Nicolas U. Weir

Impact of a Stroke Unit on Length of Hospital Stay and In-Hospital Case Fatality

Background and Purpose— Randomized trials have demonstrated reduced morbidity and mortality with stroke unit care; however, the effect on length of stay, and hence the economic benefit, is less well-defined. In 2001, a multidisciplinary stroke unit was opened at our institution. We observed whether a stroke unit reduces length of stay and in-hospital case fatality when compared to admission to a general neurology/medical ward. Methods— A retrospective study of 2 cohorts in the Foothills Medical Center in Calgary was conducted using administrative databases. We compared a cohort of stroke patients managed on general neurology/medical wards before 2001, with a similar cohort of stroke patients managed on a stroke unit after 2003. The length of stay was dichotomized after being centered to 7 days and the Charlson Index was dichotomized for analysis. Multivariable logistic regression was used to compare the length of stay and case fatality in 2 cohorts, adjusted for age, gender, and patient comorbid conditions defined by the Charlson Index. Results— Average length of stay for patients on a stroke unit (n=2461) was 15 days vs 19 days for patients managed on general neurology/medical wards (n=1567). The proportion of patients with length of stay >7 days on general neurology/medical wards was 53.8% vs 44.4% on the stroke unit (difference 9.4%; P<0.0001). The adjusted odds of a length of stay >7 days was reduced by 30% (P<0.0001) on a stroke unit compared to general neurology/medical wards. Overall in-hospital case fatality was reduced by 4.5% with stroke unit care. Conclusions— We observed a reduced length of stay and reduced in-hospital case-fatality in a stroke unit compared to general neurology/medical wards.

How well does ASPECTS predict the outcome of acute stroke treated with IV tPA

The authors measured the association of early ischemic change on CT scan, measured using the Alberta Stroke Programme Early CT score (ASPECTS), and functional outcome in 825 patients with anterior circulation stroke treated with IV thrombolysis within 3 hours of onset. ASPECTS predicted outcome in a graded fashion (linearly for ASPECTS 6 through 10; pattern ill-defined for ASPECTS 0 through 5) but discriminated individual outcomes weakly. Except perhaps when early ischemic change is extensive, clinicians should not estimate prognosis using ASPECTS alone.

Towards a National System for Monitoring the Quality of Hospital-Based Stroke Services

Background and Purpose— We sought to evaluate a system for monitoring the quality of hospital-based stroke services that uses routinely collected case fatality data, adjusted for case mix, as well as simple measures of the process of stroke care. Methods— We compared the process of care and case fatality after stroke between 5 Scottish hospitals (A through E) during 1995–1997. We retrospectively identified 2724 patients with acute stroke using routine discharge data and obtained case mix and process of care data from the medical record. We ascertained case fatality by record linkage and adjusted for case mix using a simple, externally validated regression model. Results— Crude case fatality varied by 21 deaths per 100 admissions between the 5 hospitals. After adjustment, case fatality still differed significantly (P =0.047), with 5 to 7 more deaths per 100 admissions at Hospital A than at Hospitals B through E. There were major shortcomings in the specialization and organization of care, the use of CT scanning, and the completeness of documentation at Hospital A compared with the other hospitals. There were smaller, but clinically important, differences in care between Hospitals B through E but no significant differences in adjusted case fatality. Conclusions— Once adjusted for important prognostic variables, routinely collected case fatality data might identify hospitals with major shortcomings in the processes of stroke care. More moderate, but still clinically important, variations in stroke care can only be identified by monitoring the process of care directly.

A study of the workload and effectiveness of a comprehensive acute stroke service

Objective: To study the workload of and use of acute intervention within an established acute stroke service, the Calgary Stroke Programme (CSP). Methods: Prospective record of all acute referrals, diagnoses, and management decisions over a 4 month period. Results: The CSP received 572 referrals (median: 32 per week), 88% of which were made between 7 am and midnight. Of the 427 patients seen in person, 29% had not had an acute stroke or transient ischaemic attack (TIA). Fifty percent of patients with suspected acute stroke were referred within 3 h of symptom onset and 11% with acute ischaemic stroke (equating to 35% of those referred within 3 h of onset and seen in person) were treated with thrombolysis. Conclusion: Centralisation of services facilitates the rapid referral of, and use of acute interventions in, patients with acute stroke and TIA. Centralised services are likely to be busy (although less so at night), to attract large numbers of patients with disorders that mimic stroke and TIA, and yet still likely to treat only the minority of acute strokes using thrombolysis. These observations may help those planning similar services and underline the need to develop more widely applicable treatments for acute stroke.

Small vessel infarcts and microbleeds associated with radiation exposure.

CASE DESCRIPTION Mr. WG, a 51-year-old gentleman was treated with radiotherapy for pontine glioma in 1984. He received 50 Gy over one month in 16 sittings. He remained asymptomatic until 1994 when, aged 37 years, he had his first stroke which caused a right facial weakness. Computed tomogram (CT) and magnetic resonance image (MRI) brain did not reveal any acute infarct. The CT angiography of the cerebral and cervical vessels was normal. Two years later he re-presented with acute dysarthria and MRI brain scan showed chronic lacunar infarcts in the gangliocapsular regions, but no acute infarcts. In September 2005, he presented with a right hemiparesis caused by a thalamic hemorrhage on CT (Figure 1). In 2007 he returned with a right hemiparesis and dysphagia, with no acute lesion seen on CT, chronic lacunar infarcts were present. Most recently, in 2008 he presented with a sudden worsening of dysarthria and dysphagia. In addition, over the last ten years he had progressive bilateral hearing loss and recurrent headaches (one to two per month). He had no past history of hypertension, diabetes mellitus, dyslipidemia or coronary artery disease. There was no family history of strokes. He was a moderate smoker until 2005.

Stroke prevention. MATCHing therapy to the patient with TIA.

PREVIEW The short-term risk of stroke after transient ischemic attack (TIA) is about 10% to 20% in the first 3 months, with much of the risk front-loaded in the first week. Unfortunately, little is known about the best therapies for hyperacute stroke prevention after TIA. A recent trial referred to by the acronym MATCH (for Management of Atherothrombosis With Clopidogrel in High-risk Patients With Recent Transient Ischemic Attack or Ischemic Stroke) provides hypothesis-generating data to suggest that double antiplatelet therapy in the short term may be appropriate. Here, the authors discuss treatment considerations, outlining the current knowledge and stressing the need for formal randomized trials to definitively establish the effectiveness of preventive therapies after minor stroke or TIA.

A triumph of hope and expediency over experience and reason

The practice of using outcomes data to indicate the quality of hospital stroke services is based on the assumption that, provided adjustment is made for differences in the characteristics of patients admitted and the play of chance, then most of the residual variation is likely to reflect differences in the quality of care. The paper by Lingsma1 and colleagues, published in this issue of J Neurol Neurosurg Psychiatry ( see page 888 ), helps to show the extent to which this thinking is wrong and ultimately unhelpful in driving forward improvements in stroke care. The study tested an idealised system of comparing the outcomes of patients admitted to 10 Dutch hospitals and …

Measuring and Improving the Quality of Care

INTRODUCTION Quality measurement and improvement have an image problem. It just isn’t sexy. This is not to say that clinicians aren’t interested in providing excellent care, quite the reverse. Nonetheless, compared with treating patients or research, reflecting on daily practice can seem rather mundane. The lack of time and resources traditionally devoted to the topic, together with a recent emphasis on publishing performance ‘league tables’, have also hampered our proper engagement. In truth, an element of complacency has also held us back. Audit and quality improvement are often regarded as a chore, a box to be ticked or a task to be delegated to junior staff. Inevitably, the fruits of these labours are often superficial, irrelevant, disconnected or even threatening, and contribute to the disenchantment. Most hospitals still lack effective systems for monitoring and improving the quality of their clinical services. However, this state of affairs must, and is, coming