Joosup Kim

National stroke registries for monitoring and improving the quality of hospital care: a systematic review

Background Routine monitoring of the quality of stroke care is becoming increasingly important since patient outcomes could be improved with better access to proven treatments. It remains unclear how many countries have established a national registry for monitoring stroke care. Aims To describe the current status of national, hospital-based stroke registries that have a focus on monitoring access to evidence-based care and patient outcomes and to summarize the main features of these registries. Summary of review We undertook a systematic search of the published literature to identify the registries that are considered in their country to represent a national standardized dataset for acute stroke care and outcomes. Our initial keyword search yielded 5002 potential papers, of which we included 316 publications representing 28 national stroke registries from 26 countries. Where reported, data were most commonly collected with a waiver of patient consent (70%). Most registries used web-based systems for data collection (57%) and 25% used data linkage. Few variables were measured consistently among the registries reflecting their different local priorities. Funding, resource requirements, and coverage also varied. Conclusions This review provides an overview of the current use of national stroke registries, a description of their common features relevant to monitoring stroke care in hospitals. Formal registration and description of registries would facilitate better awareness of efforts in this field.

Discharge Is a Critical Time to Influence 10-Year Use of Secondary Prevention Therapies for Stroke

Background and Purpose— When optimally managed, patients with stroke are less likely to have further vascular events. We aimed to identify factors associated with optimal use of secondary prevention therapies in long-term survivors of stroke. Methods— We carefully documented discharge medications at baseline and self-reported use of medications at annual follow-up in the Northeast Melbourne Stroke Incidence Study (NEMESIS). We defined optimal medication use when patients reported taking (1) antihypertensive agents and (2) statin and antithrombotic agents (ischemic stroke only). Logistic regression was used to assess factors associated with optimal medication use between 2 and 10 years after stroke. Results— We recruited 1241 patients with stroke. Optimal prescription at discharge from hospital was the most important factor associated with optimal medication use at each time point: odds ratio (OR), 32.2 (95% confidence interval [CI], 13.6–76.1) at 2 years; OR, 7.86 (95% CI, 4.48–13.8) at 5 years (425 of 505 survivors); OR, 6.04 (95% CI, 3.18–11.5) at 7 years (326 of 390 survivors); and OR, 2.62 (95% CI, 1.19–5.77) at 10 years (256 of 293 survivors). Associations were similar in men and women. The association between optimal prescription at discharge and optimal medication use at each time point was greater in those who were not disadvantaged, particularly women. Conclusions— Prescription of medications at hospital discharge was the strongest predictor of ongoing medication use in survivors of stroke, even at 10 years after stroke. Ensuring that patients with stroke are discharged on optimal medications is likely to improve their long-term management, but further strategies might be required among those who are disadvantaged.

Lower systolic blood pressure is associated with poorer survival in long-term survivors of stroke

Background: Lowering blood pressure after stroke reduces the risk of recurrent stroke and other vascular events. However, there is recent evidence that low blood pressure may also result in poor outcome. For the first time, this study aimed to investigate the relationship between blood pressure and outcome in long-term survivors of stroke. Methods: Participants from the North East Melbourne Stroke Incidence Study were contacted at 5 years after stroke for a follow-up assessment. Blood pressure was measured according to a strict protocol. A multivariable Cox proportional hazards regression model was used to assess the association between SBP measurements at 5 years after stroke and outcome (death, acute myocardial infarction or recurrent stroke) to 10 years after stroke. Results: In 5-year survivors of stroke, compared to a SBP of 131–141 mmHg, a SBP of 120 mmHg or less was associated with a 61% greater risk of stroke, acute myocardial infarction and death (hazard ratio 1.61, 95% confidence interval 1.08–2.41, P = 0.019). Compared to the reference category of SBP 131–141 mmHg, there were no differences in outcome in the patients with SBP 121–130 mmHg (P = 0.491) or 142–210 mmHg (P = 0.313). These findings were not modified when adjusting for prescription of antihypertensive medications. Conclusion: There was a greater risk of poor outcome in long-term survivors of stroke with low SBP. This is further evidence that low SBP may result in poor prognosis. Ideal blood pressure levels for long-term survivors of stroke may need to be reassessed.

Baseline Smoking Status and the Long-Term Risk of Death or Nonfatal Vascular Event in People with Stroke A 10-Year Survival Analysis

Background and Purpose— Smoking may exacerbate the risk of death or further vascular events in those with stroke, but data are limited. Methods— 1589 cases of first-ever and recurrent stroke were recruited between 1996 and 1999 from a defined geographical region in North East Melbourne. Both hospital and nonhospital cases were included. Over a 10-year period, all deaths, recurrent stroke events, and acute myocardial infarctions that were reported at follow-up interviews were validated using medical records. Cox proportional hazards regression was used to assess the association between baseline smoking status (never, ex, and current) and outcome (death, acute myocardial infarction, or recurrent stroke). Results— Patients who were current smokers (Hazard Ratio [HR], 1.30; 95% Confidence Interval [CI], 1.06–1.60; P=0.012) at the time of their stroke had poorer outcome when compared with those who had never smoked. Among those who survived the first 28 days of stroke, current smokers (HR, 1.42; 95% CI, 1.13–1.78; P<0.003) and ex-smokers (HR, 1.18; 95% CI, 1.01–1.39; P=0.039) at baseline had poorer outcome than those who had never smoked. Current smokers also had a greater risk of recurrent events than past smokers (HR, 1.23; 95% CI, 1.00–1.50; P=0.050). Conclusions— Patients who smoked at the time of their stroke or had smoked before their stroke had greater risk of death or recurrent vascular events when compared with patients who were never smokers. There are benefits of smoking cessation, with ex-smokers appearing to have a lesser risk of recurrent vascular events than current smokers.

Better outcomes for hospitalized patients with TIA when in stroke units An observational study

Objectives: To investigate differences in management and outcomes for patients admitted to the hospital with TIA according to care on a stroke unit (SU) or alternate ward setting up to 180 days post event. Methods: TIA admissions from 40 hospitals participating in the Australian Stroke Clinical Registry during 2010–2013 were assessed. Propensity score matching was used to assess outcomes by treatment group including Cox proportional hazards regression to compare survival differences and other appropriate multivariable regression models for outcomes including health-related quality of life and readmissions. Results: Among 3,007 patients with TIA (mean age 73 years, 54% male), 1,110 pairs could be matched. Compared to management elsewhere in hospitals, management in an SU was associated with improved cumulative survival at 180 days post event (hazard ratio 0.57, 95% confidence interval 0.35–0.94; p = 0.029), despite not being statistically significant at 90 days (hazard ratio 0.66, 95% confidence interval 0.33–1.31; p = 0.237). Overall, there were no differences for being discharged on antihypertensive medication or with a care plan, and the 90- to 180-day self-reported outcomes between these groups were similar. In subgroup analyses of 461 matched pairs treated in hospitals in one Australian state (Queensland), patients treated in an SU were more often prescribed aspirin within 48 hours (73% vs 62%, p < 0.001) and discharged on antithrombotic medications (84% vs 71%, p < 0.001) than those not treated in an SU. Conclusions: Hospitalized patients with TIA managed in SUs had better survival at 180 days than those treated in alternate wards, potentially through better management, but further research is needed.

Risk factor management in survivors of stroke: a double-blind, cluster-randomized, controlled trial.

Background Comprehensive community care has the potential to improve risk factor management of patients with stroke or transient ischaemic attack. Aim The primary aim is to determine the effectiveness of an individualized management program on risk factor management for patients discharged from hospital after stroke. Design Multicentre, cluster-randomized, controlled trial, with clusters by general practice. Participants are randomized to receive intervention or control after a baseline assessment undertaken after discharge from hospital. The general practice they attend is marked as an intervention or control accordingly. All subsequent participants attending those practices are automatically assigned as intervention or control. Baseline and all outcome assessments, including an analysis of risk factors, are undertaken by assessors blinded to patient randomization. Intervention Details Based on the results of blinded assessments, the individualized management program group will receive targeted advice on how to manage their risk factors using a standardized, evidence-based template to communicate ‘ideal’ management with their general practitioner. In addition, patients randomized to the individualized management program group will receive counselling and education about stroke risk factor management by an intervention study nurse. Individualized management programs will be reviewed at three-months, six-months, 12 months, and 18 months after stroke, at which times they will be modified if appropriate. Stroke risk management will be evaluated using changes in the Framingham cardiovascular risk score. Analysis will be on an intention-to-treat basis using analysis of covariance or generalized linear model to adjust for baseline risk score and other relevant confounding factors.

Exploring the benefits of a stroke telemedicine programme: An organisational and societal perspective.

We undertook a qualitative analysis to identify the broader benefits of a state-wide acute stroke telemedicine service beyond the patient-clinician consultation. Since 2010, the Victorian Stroke Telemedicine (VST) programme has provided a clinical service for regional hospitals in Victoria, Australia. The benefits of the Victorian Stroke Telemedicine programme were identified through document analysis of governance activities, including communications logs and reports from hospital co-ordinators of the programme. Discussions with the Victorian Stroke Telemedicine management were undertaken and field notes were also reviewed. Several benefits of telemedicine were identified within and across participating hospitals, as well as for the state government and community. For hospitals, standardisation of clinical processes was reported, including improved stroke care co-ordination. Capacity building occurred through professional development and educational workshops. Enhanced networking, and resource sharing across hospitals was achieved between hospitals and organisations. Governments leveraged the Victorian Stroke Telemedicine programme infrastructure to provide immediate access to new treatments for acute stroke care in regional areas. Standardised data collection allowed routine quality of care monitoring. Community awareness of stroke symptoms occurred with media reports on the novel technology and improved patient outcomes. The value of telemedicine services extends beyond those involved in the clinical consultation to healthcare funders and the community.

Effectiveness of a shared team approach between nurses and doctors for improved risk factor management in survivors of stroke: a cluster randomized controlled trial.

Limited evidence exists on the benefits of organized care for improving risk factor control in patients with stroke or transient ischaemic attack. The effectiveness of an individualized management programme in reducing absolute cardiovascular disease risk in this high‐risk population was determined.

Risk-adjusted hospital mortality rates for stroke: evidence from the Australian Stroke Clinical Registry (AuSCR)

Objectives: Hospital data used to assess regional variability in disease management and outcomes, including mortality, lack information on disease severity. We describe variance between hospitals in 30‐day risk‐adjusted mortality rates (RAMRs) for stroke, comparing models that include or exclude stroke severity as a covariate.

Community-Based Intervention to Improve Cardiometabolic Targets in Patients With Stroke: A Randomized Controlled Trial

Background and Purpose— Many guidelines for secondary prevention of stroke focus on controlling cardiometabolic risk factors. We investigated the effectiveness of a management program for attaining cardiometabolic targets in survivors of stroke/transient ischemic attack. Methods— Randomized controlled trial of survivors of stroke/transient ischemic attack aged ≥18 years. General practices were randomized to usual care (control) or an intervention comprising specialist review of care plans and nurse education in addition to usual care. The outcome is attainment of pre-defined cardiometabolic targets based on Australian guidelines. Multivariable regression was undertaken to determine efficacy and identify factors associated with attaining targets. Results— Overall, 283 subjects were randomized to the intervention and 280 to controls. Although we found no between-group difference in overall cardiometabolic targets achieved at 12 months, the intervention group more often achieved control of low-density lipoprotein cholesterol (odds ratio, 1.97; 95% confidence interval, 1.18–3.29) than controls. At 24 months, no between-group differences were observed. Medication adherence was ≥80% at follow-up, but uptake of lifestyle/behavioral habits was poor. Older age, being male, being married/living with partner, and having greater functional ability or a history of diabetes mellitus were associated with attaining targets. Conclusions— The intervention in this largely negative trial only had a detectable effect on attaining target for lipids but not for other factors at 12 months or any factor at 24 months. This limited effect may be attributable to inadequate uptake of behavioral/lifestyle interventions, highlighting the need for new or better approaches to achieve meaningful behavioral change. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: ACTRN12608000166370.