1 Advan Ad Advan Ad vances in vances in ces in th ces in th - - PDF document

SLIDE 1

1

Ma Mana nage geme ment nt of Acu

• f Acute St

Stro roke ke Ma Mana nage geme ment nt of Acu

• f Acute St

Stro roke ke Im Impac pact o t of Re Registr gistratio tion St Studies udies Im Impac pact o t of Re Registr gistratio tion St Studies udies

Harold P. Adams, Jr., M.D. Harold P. Adams, Jr., M.D. Department of Neurology Department of Neurology Carver College of Medicine Carver College of Medicine University of Iowa Health Care Stroke Center University of Iowa Health Care Stroke Center Iowa City, Iowa Iowa City, Iowa

Is Isch chemic emic St Stro roke ke as a P as a Public ublic He Health alth Is Isch chemic emic St Stro roke ke as a P as a Public ublic He Health alth Pr Problem in

• blem in Taiw a

Taiw an Pr Problem in

• blem in Taiw a

Taiw an

• Stroke is a leading cause of death and disability in

Stroke is a leading cause of death and disability in Taiwan Taiwan

• Recent report on stroke in Taiwan

Recent report on stroke in Taiwan – – 1998 1998 – – 2007 2007

• 258,167 patients with ischemic stroke

258,167 patients with ischemic stroke

• National Health Insurance Research Database

National Health Insurance Research Database

• 30

30-

• day mortality rate increased following cuts in

day mortality rate increased following cuts in reimbursement reimbursement

Tung & Chang; Stroke, 2010; 41:504 Tung & Chang; Stroke, 2010; 41:504

St Stro roke is an E ke is an Expe xpensive Dise nsive Disease ase St Stro roke is an E ke is an Expe xpensive Dise nsive Disease ase

• Direct costs of stroke

Direct costs of stroke

• Prevention

Prevention

• Treatment of risk factors

Treatment of risk factors

• Antithrombotic

Antithrombotic medications medications

• Surgery

Surgery

• Acute treatment

Acute treatment

• Treatment of acute stroke

Treatment of acute stroke

• Prevention and treatment of complications

Prevention and treatment of complications

• Rehabilitation and long

Rehabilitation and long-

• term care

term care

• Indirect costs of stroke

Indirect costs of stroke

• Loss of productivity

Loss of productivity

• Welfare disability

Welfare disability

St Stro roke in ke in th the United St e United Stat ates es St Stro roke in ke in th the United St e United Stat ates es

• 795,000 new strokes annually

795,000 new strokes annually

• 610,000 first strokes

610,000 first strokes

• 185,000 recurrent strokes

185,000 recurrent strokes

• 1/18 deaths in the United States

1/18 deaths in the United States

• Mortality from stroke, 1996

Mortality from stroke, 1996 – – 2006 2006

• Estimated annual health care costs

Estimated annual health care costs -

• $80 billion

$80 billion

Lloyd Lloyd-

• Jones, Circulation, 2010; 121: e46

Jones, Circulation, 2010; 121: e46-

• e215

e215

Pa Past st Ma Mana nage geme ment nt of Pat

• f Patients w

s w ith Pa Past st Ma Mana nage geme ment nt of Pat

• f Patients w

s w ith Ce Cere rebr brovas

• vascular

cular Ce Cere rebr brovas

• vascular

cular Disease Disease Disease Disease

• Sense of hopeless by patients and helpless by health

Sense of hopeless by patients and helpless by health care providers care providers

• Nothing established as effective in improving outcomes

Nothing established as effective in improving outcomes

• No sense of urgency in diagnosis and treatment

No sense of urgency in diagnosis and treatment

• The approach to stroke was summarized by the term of

The approach to stroke was summarized by the term of cerebrovascular cerebrovascular accident accident

• Nothing accidental about stroke

Nothing accidental about stroke

SLIDE 2

2

Ad Advan vances in ces in th the Tr e Treatm eatment o

• f

Ad Advan vances in ces in th the Tr e Treatm eatment o

• f

Ce Cere rebr brovas

• vascular

cular Ce Cere rebr brovas

• vascular

cular Disease Disease Disease Disease

• Early 1970

Early 1970’ ’s s – – advent of CT to differentiate ischemic advent of CT to differentiate ischemic from hemorrhagic stroke from hemorrhagic stroke

• Late 1970

Late 1970’ ’s s – – utility of aspirin to prevent ischemic utility of aspirin to prevent ischemic stroke stroke

• Mid 1980

Mid 1980’ ’s s – – nimodipine nimodipine effective in treatment of SAH effective in treatment of SAH

• Late 1980

Late 1980’ ’s s – – use of MRI to improve diagnosis of acute use of MRI to improve diagnosis of acute stroke stroke

• 1995

1995 – – utility of intravenous utility of intravenous rtPA rtPA for treatment of stroke for treatment of stroke

• 2000

2000’ ’s s – – intra intra-

• arterial techniques to treat acute stroke

arterial techniques to treat acute stroke

Interv rven ention tions fo s for Tr r Treatm eatment Interv rven ention tions fo s for Tr r Treatm eatment

• f Ac

Acut ute St e Stroke

• ke
• f Ac

Acut ute St e Stroke

• ke
• Much of the management of stroke has not been tested

Much of the management of stroke has not been tested in clinical trials in clinical trials

• Recommendations in guidelines based on consensus

Recommendations in guidelines based on consensus

• Area for considerable future research

Area for considerable future research

• A larger number of interventions have been tested in

A larger number of interventions have been tested in the setting with stroke with largely negative results the setting with stroke with largely negative results

• Neuroprotective

Neuroprotective therapies in treatment of ischemic stroke therapies in treatment of ischemic stroke

• Anticoagulants in treatment of ischemic stroke

Anticoagulants in treatment of ischemic stroke

• Surgical evacuation of large deep hemisphere

Surgical evacuation of large deep hemisphere hematoma hematoma

• Recombinant Factor

Recombinant Factor VIIa VIIa in treatment of hemorrhage in treatment of hemorrhage

Re Regula gulatory Ap y Appr prove

• ved I

Interv rven ention tions Re Regula gulatory Ap y Appr prove

• ved I

Interv rven ention tions Tr Trea eatmen tment o t of Ac Acut ute St e Stroke

• ke

Tr Trea eatmen tment o t of Ac Acut ute St e Stroke

• ke
• Regulatory approvals vary among countries and lists of

Regulatory approvals vary among countries and lists of approved medications may differ considerably approved medications may differ considerably

• Local interpretation of data and different requirements

Local interpretation of data and different requirements

• Still, some interventions have received approval for

Still, some interventions have received approval for treatment of acute stroke treatment of acute stroke

• Nimodipine

Nimodipine for preventing ischemia after for preventing ischemia after aneurysmal aneurysmal subarachnoid subarachnoid hemorrhage hemorrhage

• Intravenous

Intravenous thrombolysis thrombolysis with with rtPA rtPA for acute ischemic stroke for acute ischemic stroke

• Mechanical interventions to extract clots

Mechanical interventions to extract clots

Util Utilization of ization of Util Utilization of ization of rt rtPA PA rt rtPA PA fo for Tr r Trea eatmen tment o t of fo for Tr r Trea eatmen tment o t of St Stro roke in ke in th the United St e United Stat ates es St Stro roke in ke in th the United St e United Stat ates es

• Review of Medicare claims in the US 2005

Review of Medicare claims in the US 2005-

• 2007

2007

• 4750 Hospitals

4750 Hospitals

• 495186 Patients with acute ischemic stroke

495186 Patients with acute ischemic stroke

• Treatment with

Treatment with rtPA rtPA

• 64% of hospitals had not treated a single case

64% of hospitals had not treated a single case

• 0.9% of hospitals had treated 10 or more cases in 2 years

0.9% of hospitals had treated 10 or more cases in 2 years

• Least likely in small, rural, underserved areas

Least likely in small, rural, underserved areas

• Despite having a therapy of proven efficacy, it is being

Despite having a therapy of proven efficacy, it is being underutilized and there is considerable room for underutilized and there is considerable room for improvement improvement

Kleindorfer et al, Stroke, 2009; 40: 3580 Kleindorfer et al, Stroke, 2009; 40: 3580

Guidelines in M Guidelines in Manageme agement t of Str

• f Stroke

Guidelines in M Guidelines in Manageme agement t of Str

• f Stroke
• Written by professional panels of experts

Written by professional panels of experts

• Physicians of multiple specialties

Physicians of multiple specialties

• Other health care providers

Other health care providers

• Adapted to local country or region of the world

Adapted to local country or region of the world

• Sponsored by professional, public interests, or governmental

Sponsored by professional, public interests, or governmental bodies bodies

• Guidelines may have different formats

Guidelines may have different formats

• American Heart Association

American Heart Association – – several complementary several complementary statements statements

• European Stroke Association

European Stroke Association – – single major statement single major statement

SLIDE 3

3

Au Audienc diences f es for S r Stroke Guideline Guidelines Au Audienc diences f es for S r Stroke Guideline Guidelines

• Physicians of multiple specialties

Physicians of multiple specialties

• Emergency medical services

Emergency medical services

• Other health care professionals

Other health care professionals

• Administrators

Administrators

• Governmental regulators

Governmental regulators

• Insurance companies

Insurance companies

• The public

The public

Get w ith th Get w ith the e Guidelin Guidelines es Get w ith th Get w ith the e Guidelin Guidelines es Ame American Hea ican Heart As rt Asso sociation ciation Ame American Hea ican Heart As rt Asso sociation ciation

• www.strokeassociation.org

www.strokeassociation.org

• Developed in 2004

Developed in 2004 – – to improve implementation of to improve implementation of guidelines and quality of care for stroke guidelines and quality of care for stroke

• Includes educational programs and data collection

Includes educational programs and data collection materials materials

• Information used for quality improvement

Information used for quality improvement

• Activities linked with reimbursement by the insurance

Activities linked with reimbursement by the insurance companies and the government companies and the government

• This program has been very successful

This program has been very successful

Get w ith th Get w ith the e Guidelin Guidelines es Get w ith th Get w ith the e Guidelin Guidelines es Hospit Hospital Tr al Trea eatme tment t of S

• f Stroke
• ke

Hospit Hospital Tr al Trea eatme tment t of S

• f Stroke
• ke

Get w ith th Get w ith the e Guidelin Guidelines es Get w ith th Get w ith the e Guidelin Guidelines es

• 18,410 patients with ischemic stroke or TIA in 99

18,410 patients with ischemic stroke or TIA in 99 community or teaching hospitals in US community or teaching hospitals in US

• 12 measures of care were compared at baseline and in

12 measures of care were compared at baseline and in the subsequent year the subsequent year

• Use of

Use of thrombolysis thrombolysis in patients seen < 2 hours in patients seen < 2 hours

• 23.5% vs. 40.8% (p < .001)

23.5% vs. 40.8% (p < .001)

• Use of

Use of antithrombotic antithrombotic medications at discharge medications at discharge

• 91% vs. 97.9& (p < .001)

91% vs. 97.9& (p < .001)

• Lipid treatment at discharge (for LDL > 100 mg/

Lipid treatment at discharge (for LDL > 100 mg/dL dL) )

• 58.7% vs. 77% (p <. 001)

58.7% vs. 77% (p <. 001) LeBresh LeBresh et al, Arch Intern Med, 2008; 168: 411 et al, Arch Intern Med, 2008; 168: 411

Hospit Hospital Tr al Trea eatme tment t of S

• f Stroke
• ke

Hospit Hospital Tr al Trea eatme tment t of S

• f Stroke
• ke

Get w ith th Get w ith the e Guidelin Guidelines es Get w ith th Get w ith the e Guidelin Guidelines es

• 322,847 patients with ischemic stroke and TIA at 790

322,847 patients with ischemic stroke and TIA at 790 community or academic hospitals in US community or academic hospitals in US

• Comparison of 2003

Comparison of 2003 – – 2007 2007

• Prophylaxis deep vein thrombosis

Prophylaxis deep vein thrombosis

• 73.8% vs. 89.5%

73.8% vs. 89.5%

• Discharge anticoagulants for

Discharge anticoagulants for atrial atrial fibrillation fibrillation

• 95% vs. 98.4%

95% vs. 98.4%

• Composite management (all factors)

Composite management (all factors)

• 83.5% vs. 94% ( p < .0001)

83.5% vs. 94% ( p < .0001) Schwamm et al, Circulation, 2009; 119: 107 Schwamm et al, Circulation, 2009; 119: 107

St Stro roke C ke Center Ce Certific ificatio ation St Stro roke C ke Center Ce Certific ificatio ation Primar Primary Str y Stroke Ce Cent nter er Primar Primary Str y Stroke Ce Cent nter er

• Nationwide program in US by Joint Commission

Nationwide program in US by Joint Commission

• www.jointcommission.org/

www.jointcommission.org/

• CertificationPrograms/PrimaryStrokeCenters

CertificationPrograms/PrimaryStrokeCenters

• Also developed by state departments of health

Also developed by state departments of health

• Application, review, certification, re

Application, review, certification, re-

• certification

certification

• Aimed at a smaller community hospital

Aimed at a smaller community hospital

• Emphasizes emergency treatment of stroke

Emphasizes emergency treatment of stroke

• May involve close interaction with a comprehensive

May involve close interaction with a comprehensive stroke center stroke center

SLIDE 4

4

Joint Com Joint Commission ission Joint Com Joint Commission ission St Stro roke C ke Center Ce Certific ificatio ation n St Stro roke C ke Center Ce Certific ificatio ation n Mission Mission of a P

• f a Primary St

imary Stro roke C ke Center Mission Mission of a P

• f a Primary St

imary Stro roke C ke Center

• Because of geography or other reasons, patient may

Because of geography or other reasons, patient may not be able to reach a comprehensive center in time to not be able to reach a comprehensive center in time to have stroke treated within current time windows have stroke treated within current time windows

• Goals are to provide emergency care by primary care

Goals are to provide emergency care by primary care

• r emergency medicine physicians and staff
• r emergency medicine physicians and staff
• General emergency treatment

General emergency treatment

• Treatment of acute complications of stroke

Treatment of acute complications of stroke

• Treatment of the acute stroke itself

Treatment of the acute stroke itself

Com Compon ponent ents of s of Emerg Emergency y Com Compon ponent ents of s of Emerg Emergency y Evalua Evaluation tion Evalua Evaluation tion – – Primar Primary St y Stro roke C ke Center Primar Primary St y Stro roke C ke Center

• Emergency triage

Emergency triage – – highest priority highest priority

• Clinical assessments

Clinical assessments – – available 24/365 available 24/365

• History of event

History of event

• Vital signs and general medical

Vital signs and general medical

• Neurological and NIH Stroke Scale

Neurological and NIH Stroke Scale

• Laboratory assessments

Laboratory assessments – – available 24/365 available 24/365

• CBC, clotting studies

CBC, clotting studies

• Glucose and other chemistries

Glucose and other chemistries

• Brain imaging

Brain imaging – – available 24/365 available 24/365

• CT of the brain

CT of the brain

• Includes physician interpretation

Includes physician interpretation

Hospit Hospital Eme al Emergenc ency Se y Services rvices Hospit Hospital Eme al Emergenc ency Se y Services rvices Oklahoma De Oklahoma Depa partm rtment ent of Healt

• f Health

Oklahoma De Oklahoma Depa partm rtment ent of Healt

• f Health
• Medical personnel available 24/365

Medical personnel available 24/365

• Physician

Physician

• Stroke team

Stroke team

• Written policies on management of stroke

Written policies on management of stroke

• Written agreement with a

Written agreement with a “ “stroke center stroke center” ”

• Neurologist available in person, telephone, electronically

Neurologist available in person, telephone, electronically

• Diagnostic imaging (CT/MRI) available 24/365

Diagnostic imaging (CT/MRI) available 24/365

• Clinical laboratory services available 24/365

Clinical laboratory services available 24/365

• Have approved medications available in ED

Have approved medications available in ED

• In effect, primary medication is

In effect, primary medication is rtPA rtPA

Su Subseq bseque uent nt M Mana anageme gement t of Patie

• f Patients

Su Subseq bseque uent nt M Mana anageme gement t of Patie

• f Patients

w it w ith Ac Acut ute St e Stro roke ke w it w ith Ac Acut ute St e Stro roke ke

• Smaller hospitals may not have all resources and

Smaller hospitals may not have all resources and expertise for overall management expertise for overall management

• Physicians and other health care professionals

Physicians and other health care professionals

• Complex interventions

Complex interventions

• Diagnostic studies

Diagnostic studies

• Goal to transfer to a comprehensive stroke center for

Goal to transfer to a comprehensive stroke center for specialized treatment specialized treatment

• Emergency basis

Emergency basis

• “

“Drip and Ship Drip and Ship” ” approach to treatment of stroke approach to treatment of stroke

St Stro roke C ke Center Ce Certific ificatio ation St Stro roke C ke Center Ce Certific ificatio ation Com Comprehen ehensive Str sive Stroke Ce Cent nter er Com Comprehen ehensive Str sive Stroke Ce Cent nter er

• Larger tertiary hospital

Larger tertiary hospital

• Additional expertise

Additional expertise

• Vascular neurology

Vascular neurology

• Neurosurgery and vascular surgery

Neurosurgery and vascular surgery

• Neurointerventional

Neurointerventional services services

• Additional resources

Additional resources

• Stroke unit or intensive care unit

Stroke unit or intensive care unit

• Rehabilitation

Rehabilitation

• Advanced diagnostic studies

Advanced diagnostic studies

• Stroke educational and research programs

Stroke educational and research programs

SLIDE 5

5

Re Regional St gional Stroke P

• ke Programs

ms Re Regional St gional Stroke P

• ke Programs

ms

• Based on the nature of region and community

Based on the nature of region and community

• Rural, suburban, urban

Rural, suburban, urban

• Availability of community hospitals and their resources

Availability of community hospitals and their resources

• Availability of a comprehensive stroke center

Availability of a comprehensive stroke center

• Linking the public, health care providers, governmental

Linking the public, health care providers, governmental bodies and insurance companies bodies and insurance companies

• Protocols to correct all potential bottlenecks to rapid

Protocols to correct all potential bottlenecks to rapid evaluation and treatment of patients with stroke evaluation and treatment of patients with stroke

• Develop a coordinated approach among all health care

Develop a coordinated approach among all health care providers. providers.

Brain At ain Attac tack Brain At ain Attac tack

• Approach to acute stroke is modeled on that for acute

Approach to acute stroke is modeled on that for acute myocardial ischemia myocardial ischemia

• Both are life

Both are life-

• threatening vascular diseases that are

threatening vascular diseases that are associated with serious complications associated with serious complications

• Ischemic stroke/myocardial infarction

Ischemic stroke/myocardial infarction -

• thrombosis

thrombosis

• Two most common causes of sudden death

Two most common causes of sudden death

• Management revolves around emergency treatment of

Management revolves around emergency treatment of the vascular event and complications the vascular event and complications

• Key is early reperfusion in cases of arterial occlusion

Key is early reperfusion in cases of arterial occlusion

Brain At ain Attac tack Brain At ain Attac tack

• Gives a sense of urgency to treatment of stroke

Gives a sense of urgency to treatment of stroke

• Public

Public

• Health care system

Health care system

• Programs for diagnosis and treatment may be built on

Programs for diagnosis and treatment may be built on existing programs for treatment of acute myocardial existing programs for treatment of acute myocardial infarction infarction

• Emergency medical services

Emergency medical services

• Emergency department

Emergency department

• Physicians and other health care professionals

Physicians and other health care professionals

Ch Chain of Su ain of Survival fo rvival for St r Stro roke ke Ch Chain of Su ain of Survival fo rvival for St r Stro roke ke

• Prompt recognition of signs and symptoms of stroke

Prompt recognition of signs and symptoms of stroke

• A leading cause of delay in treatment

A leading cause of delay in treatment

• Public educational program

Public educational program

• Both high

Both high-

• risk persons and general public

risk persons and general public

• Correct response to signs and symptoms of stroke

Correct response to signs and symptoms of stroke

• Call emergency medical services

Call emergency medical services – – ambulance ambulance

• Go to the hospital emergency department

Go to the hospital emergency department

• Protocol at emergency medical services

Protocol at emergency medical services

• Priority dispatch of paramedics

Priority dispatch of paramedics

• Prompt in

Prompt in-

• the

the-

• field evaluation

field evaluation

• Education of emergency medical services personnel

Education of emergency medical services personnel

Ch Chain of Su ain of Survival of St rvival of Stro roke ke Ch Chain of Su ain of Survival of St rvival of Stro roke ke -

• II

II II II

• Emergency transportation of patient to hospital

Emergency transportation of patient to hospital

• Go to those hospitals identified as primary stroke centers

Go to those hospitals identified as primary stroke centers

• Bypass other hospitals

Bypass other hospitals

• Emergency department protocol to treat stroke

Emergency department protocol to treat stroke

• Rapid clinical and laboratory evaluation

Rapid clinical and laboratory evaluation

• Confirm diagnosis of stroke

Confirm diagnosis of stroke

• Screen for indications or contraindications for

Screen for indications or contraindications for thrombolytic thrombolytic medications medications

• Administer

Administer thrombolytic thrombolytic medications medications

• Transfer the patient to a comprehensive stroke center

Transfer the patient to a comprehensive stroke center

SLIDE 6

6

Re Regional St gional Stroke Hu

• ke Hub

Re Regional St gional Stroke Hu

• ke Hub-
• an

and an and-

• Spo

Spoke ke Spo Spoke ke Sys System em Sys System em

• Coordination between community hospitals (primary

Coordination between community hospitals (primary stroke center) and large tertiary care hospital stroke center) and large tertiary care hospital (comprehensive stroke center) (comprehensive stroke center)

• The primary stroke centers are located in areas that

The primary stroke centers are located in areas that are relatively close to comprehensive center are relatively close to comprehensive center

• Land or air evacuation

Land or air evacuation

• Initial emergency treatment of stroke in primary stroke

Initial emergency treatment of stroke in primary stroke centers centers

• With or without consultation

With or without consultation

• Telephone consultation

Telephone consultation

• Teleradiology

Teleradiology and telemedicine consultation. and telemedicine consultation.

Com Comprehen ehensive Str sive Stroke Ce Cent nter er Com Comprehen ehensive Str sive Stroke Ce Cent nter er

• Is the hub of a regional network

Is the hub of a regional network

• Patients sent from smaller outlying centers

Patients sent from smaller outlying centers

• Concentrates resources and expertise

Concentrates resources and expertise

• Provides state

Provides state-

• of
• f-
• the

the-

• art care to patients

art care to patients

• Availability of services not available in smaller center

Availability of services not available in smaller center

• Complements the activities of the smaller centers

Complements the activities of the smaller centers

• Cost

Cost-

• effective strategy

effective strategy

• Avoids duplication of expensive technologies

Avoids duplication of expensive technologies

• Avoids duplication of expensive medical services

Avoids duplication of expensive medical services

Vinton EMS Oskaloosa EMS Ames EMS Sigourney EMS Marshalltown EMS Dubuque Fire EMS Sartori Paramedics Waterloo Fire EMS Waverly EMS Henry Co. EMS Johnson Co. EMS

24 EMS Systems 24 EMS Systems

• 710 EMS Personnel

710 EMS Personnel

• 22 Hospitals

22 Hospitals

• 188 Physicians

188 Physicians

• 309 ER Nurses

309 ER Nurses

AirCare I Jackson Co. EMS AirCare II Clinton Fire EMS Oelwein Mercy EMS Muscatine Fire EMS Washington Co. EMS Ottumwa EMS Air Evac Burlington Fire EMS Med Force

UIHC Comprehensive Stroke Center

Lee Co. EMS Air Evac

Local Hospital Aeromedical EMS

Iowa Co. EMS Grinnell EMS Blairstown EMS Belle Plain EMS

Ground EMS

Covenant EMS

Telemedicine and Telemedicine and Stro troke ke Telemedicine and Telemedicine and Stro troke ke

• Reports from institutions around the world

Reports from institutions around the world

• Variety of health care systems and communities

Variety of health care systems and communities

• Alternative to telephone consultation with the goal of

Alternative to telephone consultation with the goal of speeding evaluation and treatment of patients at speeding evaluation and treatment of patients at remote locations or small hospitals remote locations or small hospitals

• Increase the administration of

Increase the administration of rtPA rtPA

• Advantages

Advantages

• May directly assess the patient

May directly assess the patient

• May directly evaluate the brain imaging study

May directly evaluate the brain imaging study

• May speed enrollment into time

May speed enrollment into time-

• sensitive clinical trials

sensitive clinical trials

• Springboard for other interactions

Springboard for other interactions

Re Remo mote te Su Supe pervis rvisio ion Re Remo mote te Su Supe pervis rvisio ion Thromboly Thrombolysis is Thromboly Thrombolysis is for Is for Ischemic Stroke chemic Stroke for Is for Ischemic Stroke chemic Stroke

• Experience from Massachusetts General Hospital

Experience from Massachusetts General Hospital

• 181 patients treated at outside hospitals and 115 in MGH

181 patients treated at outside hospitals and 115 in MGH

• Outside hospitals

Outside hospitals – – telephone consultation or telephone consultation or telemedicine telemedicine

• Patients at outside hospitals generally were younger

Patients at outside hospitals generally were younger and had less severe strokes and had less severe strokes

• Outcomes were similar whether treated at MGH or at

Outcomes were similar whether treated at MGH or at

• utside hospital
• utside hospital
• Bleeding, mortality, length of stay, or status at discharge

Bleeding, mortality, length of stay, or status at discharge Pervez Pervez et al, Stroke 2010 et al, Stroke 2010

SLIDE 7

7

Telemedicine and Telemedicine and Stro troke ke Telemedicine and Telemedicine and Stro troke ke

• Expensive system to purchase and maintain

Expensive system to purchase and maintain

• Computers or robots at central hospital and local hospitals

Computers or robots at central hospital and local hospitals

• Rapidly evolving field with technology that becomes out

Rapidly evolving field with technology that becomes out-

• of
• f-
• date

date

• Cost

Cost-

• effectiveness is questioned if used only for stroke

effectiveness is questioned if used only for stroke

• Educational requirements

Educational requirements

• Central hospital and local hospitals

Central hospital and local hospitals

• This has eased with advances in technology

This has eased with advances in technology

• Reimbursement

Reimbursement

• Credentialing and licensing

Credentialing and licensing

• Legal (malpractice) issues

Legal (malpractice) issues

Physician Ex Physician Expe pertise in S rtise in Stroke Physician Ex Physician Expe pertise in S rtise in Stroke

• Encourage physicians to specialize in the diagnosis

Encourage physicians to specialize in the diagnosis and treatment of patients with stroke and treatment of patients with stroke

• Special area of expertise and research

Special area of expertise and research

• Special meetings and scientific literature

Special meetings and scientific literature

• Distinct body of knowledge

Distinct body of knowledge

• Subspecialty of Vascular Neurology

Subspecialty of Vascular Neurology

• American Board of Psychiatry and Neurology

American Board of Psychiatry and Neurology

• Subspecialty of neurology with pre

Subspecialty of neurology with pre-

• requisite neurology training

requisite neurology training

• Minimum of one year of training with defined content

Minimum of one year of training with defined content

• Certification examination with time

Certification examination with time-

• limited certificate

limited certificate

St Stro roke Unit ke Units St Stro roke Unit ke Units

• A core resource in a comprehensive stroke center

A core resource in a comprehensive stroke center

• Definition varies

Definition varies

• May include a rehabilitation component

May include a rehabilitation component

• May include an intensive care unit component/monitoring

May include an intensive care unit component/monitoring

• Geographically defined facility

Geographically defined facility

• Staffed by physicians, nurses, rehabilitation specialists

Staffed by physicians, nurses, rehabilitation specialists with special expertise in stroke care with special expertise in stroke care

• Close interactions and communications

Close interactions and communications

• Predefined protocols and care maps

Predefined protocols and care maps

Responsibi Responsibilities lities Responsibi Responsibilities lities Com Comprehen ehensive Str sive Stroke Ce Cent nter er Com Comprehen ehensive Str sive Stroke Ce Cent nter er

• Provide overall leadership for the regional stroke

Provide overall leadership for the regional stroke program program

• Develop care protocols

Develop care protocols

• Used both in satellite centers and the hub

Used both in satellite centers and the hub

• For both ischemic and hemorrhagic stroke

For both ischemic and hemorrhagic stroke

• Cover all components of management

Cover all components of management – – prevention, acute prevention, acute treatment, hospitalization, rehabilitation, return to society treatment, hospitalization, rehabilitation, return to society

• Develop public educational programs

Develop public educational programs

• May be adapted from national or other programs

May be adapted from national or other programs

• Symptoms of stroke or TIA

Symptoms of stroke or TIA

• Correct response to seek care immediately

Correct response to seek care immediately

Responsibi Responsibilities lities Responsibi Responsibilities lities Com Comprehen ehensive Str sive Stroke Ce Cent nter er Com Comprehen ehensive Str sive Stroke Ce Cent nter er

• Develop professional educational programs

Develop professional educational programs

• In person lectures or seminars

In person lectures or seminars

• Computer based training

Computer based training

• Programs tailored to audiences

Programs tailored to audiences

• Physicians

Physicians

• Hospital personnel

Hospital personnel

• Emergency medical services

Emergency medical services

• Availability for emergency consultation and referral

Availability for emergency consultation and referral

• Organize and coordinate clinical research studies

Organize and coordinate clinical research studies

• Wide variety of opportunities including translational research

Wide variety of opportunities including translational research

• Multiple areas of potential research

Multiple areas of potential research

Responsibi Responsibilities lities Responsibi Responsibilities lities Com Comprehen ehensive Str sive Stroke Ce Cent nter er Com Comprehen ehensive Str sive Stroke Ce Cent nter er

• Advocacy for stroke and stroke patients

Advocacy for stroke and stroke patients

• Government and insurance companies

Government and insurance companies

• Public health and other administrators

Public health and other administrators

• Public

Public

• Address issues of health care

Address issues of health care

• Proper funding and attention to stroke research

Proper funding and attention to stroke research

• Proper funding and attention to care of persons with stroke

Proper funding and attention to care of persons with stroke

• Emphasize the importance of stroke in Taiwan

Emphasize the importance of stroke in Taiwan

• Emphasize the advances in stroke care

Emphasize the advances in stroke care

SLIDE 8

8

Co Conclusion nclusions Co Conclusion nclusions

• Stroke is a life

Stroke is a life-

• changing or threatening disease

changing or threatening disease

• It is expensive in health care costs and lost productivity

It is expensive in health care costs and lost productivity

• It is a leading cause of human suffering

It is a leading cause of human suffering

• The care of patients with stroke is advancing

The care of patients with stroke is advancing

• The risk of stroke can be reduced

The risk of stroke can be reduced

• Stroke can be prevented

Stroke can be prevented

• The consequences of stroke can be limited

The consequences of stroke can be limited

• Stroke can be cured

Stroke can be cured

• Requires the collaboration of

Requires the collaboration of

• Public

Public

• Health care professionals

Health care professionals

• Administrators

Administrators

• Government and insurance companies

Government and insurance companies

• Advances in stroke care likely will continue

Advances in stroke care likely will continue

• Regardless of advances, success likely will be linked to

Regardless of advances, success likely will be linked to the time from onset of stroke the time from onset of stroke

• Time truly is brain

Time truly is brain