Thursday, February 11, 2016

Organization of stroke care systems in Canada cut mortality rates

And yet that still leaves the 30day mortality too high. What is the followup strategy to get them even lower? What did the autopsies have to say about why they died? They died from neuronal death, not the stroke which is probably on the death certificate.
http://www.medpagetoday.com/Cardiology/Strokes/56129?
Stroke care coordinated regionally to cover primary prevention to rehabilitation and ensure appropriate interventions, such as thrombolysis and stroke unit care, was associated with lower stroke mortality, a population-based study from Canada showed.
Provinces with integrated systems of stroke care saw crude 30-day mortality rates decline from 15.8% in 2003/2004 to 12.7% in 2012/2013, whereas provinces that didn't have such systems saw no such decline, with those rates remaining 14.5% at both time points.
And "there was a clear reduction in relative mortality in provinces with stroke systems vs those without," with a significant adjusted incidence rate ratio of 0.85 for 30-day in-hospital mortality among stroke or transient ischemic attack (TIA) patients starting with the fiscal year 2009/2010, Michael D. Hill, MD, of the University of Calgary, Alberta, and colleagues reported online in Neurology.
"The surveys indicated that facilities in provinces with such systems were more likely to care for patients on a stroke unit, and have timely access to a stroke prevention clinic and telestroke services," they added.
The study considered a total of 319,972 stroke or TIA patients in the Canadian Institute of Health Information's Discharge Abstract Database over 11 fiscal years in five provinces with integrated systems and seven provinces or territories (excluding Quebec).
The findings demonstrate that stroke systems of care do indeed make a difference, which wasn't a foregone conclusion, Jeffrey J. Fletcher, MD, of the University of Michigan in Ann Arbor, and Jennifer J. Majersik, MD, of the University of Utah in Salt Lake City, noted in an accompanying editorial:
"To improve stroke patient care, the American Heart Association/American Stroke Association (AHA/ ASA) provided policy recommendations in 2013 for key elements of stroke systems of care, including emergency medical services (EMS) routing policies, use of telemedicine where specialists are scarce, multidisciplinary and protocol-driven in-hospital care, conduction of quality improvement programs, and access to poststroke rehabilitation.
"In 2014, the AHA/ASA considered the evidence for factors that may have contributed to the accelerated decline in stroke mortality over the past few decades and found surprisingly sparse evidence for outcomes improvement resulting from integration of these distinct elements into a stroke system of care."
That 2014 document had cited potentially strong effects but suggested such systems "have not been in place long enough to indicate their influence on the decline."
The Canadian data still couldn't provide causal proof or say which components were key, and were missing data on factors like thrombolysis, intensity of life-sustaining therapies, or early rehabilitation, the editorialists noted, but "despite these limitations, the positive findings are encouraging" anyway.
The Canadian healthcare system differs from fragmented systems lacking federal or state level coordination, Fletcher and Majersik pointed out:
"However, these are perhaps the data we have been missing: rather than attempting to provide piecemeal evidence, this work shows that enacting full-spectrum stroke systems improves stroke mortality. The authors have highlighted an opportunity that may have profound implications for reducing the global burden of stroke: implementation of centralized systems of stroke care with high-level government oversight."

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