Dora C. Pearce

Multicenter comparison of processes of care between Stroke Units and conventional care wards in Australia

Background and Purpose— Approximately 23% of Australian hospitals provide Stroke Units (SUs). Evidence suggests that clinical outcomes are better in SUs than with conventional care. Reasons may include greater adherence to processes of care (PoC). The primary hypothesis was that adherence to selected PoC is greater in SUs than in other acute care models. Methods— Prospective, multicenter, single-blinded design. Models of care investigated: SUs, mobile services, and conventional care. Selected PoC were related to care models and participant outcomes. Data were collected at acute hospitalization (median 9 days) and at medians of 8 and 28 weeks after stroke. Results— 1701 patients were screened from 8 hospitals, 823 were eligible, and 468 participated. Response rate was 96% at final follow-up. Mean age was 73 years (SD 14). Overall PoC adherence rates for individual care models were SU 75%, mobile service 65%, and conventional care 52% (P <0.001). The adjusted odds of participants being alive at discharge if adhering to all or all but 1 PoC was significant (aOR 3.63; 95% CI: 1.04 to 12.66; P =0.043). Important trends at 28 weeks were found for being at home (aOR 3.09; 95% CI: 0.96 to 9.87; P =0.058) and independent (aOR 2.61; 95% CI: 0.96 to 7.10; P =0.061), with complete PoC adherence. Conclusion— Adherence to key PoC was higher in SUs than in other models. For all patients, adherence to PoC was associated with improved mortality at discharge and trends found with independence at home, providing support for the need to increase access to stroke units.

Improvements in the quality of care and health outcomes with new stroke care units following implementation of a clinician-led, health system redesign programme in New South Wales, Australia.

Background and objectives: Provision of evidence-based hospital stroke care is limited worldwide. In Australia, about a fifth of public hospitals provide stroke care units (SCUs). In 2001, the New South Wales (NSW) state government funded a clinician-led, health system redesign programme that included inpatient stroke services. Our objective was to determine the effects of this initiative for improving: (i) access to SCUs and care quality and (ii) health outcomes. Design, setting and participants: Preintervention–postintervention design (12 months prior and a minimum 6–12 months following SCU implementation). Retrospective, public hospital audit of 50 consecutive medical records per time period of stroke admissions (using International Classification of Diseases (ICD)-10 codes). Combined analyses for 15 hospitals presented. Outcomes: Process of care indicators and patient independence (proportional odds modelling using modified Rankin scale). Results: Pre-programme cases (n = 703) (mean (SD) age 74 (14) years; female: 51%) and post-programme cases (n = 884) (mean age 74 (14) years; female: 49%) were comparable. Significant post-programme improvements for most process indicators were found, such as more brain imaging within 24 hours. Post-programme, access to SCUs increased 22-fold (95% CI 16.8 to 28.3). Improvement in inpatient independence at post-programme discharge was significant compared with pre-programme outcomes (proportional odds ratio 0.73, 95% CI 0.57 to 0.94; p = 0.013) when adjusted for patient clustering and case mix. Conclusions: This distinctive SCU initiative was shown as effective for improving clinical practice and significantly reducing disability following stroke.

Economic evaluation of australian stroke services : A prospective, multicenter study comparing dedicated stroke units with other care modalities

Background and Purpose— Level I evidence from randomized controlled trials demonstrates that the model of hospital care influences stroke outcomes; however, the economic evaluation of such is limited. An economic appraisal of 3 acute stroke care models was facilitated through the Stroke Care Outcomes: Providing Effective Services (SCOPES) study in Melbourne, Australia. The aim was to describe resource use up to 28 weeks poststroke for each model and examine the cost-effectiveness of stroke care units (SCUs). Methods— A prospective, multicenter, cohort study design was used. Costs and outcomes of stroke patients receiving 100% treatment in 1 of 3 inpatient care models (SCUs, mobile service, conventional care) were compared. Health-sector resource use up to 28 weeks was measured in 1999. Outcomes were thorough adherence to a suite of important clinical processes and the number of severe inpatient complications. Results— The sample comprised 395 participants (mean age 73 [SD 14], 77% first-ever strokes, males 53%). When compared with conventional care (n=84), costs for mobile service (n=209) were significantly higher (P=0.024), but borderline for SCU (n=102, P=0.08;

Access to stroke care units in Australian public hospitals: facts and temporal progress

AUD12 251;

Is prestroke use of angiotensin-converting enzyme inhibitors associated with better outcome?

AUD15 903;

Sleep disordered breathing in chronic stroke survivors. A study of the long term follow-up of the SCOPES cohort using home based polysomnography.

AUD15 383 respectively). This was primarily explained by the greater use of specialist medical services. The incremental cost-effectiveness of SCUs over conventional care was

Arsenic microdistribution and speciation in toenail clippings of children living in a historic gold mining area.

AUD9867 per patient achieving thorough adherence to clinical processes and

Patterns of stroke recurrence according to subtype of first stroke event: the North East Melbourne Stroke Incidence Study (NEMESIS)

AUD16 372 per patient with severe complications avoided, based on costs to 28 weeks. Conclusions— Although acute SCU costs are generally higher, they are more cost-effective than either mobile service or conventional care.

Cancer incidence and soil arsenic exposure in a historical gold mining area in Victoria, Australia: A geospatial analysis

Background: There is level I evidence that management of stroke patients in stroke units (SU) improves outcomes (death and institutionalization) by approximately 20%. In Australia, there is uncertainty as to the proportion of incident cases that have access to SU. Recent national and State‐based policy initiatives to increase access to SU have been taken. However, objective evidence related to SU implementation progress is lacking. The aims of the study were (i) to determine the number of SU in Australian acute public hospitals in 2004, (ii) to describe hospitals according to national SU policy criteria and (iii) to compare results to the 1999 survey to track progress.

The societal benefits of reducing six behavioural risk factors: an economic modelling study from Australia

Background: There is evidence that angiotensin-converting enzyme inhibitors (ACEIs) reduce the risk of stroke. However, it is unclear whether ACEI use before stroke provides a vasoprotective effect resulting in less severe stroke. Methods: We ascertained all strokes occurring in a defined population in Melbourne, Australia. Prestroke use of ACEIs and concomitant medications was obtained from medical records. Initial neurologic deficit was dichotomized according to a NIH Stroke Scale (NIHSS) score < 8 (less severe deficit) or ≥ 8 (severe deficit). Logistic regression was used to assess the association between prestroke use of ACEIs and stroke severity (measured by severity of neurologic deficits and death at 28 days). Results: Seven hundred sixteen first-ever ischemic stroke patients were included. Previous use of ACEIs was independently associated with a reduced risk of severe neurologic deficits (odds ratio [OR] 0.56; 95% CI 0.35 to 0.91) and death within 28 days (OR 0.46; 95% CI 0.24 to 0.87). Diuretics were associated with an increased risk of severe neurologic deficits (OR 1.81; 95% CI 1.13 to 2.90). Factors associated with a greater NIHSS score were older age, atrial fibrillation, heart failure, and use of diuretics. These factors and claudication were associated with an increased risk of 28-day mortality, whereas use of anticoagulants was associated with a reduced risk of severe neurologic deficits and death. Conclusion: Within this large community-based cohort, prestroke use of angiotensin-converting enzyme inhibitors was associated with a reduced risk of severe stroke.