaboration throughout the health care system.

Poststroke Care

See related article, pages 1899–1904. “Thinking is easy, acting is difficult, and to put one’s thoughts into action is the most difficult thing in the world”. — —Goethe (1749–1832) Major advances in acute stroke management have been seen over the past decade, including the use of thrombolysis, antithrombotic therapy, and organized in-hospital stroke care. However, relatively few studies have evaluated the effectiveness of these interventions in routine clinical practice, or have assessed issues related to delivery of services, access to care, and long-term care after discharge from stroke. In this issue of Stroke , Bravata et al1 contribute to our understanding of outcomes after stroke by analyzing readmissions and deaths in the first 5 years after a hospitalization for stroke. The target population included stroke survivors aged over 65 years who were Medicare beneficiaries and who were discharged from Connecticut acute care hospitals in 1995. This population was followed from discharge in 1995 through 2000 using Medicare claims and Social Security Administration mortality data. Among 2603 patients discharged alive, 40% were readmitted at least once within the first year of discharge, 53% had died or been readmitted within 1 year and only 15% survived admission-free for 5 years. Leading causes for readmission included pneumonia (8.2% to 9.0%), stroke (3.9% to 6.1%) and acute myocardial infarction (4.2% to 6.0%). There was no apparent association between length of hospital stay and readmission rate (unreported data kindly provided by the authors, 2007), and no information was available on potential patient and system factors associated with higher hospital readmission rates. Lower readmission rates of 25% to 27% within 1 year have been previously reported.2,3 These studies found that the average number of days of rehospitalization was 23.2 Stroke was the single most frequent reason for readmission followed by cardiac disease, …

Practice Style Traits: Do they help explain practice behaviours of stroke rehabilitation professionals?

The gap in knowledge translation from research to clinical practice is under scrutiny in stroke rehabilitation. One possible reason for this gap may be a poor understanding of clinicians' practice style traits and how they influence practice behaviours. To identify the prevalence of practice style traits in physical therapists and occupational therapists working in stroke rehabilitation and, to explore associations between these traits and practice behaviours, where practice behaviours are defined as the clinicians' reasons for choosing assessments and interventions used in practice. The influence of more traditional personal and organizational factors on practice behaviours was also explored. Cross-sectional survey of a representative random sample of 243 clinicians (117 occupational therapists and 126 physical therapists) working across the continuum of stroke care in Ontario, Canada. A telephone-administered validated clinical practice survey elicited information in 4 areas: practice style traits using the validated Practice Style Questionnaire, therapists' reasons for choosing assessments and interventions (practice behaviours), personal factors and organizational factors. For both disciplines, the most prevalent trait was pragmatist and the least prevalent was seeker. Seekers were the most likely to use evidence-based reasons for choosing assessments, but this finding did not reach significance (chi2 = 5.430, df = 3; p = 0.14). The most typical reason for choosing an intervention was that the clinician had learned it during professional training, an interesting finding given that approximately half of clinicians had more than 10 years of experience. Of the 21 potential explanatory variables examined, few explained clinicians' reasons for choosing assessments or interventions. While understanding practice traits is not going to be the single solution to closing the knowledge translation gap, it may help to guide best practice implementation strategies.

Advancing Nursing Practice

Both patient and staff satisfaction with the SNP role has been high as it relates to quality of care delivery and accessibility of care and service. In particular, patients express satisfaction with the continuity of care experienced throughout the stroke care continuum, from acute in-hospital care to postdischarge follow-up. Improvements have been realized in systems and processes of care with the implementation of the SNP role. These include reductions in door-to-needle times in the administration of tPA (from 90 minutes to 60 minutes), rapid assessment and diagnostic interventions through coordination of are activities (e.g., door-to-CT scan times reduced from 60 minutes to 30 minutes), and faster consultation responses within the organization. Instituting the nurse practitioner role early in the development of the Calgary Stroke Program enhanced patient care while advancing the nursing discipline. The SNP has created a role that extends beyond that of physician helper to an autonomous nursing practice that has been beneficial to both patients with stroke and the regional healthcare delivery system. With the ability to practice autonomously, the nurse practitioner can aid in the expedient delivery of complex, comprehensive stroke care, as has been the case in the Calgary Stroke Program.

Prioritizing interventions to improve rates of thrombolysis for ischemic stroke

Thrombolytic treatment has been shown to be effective in the treatment of ischemic stroke when initiated within 3 hours of symptom onset, yet few patients receive thrombolytics. To estimate expected increases in use of thrombolytics for ischemic stroke given the following interventions: educating patients to present earlier, optimizing Emergency Medical Services (EMS) response/transport times, optimizing hospital systems, and extending the treatment window. As part of a Centers for Disease Control-sponsored Coverdell Acute Stroke Pilot Registry, the authors prospectively identified all patients with an initial diagnosis of ischemic stroke at 11 hospitals in California over a 3-month period. Timing of symptom onset, EMS response, hospital arrival, treatment, and reasons for nontreatment were evaluated, and hypothetical treatment rates for thrombolysis for interventions on the stroke-care continuum were derived based on observed rates of eligibility and treatment. Of 374 patients with ischemic stroke, 88 (23.5%) arrived at the emergency department within 3 hours of symptom onset, of whom 16 (4.3%) received thrombolysis. If all patients with known onset times had called 911 immediately, the expected overall rate of thrombolytic treatment within 3 hours would have increased from 4.3 to 28.6%. Expected rates of thrombolysis were lower for other interventions: instantaneous prehospital response 5.5%, perfect hospital care 11.5%, and extension of time window to 6 hours 8.3%. If all patients with known onset had arrived within 1 hour and been optimally treated, 57% could have been treated. Campaigns that educate patients to seek treatment sooner should be major components of system-wide interventions to increase rates of thrombolysis for acute ischemic stroke.

Trial Application of a Model of Resource Utilization, Costs, and Outcomes for Stroke (MORUCOS) to Assist Priority Setting in Stroke

Cost-effectiveness data for stroke interventions are limited, and comparisons between studies are confounded by methodological inconsistencies. The aim of this study was to trial the use of the intervention module of the economic model, a Model of Resource Utilization, Costs, and Outcomes for Stroke (MORUCOS) to facilitate evaluation and ranking of the options. The approach involves using an economic model together with added secondary considerations. A consistent approach was taken using standard economic evaluation methods. Data from the North East Melbourne Stroke Incidence Study (NEMESIS) were used to model "current practice" (base case), against which 2 interventions were compared. A 2-stage process was used to measure benefit: health gains (expressed in disability-adjusted life years [DALYs]) and filter analysis. Incremental cost-effectiveness ratios (ICERs) were calculated, and probabilistic uncertainty analysis was undertaken. Aspirin, a low-cost intervention applicable to a large number of stroke patients (9153 first-ever cases), resulted in modest health benefits (946 DALYs saved) and a mean ICER (based on incidence costs) of US 1421 dollars per DALY saved. Although the health gains from recombinant tissue-type plasminogen activator (rtPA) were less (155 DALYs saved), these results were impressive given the small number of persons (256) eligible for treatment. rtPA dominates current practice because it is more effective and cost-saving. If used to assess interventions across the stroke care continuum, MORUCOS offers enormous capacity to support decision-making in the prioritising of stroke services.