Karin Rossnagel

Medical resource use and costs of health care after acute stroke in Germany

The purpose of this study was to determine the 12 months medical resource use following admission to hospital with acute stroke and to calculate costs from a societal perspective. Data of consecutive patients with confirmed stroke were analysed. Acute hospital data were taken from medical records, socio‐demographic variables from patients’ interviews. A follow‐up questionnaire about resource utilization was completed by patients or proxies 12 months after acute hospital admission. Costs were calculated by multiplying medical resource units used with cost factors per unit. Mean age of a total of 383 patients was 65 years and 41% were female. The median length of the initial stay in the acute hospital was 12 days at an average cost of €4650 per patient (49% of direct costs). Rehabilitation (16%), readmission (11%), medication (9%), and nursing costs (6%) were other contributors to the direct costs which amounted to a total of €9452 ± 7599 per patient during 12 months. Indirect cost amounted to a total of €2014 ± 5312. Patients’ age, severity and type of stroke influenced the total stroke‐associated costs. The large economic burden of stroke indicates the need for assessing and improving efficient health care for affected patients.

The Use of the 12-Item Short-Form Health Status Instrument in a Longitudinal Study of Patients with Stroke and Transient Ischaemic Attack

The 36-item short-form health survey (SF-36) is one of the most commonly used health status instruments in patients with cerebrovascular disease. However, responsiveness to change in health-related quality of life (HRQoL) has not yet been assessed for the SF-36 and its shortened version, the SF-12. The main objective of the present study was to determine responsiveness to change of the SF-12 in patients with cerebrovascular disease. Patients with stroke/transient ischaemic attack (TIA) were included at admission to one of four participating hospitals. HRQoL was assessed with the Physical (PCS-12) and Mental (MCS-12) Component Summary scales at baseline (referring to the status prior to the event) and after 12 months. Responsiveness to change was determined with the standardized response mean (SRM) and classified as small (SRM 0.20–0.49), moderate (0.50–0.79) or large (≧0.80). A total of 558 patients were included [55% men, mean age 65 (SD, 13) years; 45% women, mean age 69 (SD, 14) years]. Indications for admission were stroke (74%) and TIA (26%). In patients with stroke, SRMs were small for the PCS-12 [SRM 0.49; absolute change –5.9 (SD, 12)] and moderate for the MCS-12 [SRM 0.52; absolute change –6.6 (SD, 13)]. In patients with TIA, SRMs were below 0.2 for the PCS-12 [absolute change –0.7 (SD, 11)] and small for the MCS-12 [SRM 0.34; absolute change –3.7 (SD, 11)]. SRMs increased with stroke severity as indicated by the NIHSS score. The SF-12 summary scales showed a small to moderate responsiveness to change in patients after stroke. Responsiveness to change was higher in patients with increased symptom severity.

Emergency department delays in acute stroke – analysis of time between ED arrival and imaging

We determined the factors leading to emergency department (ED) delays in patients with acute stroke. Data were collected prospectively in four Berlin inner‐city hospitals by ED documentation, medical records, imaging files and patient interviews. An extended Cox proportional hazards model was fitted to the data. Analyses were performed in 558 patients with confirmed diagnosis of stroke. Median time from admission at ED to beginning of computed tomography/magnetic resonance imaging (CT/MRI) was 108 min. In a subgroup of patients potentially eligible for thrombolysis with a pre‐hospital delay <120 min and a National Institutes of Health Stroke Scale (NIHSS) >4 (n = 74), the median interval to imaging was 68 min. Multivariable analysis revealed that a more severe initial NIHSS, a pre‐hospital delay <3 h, admission at two specific hospitals, admission at weekends, and private health insurance were significantly associated with reduced delays. In stroke patients, the time interval between ED admission and imaging depends both on factors that emerge from clinical needs and on factors independent of clinical necessities. Considering the urgency of therapeutic measures in acute stroke, there is necessity and room for both improvement of in‐hospital management and of medical and non‐medical factors influencing pre‐hospital delays.

Prevalence of Stroke and Stroke Symptoms: A Population-Based Survey of 28,090 Participants

Background: Stroke is associated with a considerable burden of disease worldwide. Data about prevalence needs regular updating to facilitate health care planning and resource allocation. The purpose of the present study was to determine stroke prevalence in a large urban population in an easy and reliable way. Methods:In a population survey a total of 75,720 households with at least 1 person ≧50 years received information about stroke symptoms by mail. In addition, the Stroke Symptom Questionnaire assessing the prevalence of stroke and of stroke symptoms was sent. Stroke prevalence was determined by a single physician-diagnosed stroke-screening question or by the combination of the latter with reported visual impairment and/or articulation problems in the past. Results: A total of 28,090 persons responded (37.5%). Mean (±SD) age was 64.4 ± 9.7 years, 62.9 ± 8.9 for men (43.3%), and 65.5 ± 10.2 for women. Of all participants 2.7% reported impaired vision, 2.8% facial weakness, 2.8% articulation problems, 3.9% limb weakness, and 5% sensory disturbances. A total of 4.5% reported a physician-diagnosed stroke (women 4.3%; men 4.9%). Combining reported stroke history with reported impaired vision and/or articulation problems, the prevalence of stroke increased to 7.6% (men 8.4%; women 7.2%). Factors associated with higher prevalence were higher age, male gender, non-German nationality, lower education, positive family history of stroke, and living alone. Conclusions: The combination of questions concerning a prior stroke and stroke symptoms is a useful and easy approach to assess prevalence. It results in prevalence numbers which might compensate for an underestimation of stroke numbers.

Vascular risk factor awareness before and pharmacological treatment before and after stroke and TIA

Background and purpose:  Educating the public to screen for vascular risk factors and have them treated is a major public health issue. We assessed the vascular risk factor awareness and frequency of treatment in a cohort of patients with cerebral ischaemia.

Medical management in patients following stroke and transitory ischemic attack: a comparison between men and women

Study Objective: Differences between men and women in management and outcome following cerebrovascular events have been described. However, most of the differences observed have only been partially adjusted for baseline differences, or not at all. The objective of the present study was to compare acute and follow-up management between men and women after stroke and transitory ischemic attacks, adjusting for potential confounders. Design: Patients with symptoms of stroke were included at admission to one of four participating hospitals in the inner city of Berlin, Germany. Risk factors, clinical characteristics, and acute management were assessed from medical records. Patients were asked about socioeconomic factors and follow-up management in a baseline interview and by postal questionnaire, respectively. The follow-up was 12 months. Multiple logistic regression analyses were used to assess odds ratios for management variables. Results: A total of 558 patients were included (55% men, mean age 65 ± 13 years; 45% women, 69 ± 14 years). Indications for admission were stroke (74%) and transitory ischemic attacks (26%). In multivariable analyses, there were no differences in diagnostic procedures performed at baseline and in follow-up management between men and women. However, women were significantly more likely to receive hypoglycemic drugs (odds ratio 2.49; 95% confidence interval 1.33–4.63) in the acute management period. Regarding the need for nursing support/a nursing home after 12 months, there were no significant differences between men and women. Conclusions: After adjustment for differences in baseline characteristics, we only found few differences in acute and long-term management between men and women following hospital admission after suffering a cerebrovascular event.

Response to the Letter by Dressler et al.:Bad Data Do Not Make Good Studies

We read with much interest the article on East-West differences in cerebrovascular disease (CVD) mortality in Germany [1]. CVD mortality rates, which are roughly 50% higher (with a noticeable male predominance) in the East, i.e. in the former communist states, than in the West certainly raise serious medical, social, socioeconomic and political concerns. Searching for explanations, the authors put together a long list of readily available ‘facts’ about the East: bad food, bad drinking habits, bad environment, bad medicine, bad drugs, etc. Let’s get things straight. What are the facts? The data used in this article originate from the mortality statistics of the national statistics office (‘Statistisches Bundesamt’), an absolutely reputable source. However, their data are based entirely on death certificates (and on some corrections made when autopsies become available). And that’s it. The error rate of this data base is notorious – not only for criminal statistics [2–4]. Basically, they only record that there was a corpse at a certain time in a certain place. Even so: when you check the original data in the official mortality statistics, they show a clear and constant female:male predominance of about 60% [5–12]. This is exactly the opposite of what the authors want to make us believe. What can we learn from this? Bad data do not make good studies. Refrain from grandiose conclusions (and from old prejudices) if you cannot rely on your data base. By the way: In a study based on a sample with a 55% autopsy rate, the CVD mortality rate in 1988 was 58.2/100,000 for women and 42.1/100,000 for men [13] – in Rostock, East Germany.

The Mannheim Declaration of Stroke in Eastern Europe

Accessible online at: www.karger.com/ced Stroke is the most devastating cause of morbidity and mortality in the Eastern European countries. In this region, stroke is more frequent and the victims are younger than in Western Europe. Moreover, the incidence of stroke is significantly higher in social classes with low income, which represents a higher percentage of the Eastern European populations. Stroke is still one of the most important contributors to the mortality gap between East and West. The socioeconomic impact of stroke further weakens the economic development of these societies. The frequency of stroke is partly dependent on modifiable risk factors. In Eastern Europe, relatively more high-risk patients (hypertension + diabetes + smoking) live in worse environmental conditions compared with Western individuals. The positive tendency of decreasing mortality and morbidity could not be seen in the majority of Eastern countries, therefore urgent and efficient steps should be done to improve the situation. To avoid death and permanent disability caused by stroke in Eastern Europe, a specialised action plan has been established. This action plan is based on the Helsingborg Declaration and the 10-Point Action Plan to Tackle Stroke summarised by the European Parliament in June, 2003. The governments of these countries should elaborate a countryspecific programme based on the following elements. 1 Highlight the link between stroke and risk factors to physicians, emergency medical personnel, other health care professionals and the general public by facilitating education programmes. Recognition of symptoms of stroke is the cornerstone of successful stroke management. 2 Health care budgets should be allocated considering stroke prevention and therapy as a priority. 3 In specialised stroke units, widespread application of diagnostic interventions, pharmacological and surgical treatments should be available for all patients with stroke. The prevention and treatment of stroke should be based on the principle of evidence-based medicine. There is a pressing need for further randomised and placebo-controlled trials. 4 Stroke patients should receive an individual, patient-centred rehabilitation treatment carried out by an interdisciplinary team and involving the family. 5 Ensure the timely prevention of stroke by adequately treated modifiable risk factors such as hypertension, diabetes, hyperlipidaemia and atrial fibrillation by helping physicians making their treatment decisions using swiftly adoptable guidelines. 6 Because stroke is an emergency and efficient therapy is possible only in a limited time window, simplify the transport of acute stroke patients from their home to the stroke units and try to shorten the stroke-to-needle time. 7 Persuade people of the importance of changing their lifestyle including smoking, heavy alcohol and calorie intake, lack of physical activity, mental and emotional stress, which are very common, but also modifiable risk factors of stroke in Eastern Europe. 8 Encourage active and establish new patients’ associations. Patient groups play an important role in health policy and are able to coordinate actions to promote better rehabilitation and social support for people with stroke and their families. 9 Set realistic, time-based targets for stroke management and produce population-based monitoring systems covering incidence, prevalence, mortality and disability to provide an Eastern European picture of stroke management. 10 Foundation of an East and West European Stroke Forum to share all information between Western and Eastern European stroke professionals by identifying and disseminating the best practices in stroke prevention and treatment.

Ernährungsempfehlungen und ihre wissenschaftlichen Grundlagen— welche Evidenz sollte Public Health Maßnahmen zu Grunde liegen?

Kürzlich erschienene Publikationen zum Thema Ballaststoffe und Darmkrebs haben eine grundsätzliche Diskussion über die empirische Evidenz für bestehende und neu zu entwickelnde Ernährungsempfehlungen auch in Deutschland ausgelöst. Ziel dieses Artikels ist es, Überlegungen zum Thema Evidenzfindung, d.h. Evidenzkriterien und -bewertung, im Bereich Von ,Public Health Nutrition’ anzustellen.Ein evidenzbasiertes Vorgehen hat in der kurativen Medizin zunehmend an Bedeutung gewonnen. Dieser mit einer systematischen und transparenten Literaturanalyse und -bewertung einhergehende Ansatz hat bisher in der Ableitung und Formulierung Von Ernährungsempfehlungen kaum Anwendung erfahren. Grundsätzlich muss vor dieser Anwendung eines evidenzbasierten Verfahrens überlegt werden, in wie weit dieses Konzept auch in der bevölkerzmgsbasierten Primärprävention mittels verhaltensbezogenen lnterventionsmaβnahmen Anwendung finden kann. lnsbesondere die andere Datenlage, d.h. das Überwiegen observierender Studiendesigns im Gegensatz zu den randomisierten, klinischen Studien, wie sie Für die Evaluierung von Therapie und Diagnostik gefordert werden, bedarf der kritischen Diskussion. Public Health Nutrition ist das Gebiet der Ernährungsforschung, das diese Diskussion um Evidenz- und Bewertungskriterien vorantreiben sollte, um eine wissenschaftlich fundierte Entwicklung von Präventionskonzepten durch die Integration von grundlagenwissenschaftlichen Erkenntnissen und ernährungsepidemiologischen Studienergebnissen zu Fördern. Damit würde ein Beitrag dazu geleistet, das präventive Potential im Bereich Ernährung besser auszuschöpfen.Abstract Also in Germany, recent publications about the relation of dietary fibre to colon cancer have raised the discussion about the underlying empirical evidence for current and future dietary recommendations. The aim of the following article is to discuss the issue of evidence criteria and their grading in the context of public health nutrition.In curative medicine, an evidence based approach has become increasingly important. This approach that is characterised by a systematic and transparent analysis and evaluation of the literature has not been frequently applied to the development and formulation of dietary recommendations. Whether this concept is applicable to population based primary prevention with life-style interventions, however, needs to be discussed first. Especially, the different type of data available warrants intensive discussions: as compared to the evaluation of medical therapies or diagnostic tests where randomised control trials play a crucial role, most studies in the area of nutrition prevention have an observational design.Public health nutrition is the area o f nutrition research that should take a lead in the discussion about evidence criteria and the grading of evidence. A major concern here is to promote a scientifically based development of dietary prevention concepts by the integration o f knowledge derived from both basic sciences and nutritional epidemiology. This would be an important contribution to exhaust the potential of primary prevention in the area of nutrition.