XVII. European Stroke Conference
Nice, France
XVII. European Stroke Conference
Nice, France
Poster Session: Management and economics
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
Predictors for increased physical activity after stroke: South London Stroke Register (SLSR)
J.M.Brooke
P. Heuschmann
S. Crichton
N. Smeeton
C. Wolfe
Kings College London
UNITED KINGDOM
Background: Increased physical activity after stroke is recommended for secondary prevention in several guidelines. However, data are lacking about the proportion and the characteristics of stroke patients currently undertaking physical activity post stroke. Methods: Data were collected from the South London Stroke Register (SLSR), a population-based stroke register covering a multiethnic source population of 271,817 inhabitants (2001) in South London. Information on physical activity for secondary prevention undertaken by stroke patients was collected at one year post-stroke. The sample was restricted to stroke survivors with a complete follow-up interview at 12 months. Logistic regression analysis was performed to identify independent predictors for increased physical activity post stroke including age, sex, ethnicity, stroke severity (Barthel Index) and risk factors. Results: Data were available on 418 first-ever stroke patients recorded between Jan 2004 and Dec 2006. Mean age was 69, 44.7% were female: ethnicity was categorized as white (70%), black (21%) and other (9%). Overall, 43.1% of all surviving stroke patients regularly undertook some kind of exercise for prevention 12 months after stroke. In multivariable analysis, being-physically active was associated with younger age (p<0.001), less severe stroke (p<0.007) and diagnosis of atrial fibrillation (OR 2.9; 95% CI 0.9-7.1) Discussion: Although currently around one half of stroke survivors participate in exercise at 12 months, this study has identified the need for effective management of older stroke patients and those who have had a more severe stroke to engage in long-term physical activity.
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
Indicators of length of stay in stroke units
O. Saka
A. McGuire
C.A.Wolfe
Kings College, London. Division of Health and Social Care Research
UNITED KINGDOM
Introduction Length of stay (LOS) is commonly adopted as the main indicator of costs within the hospital sector, which may be influenced, by patient characteristics, capacity constraints and discharge policies. This paper uses a survival model to estimate the conditional LOS in a stroke unit (SU) compared to in a general medical ward (GMW). Methods A Cox proportional hazards model, using patient level data on stroke, was used to estimate the conditional length of stay. Data from a prospective population-based stroke register (SLSR) including stroke patients treated in a SU or a GMW between 2001 and 2006 are included in the analysis. The influence of a number of factors (stroke severity, living conditions, social status, age, gender, and ethnicity, discharge location) Results 1207 patients (587 SU patients) were included in the study. There was an inverse relationship between functional outcome (Barthel Index, BI) and the likelihood of being discharged (HR 1.19; 95% CI 1.12-1.26). White British patients were also less likely to be discharged early with respect to all the other ethnicity groups. SU patients overall were also more likely to be discharged earlier than general medical ward patients (HR, 2.02; 95% CI 1.11-2.6). This analysis shows that SU patients have a significant reduction (23 vs. 30 days) in their overall LOS in the hospital (p<0.01), for those patients who were discharged to home. This cannot be confirmed for patients who were discharged to either to institutional care or to long-term hospital care. The fact that discharge arrangements are be more time-consuming for the patients who will be discharged to institutional care might have an impact on this finding. Conclusion Policy differences with respect to discharge can have both cost and outcome implications. Therefore reductions in length of stay might lead to overall savings in acute care expenditures for stroke patients. This factor, coupled with increased outcomes in stroke units might reflect cost savings together with outcome improvements for SU care.
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
Access to Brain Imaging in Acute Stroke; Results from the National Sentinel Audit of Stroke (England, Wales, Northern Ireland)
A. Rudd
A. Hoffman
F. Wurie
R. Grant
D. Lowe
Clinical Effectivenss and Evlauation Unit, Royal College of Physicians London
UNITED KINGDOM
Background Brain imaging after stroke is essential to establish the diagnosis and guide effective treatment. If immediate scanning is not available then acute treatment such is thrombolysis is precluded Methods National audit involving 100% of hospitals in England, Wales and Northern Ireland has been conducted biannually since 1998. Of 13,625 patients in the audit (consecutively admitted between 1st April and 30th June 2006) the time of stroke and time of scan were available for 6559. Results Overall 93% of patients received a brain scan after admission. Of the patients scanned only 9% were scanned within 3 hours of stroke and 45% within 24 hours. Over 95% of patients are scanned between the hours of 8am and 10pm with fewer scanned between 1pm and 2pm than other times. The delay from stroke to brain scan data suggests that those patients not scanned during daytime hours on the day of admission have to wait until the next working day before the scan is performed. Delays in scanning are not likely to be due to a lack of scanners. It is clear that the scanning machines are scarcely used outside normal working hours and there is also spare capacity during the lunch hour. Improving the standards for scanning needs the radiographer and radiologist staffing issues to be solved, not provision of more machines Conclusions Stroke is still not treated as a medical emergency in many hospitals in the UK. Delay in brain imaging is largely due to problems with staffing and organisation, not the lack k of equipment.
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
Telemedicine for stroke management – costs of service in different organisational models
R. Handschu
M. Scibor
B. Willaczeck
D. Asshoff
F. Erbguth
S. Schwab
for the STENO-Project
University of Erlangen, STENO Stroke Network
GERMANY
Introduction: In acute stroke management specialist knowledge is required quite rapidly to make relevant treatment decisions. The use of interactive telemedicine is now proven for augmenting local service by a remote expert. There are no reports on the average cost of such service. We aimed to investigate net costs of different organisational models Methods: Before installing the STENO-network a small pilot study was conducted. Full size audiovisual communication with remote examination of acute stroke patients was compared to audiovisual was compared to pure telephone advice. During the whole study all workflow was monitored. All workload and material of the admission and teleconsultation process was registered and used for complete accounting of all variable costs in each consultation. Fixed overhead costs were counted in part. A calculation of total costs was done for different organisational models. Results: Variable costs of one video-based teleconsultation (VTC) were 139.89 €, and 61.39 € for telephone advice (TA). Counting for the different number of patient transfers after VTC (9.1%) and TA (14.9%) corrected costs were 162.75 € for VTC and 99.12 € for TA. Yearly Total costs calculation adds up 600.000 € for hospital-based full service VTC. An on-call service would cost about 160.000 € per year. Conclusion: Counting for their different level of quality as expressed by a different number of patient transfers VTC is about 1.5 times more expensive than TA. However the main part of costs derives from fixed costs. Amount of fixed costs is mainly depends of organisational aspects. The decision for full-service or on-call teleconsultation is mainly based on total capacity and the size of the whole network. A purely telephone based service is easier to handle in a home bound on-call service. However this disadvantage may be compensated by new developments in communication technology.
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
Are There Inequities in the Access to Acute Stroke Care among Different Public Health Insurance Schemes?
Y. Nilanont
S. Chotikanuchit
N. Prayoonwiwat
N. Poungvarin
Siriraj Hospital, Mahidol University
THAILAND
Background Acute stroke unit admission, aspirin administration within 48 hours and the use of intravenous tissue-type plasminogen activator (t-PA) within 3 hours are the only three specific treatments in acute ischemic stroke. This study aimed to assess the accessibility of each of the acute stroke care according to different types of national public health insurance scheme (NPHIS): Civil Servant Medical Benefit Scheme (CSMBS), Social Security Scheme (SSS), Universal Coverage Scheme (UCS), and "others" (self paid and private insurance). Materials and methods Between July 1 and December 31, 2007, 336 acute stroke patients were consecutively admitted. Data concerning age, gender, stroke subtype, onset to door time, stroke severity measured by the NIHSS, acute stroke unit admission, aspirin therapy within 48 hours, fast track evaluation for t-PA eligibility and t-PA administration were prospectively collected. Statistical analysis was performed. Results: In the CSMBS, SSS, UCS and "others" group, the mean age was 68.2, 42.7, 58.8, 65.8 years (p<0.001); male composed of 52.1, 41.7, 47.1, 62.2% (p=0.21); schemic stroke comprised of 75, 75, 66, 84.9% (p 0.13); the initial NIHSS was 7, 10, 10, 7 (p=0.07); onset to door was 455, 180, 250, 1455 minutes (p <0.001) respectively. The frequency and percentage of patients who received each of the acute stroke intervention was shown in table1. Conclusion: Provision of acute stroke care is different among types of NPHIS. CSMBS patients received more admission in the acute stroke unit. Clinical decision-making processes are likely to influence these patterns. Further information regarding the clinician and patient roles in decision making is required to improve the equity of acute stroke care in Thailand.
http://www.eurostroke.org/ni_graphics/t_aid3035.htm
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
Recruitment into an acute stroke trial - Efficacy of Nitric Oxide in Stroke (ENOS) Trial
L.J.Gray
S.A.Utton
Y.M.Smallwood
G.M.Sare
P.M.W.Bath
For the ENOS Investigators
Recruitment into an acute stroke trial - Efficacy of Nitric Oxide in Stroke (ENOS) Trial
UNITED KINGDOM
Introduction: Recruitment is a crucial element to the success of large clinical trials and has major impacts on their length and cost. Methods: ENOS is an ongoing prospective, international, multicentre, randomised, parallel-group, blinded, controlled trial. 5,000 ischaemic or haemorrhagic stroke patients with systolic BP 140-220 mmHg, and within 48 hours of onset will be included. Subjects will be randomised to 7 days of single-blind treatment with transdermal GTN or control. Those patients taking prior antihypertensive therapy will also be randomised to continue or temporarily stop this for 7 days. A recruitment questionnaire was sent to each participating centre and the questionnaire addressed issues such as the number of eligible patients recruited, reasons for refusal and potential barriers to recruitment. Results: ENOS has 57 participating centres from 11 countries (Australia, Canada, China, Hong Kong, Malaysia, New Zealand, Philippines, Poland, Sri Lanka, Singapore, and UK); questionnaires were returned from 21 centres (36.8%). Of those who kept recruitment logs, 43% of patients eligible for ENOS were randomised into the trial; the main reasons (non exclusive) given for non consent were: relatives refusal (52%), patient refusal (e.g. not “wanting to be treated as a guinea pig”, 38%), patient indecision (33%), and concerns about side effects (29%). The major barriers to centres recruiting patients were exclusion criteria (43%) and competing trials (24%). Conclusion: Patient or relative refusal to enter the ENOS trial is a significant barrier to recruitment. For new treatments to be successfully tested patient participation is essential. There is a need to educate the public about the importance of clinical trials. Just as subjects have a right to be in clinical trials they also have a responsibility if medical progress is to be maintained.
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
How does Stop Stroke work? Qualitative process evaluation of a multiple risk factor intervention to improve stroke secondary prevention.
J. Redfern
C. Wolfe
C. McKevitt
King's College London
UNITED KINGDOM
Background: The Stop Stroke intervention was developed to improve the management of multiple risk factors post stroke, and involved provision of individualised information and prompts for action to both patients and GPs at 3 time points. The efficacy of Stop Stroke has been evaluated in a cluster randomised controlled trial (RCT). We also conducted a qualitative process evaluation of this complex intervention to investigate how the intervention influenced patients’ experiences of secondary prevention, and to help interpretation of trial outcomes. Methods: 20 semi-structured interviews with stroke survivors in the intervention arm of the RCT, 1-year post stroke. Purposive sampling was based on age, sex, ethnicity, socio-economic group, subtype and dose of intervention. Interviews were digitally recorded, transcribed and analysed for emerging themes. Results: The benefits of the intervention for risk factor management differed between patients. Three key benefits were identified: the intervention provided information about secondary prevention; it promoted continuity of care after stroke (encouraging the notion that stroke is an ongoing disease); it empowered patients to become more actively involved in risk factor management. However, not all patients benefited to the same extent. Interview data suggested that the intervention had little influence for those who did not have the most common risk factors or for those who were severely disabled. Conclusion: The intervention had a positive impact on the experience of secondary prevention but was not universally beneficial. Sub-group analysis of RCT data could be used to establish the merits for particular groups.
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
Patient involvement in a population based stroke register
C. McKevitt
N. Fudge
C.D.A.Wolfe
King's College London
UNITED KINGDOM
Background:Researchers are increasingly required to involve patients in the generation, design and dissemination of research. It is claimed that patient involvement will improve research quality, leading to research results of greater relevance which are more likely to be put into practice. However, evidence of impact and influence of patient involvement on research processes, outcomes and quality is scant. We investigated how stroke patients can be involved in stroke research and the factors which shaped and constrained their involvement in research. Methods:Data were collected over two years using an ethnographic approach entailing participant observation, thematic analysis of documents, key informant discussions with stroke patients, carers and stroke researchers (n=15). Results:A research group, for stroke patients and their carers, was established. 26 members were recruited from a population based stroke register. Members of the group identified research questions; participated in deciding how these questions should be researched; contributed to studies identified by researchers; assisted in the redesign of patient consent forms; contributed to a newsletter to disseminate research findings. Factors identified which constrained the influence of the research user group included: researchers’ attitudes to patient involvement; the academic environment; motivations for attending the research group; patient and carer expectations and understanding of research; and readiness to challenge medical and scientific authority. Conclusion:This study highlights some of the cultural and social factors that need to be addressed when involving patients and carers in research and raises questions about why this involvement is currently being encouraged.
Session:
Poster Session II
Date:
Thursday 15 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
Advantages of A Special Stroke Assitance Network. Madrid Acute Stroke Program
E. Diez-Tejedor
B. Fuentes
A. Rodriguez-Balo
M. Alonso de Leciñana
J. Egido
A. Gil-Nuñez
C. Sánchez
J. Vivancos
J. Matías-Guiu
M.A.Soria
ASOCIACIÓN MADRILEÑA DE NEUROLOGÍA. SERVVICIO MADRILEÑO DE SALUD
SPAIN
Background:Acute stroke is a medical emergency. Specialized neurological management in Stroke Units (SU) and thrombolysis are the basis for treatment. Public Health Systems and professionals should organize assistance and resources to ensure that every patient has access to appropriate care. We describe the implementation of a specific Acute Stroke Program at Madrid.Methods:A consensus between Madrid Health Service (Servicio Madrileño de Salud, SERMAS) and a panel of stroke-specialized neurologists (Madrilenian Association of Neurology) with analysis and detection of needs and available resources; organization of an stroke assistance network including primary GP care, extra and in-hospital emergency care systems, specialized stroke services, rehabilitation and secondary prevention programs. Results: National Health Services´ registers (2006) show a population of 5,938,391 in Madrid. Estimated stroke incidence is 15.099 new cases per year and prevalence is 31.759 among patients > 64 years. Madrid Sanitary Network is structured in 11 areas with 13 reference hospitals equipped with neurologists and diagnostic resources (24h brain TC, MRI, cerebral and carotid ultrasound, echocardiography) and other related medical specialities. There are neurologist on duty (24h) in 7 of these hospitals and SU in 5. Eigth hospitals are accredited to apply thrombolysis (SITS-MOST). The new program plans to set 3 new SU and 5 stroke teams (ST). Madrid Acute Stroke Program coordinates all these resources to assure rapid specialized attention to all acute stroke patients. Those with <6 h from stroke onset are translated to the nearest hospital with SU, and those with >6h to the nearest hospital with ST. After acute phase, patients are distributed to their corresponding hospital. Conclusions:From the analysis of needs and with the integrated work of Health Authorities together with stroke-specialized neurologists, it is possible to organize a Stroke Care Program to get adequate distribution of resources in order to ensure the best approach to stroke treatment for all Madrid inhabitants.
