Model Of Stroke Care Research Articles

Community-based care of stroke patients in a rural African setting.

To develop a community-based model of stroke care, we assessed discharge planning of stroke patients, available resources and continuity of care between hospital and community in a remote rural setting in South Africa. We sought to determine outcomes, family participation and support needs, and implementation of secondary prevention strategies. Thirty consecutive stroke patients from the local hospital were assessed clinically (including Barthel index and modified Rankin scores) at time of discharge and re-assessed 3 months after discharge in their homes by a trained field worker using a structured questionnaire. Two-thirds of all families received no stroke education before discharge. At discharge, 27 (90%) were either bed- or chair-bound. All patients were discharged into family care as there was no stroke rehabilitation facility available to the community. Of the 30 patients recruited, 20 (66.7%) were alive at 3 months, 9 (30%) had died, and 1 was lost to follow-up. At 3 months, 55% of the remaining cohort were independently mobile compared with 10% at discharge. Of the 20 surviving patients, 13 (65%) were visited by home-based carers. Only 45% reported taking aspirin at 3 months. The 3-month mortality rate was high. Most survivors improved functionally but were left with significant disability. Measures to improve family education and the level of home-based care can be introduced in a model of stroke care attempting to reduce carer strain and reduce the degree of functional disability in rural stroke patients.

The Positive Effect of Integrated Care on Depressive Symptoms in Stroke Survivors

Background: Depressive symptoms occur in approximately one-third of stroke patients. We sought to evaluate whether an integrated model of stroke care and secondary prevention reduced depressive symptomatology in stroke survivors. Methods: The integrated care (IC) model is a multifaceted program that provides ongoing collaboration between a specialist stroke service and primary care physicians, using telephone tracking, a bi-directional information feedback loop, management of vascular risk factors, and regular screening for depressive symptoms. Results: Patients exposed to the IC model exhibited significantly fewer depressive symptoms than controls at 12 months post stroke (as measured by the PHQ-9 screening tool; p = 0.006). At 12 months, 30/91 (33%) of the treatment group had depressive symptoms, compared to 52/95 (55%) of the control group (p = 0.003). With other variables adjusted for, the major associates of being depressed at 12 months were group allocation and physical disability. Conclusion: The integrated care approach provides a framework for detecting and monitoring depressive symptoms, and appears to be protective against post-stroke depression.

1379 Coordinated care across healthcare systems, a disease management concept: The singapore model for stroke care

1379 Coordinated care across healthcare systems, a disease management concept: The singapore model for stroke care

Editorial Comment—What Can Models Teach Us About Stroke Treatment?

The report in this issue of Stroke on the cost-effectiveness of recombinant tissue plasminogen activator (rt-PA)1 suggests – with notable uncertainty – that, when compared with standard acute stroke care, thrombolytic therapy provides, on average, greater health benefits (in terms of average quality adjusted life years [QALYs]) at a reasonable average medical cost. This is not itself a unique finding; other similar efforts suggest – with notably greater certainty – that rt-PA is a good value for money.2–4 What have we learned from these modeling exercises? Is it true, as the authors propose, that we need another trial of rt-PA? Before considering the answer, it is useful to briefly review a few basics of disease models – what they are and what they can teach us. Disease models are mathematical representations of a clinical condition, its development, and its outcome, and models are often used to evaluate the impact of potential diagnostic or therapeutic strategies. These models are usually implemented in computer code, ranging from something as simple as a spreadsheet formula to sophisticated clinical event simulations. Sandercock and colleagues1 frame the question of rt-PA use as a decision tree, with a Markov model as a “calculation engine.” The inputs to this model are epidemiological, clinical trial, and health economic data (specifically applicable to the context of the …

Development of a Decision-Analytic Model of Stroke Care in the United States and Europe

Objective Stroke places a huge burden on society in terms of premature death, disability, and costs of care. Increasingly, the cost-effectiveness of new interventions needs to be demonstrated before their widespread implementation. Clinical trials are unable to measure the long-term impact of such new interventions in stroke care, and a modeling approach is necessary. The Stroke Outcome Model has been developed in four countries: France, Germany, the United Kingdom, and the United States as a flexible tool for this purpose. Method The decision-analytic model represents the management of acute stroke and long-term care and prevention of recurrence for stroke survivors. The latter consists of semi-Markov state-transition processes, with health states defined by therapy, disability, and occurrence of further stroke. Sources of clinical data include trials, meta-analyses, and prospective cohort studies such as the Oxfordshire Community Stroke Project and the Northern Manhattan Stroke Study. Resource use data were obtained from published sources and expert clinician panels. Outcome measures used were strokes averted, life years, and quality-adjusted life-years gained. Results The model has been used to undertake economic analyses of antiplatelet therapy for the prevention of recurrent strokes, and of stroke unit care and thrombolytic therapy in acute stroke. From a health-and social-care perspective, new interventions were found to be cost saving or to provide health benefits at modest additional cost. Results were sensitive to the cost perspective, time horizon, baseline risk of stroke recurrence, and choice of effectiveness measure. Conclusion The development of this model highlights the need for improved information on prognosis and resources used by stroke survivors and the importance of differentiating between economically distinct end points such as death, disabled survival and nondisabled survival, which may be combined as outcomes in clinical trials.

PCV6 Development of A Decision-Analytic Model of Stroke Care in us And Europe

There are currently rapid developments in our ability to offer effective preventive and therapeutic interventions for sufferers of stroke. Concurrent pressure on national and local health care budgets demands that new interventions be evaluated for their cost-effectiveness before their widespread implementation. Clinical trials are of relatively short duration and therefore cannot directly measure the long-term impact of therapies. OBJECTIVE: To develop a flexible and comprehensive tool to assist rapid outcome evaluation of potential interventions in stroke care in four countries: France, Germany, UK, US. METHODS: Decision-analytic software was used to construct a Stroke Outcome Model, which consists of 4 interrelated modules: (1) primary prevention; (2) “bridge” to acute care; (3) acute care (ischaemic stroke only); and (4) long-term care/prevention of recurrence in stroke survivors. Stroke prevention was represented by Markov state transition processes, states being defined in terms of use of therapy, disability and occurrence of (further) stroke. Data sources included clinical trials and meta-analyses, and prospective cohorts: Framingham study, Oxford Community Stroke Project and North Manhattan Stroke Study. Resource use data were obtained from published sources, supplemented by in-country panels of clinical experts, and unit costs from relevant national sources. RESULTS/DISCUSSION: The modelling approach has enabled the long-term consequences of acute or preventive therapy to be evaluated. Analyses have examined the cost-effectiveness of: antiplatelets in prevention of stroke recurrence; thrombolytic therapy in acute stroke; and stroke units. Results were sensitive to the duration of follow-up and the cost perspective chosen, in particular whether long-term care costs were included. The model enables users to explore issues such as the choice of effectiveness parameter or background event risks, and how risks are projected beyond the follow-up periods reported in trials or prospective studies. More data are required on long-term care, disability and quality of life/utility, and adjusted risks for (first) stroke.