High-Value Care in the Evaluation of Stroke

Abstract

Value-based care emphasizes achieving the greatest overall health benefit for every dollar spent. We present an interesting case of stroke, which made us consider how frequently health care providers are utilizing value-based care.A 73-year-old Caucasian, who was initially admitted for a hypertensive emergency, was transferred to our facility for worsening slurring of speech and left-sided weakness. The patient had an extensive chronic cerebrovascular disease, including multiple embolic type strokes, mainly in the distribution of the right temporal-occipital cerebral artery and transient ischemic attacks (TIAs). The patient had a known history of patent foramen ovale (PFO) and occlusion of the right internal carotid artery. He was complicated by intracranial hemorrhage while on anticoagulation for pulmonary embolism. He was chronically on dual antiplatelet therapy (aspirin and clopidogrel) and statin. Following the transfer, stroke protocol, including the activation of the stroke team, a computed tomography (CT) imaging study, and the rapid stabilization of the patient was initiated. His vitals were stable, and the physical examination was significant for the drooping of the left angle of the mouth, a nonreactive right pupil consistent with the previous stroke, a decreased strength in the left upper and lower extremities, and a faint systolic murmur.His previous stroke was shown to be embolic, involving both the right temporal and occipital regions, which was re-demonstrated in a CT scan. A magnetic resonance imaging (MRI) scan of the brain showed a new, restricted diffusion in the right pons that was compatible with an acute stroke as well as diffusely atherosclerotic vessels with a focal stenosis of the branch vessels. A transthoracic echocardiogram demonstrated no new thrombus in the heart. A transesophageal echocardiogram (TEE) showed known PFO, and repeat hypercoagulation evaluation was negative, as it was in his previous cerebrovascular accident (CVA) evaluation. Appropriate medical treatment with antiplatelets, as indicated by the acute stroke guidelines, was started. The patient was not eligible for thrombolysis.Value-based care emphasizes the decreased usage in investigations or health care of options that do not contribute to the overall health and well-being of the patient.Given our patient's past medical history and the results of previous investigations, we questioned the value of ordering a hypercoagulable evaluation and TEE in our patient. The need for an evaluation of the hypercoagulable state in an elderly patient with ischemic stroke or TIA remains unknown. Our patient had a complete hypercoagulable evaluation done six years earlier. Repeating the hypercoagulable evaluation would not contribute to the treatment decisions and, as a result, would not satisfy the basic criteria for value-based care.The importance of a repeat TEE is uncertain in the evaluation of embolism for a known cause of stroke. Additionally, no change in management was anticipated regardless of the TEE findings, therefore, rep...

National Cost Estimates of Invasive Mechanical Ventilation and Tracheostomy in Acute Stroke, 2008–2017

“…Instead, value-based care aims to provide patient-centered care based on the patient’s goals, values, and shared decision-making, which do not always align with health care professions’ perception of important outcomes (eg, survival), 23 while limiting testing and services which do not contribute to the overall best care for the patient. 7,23 Understanding the extent to which patients are disabled from their stroke in the long term (especially in the postacute care phase where much of the costs of care are incurred), 24,25 and subsequently, how their disability impacts their quality of life, is imperative to understanding value in this context. Unfortunately, prognosis after severe stroke is often so uncertain that treatment decisions are made based on uncertain projections.…”

“…6 Value-based care emphasizes maximizing overall outcomes for the health care delivered per unit cost of providing this care. 7 The Centers for Medicare and Medicaid Services have led the effort to shift the US health care system to focus on value-based care, with payment models influencing both how care is delivered and how health care systems and providers are paid. 8 Patients with severe stroke may require prolonged ventilation and have long, complicated, hospital stays, 2,9 with high-intensity medical and surgical treatments that vary by stroke type and may result in distinct ventilation and tracheostomy practice patterns, 4 and therefore, differing costs.…”

“…6 Value-based care emphasizes maximizing overall outcomes for the health care delivered per unit cost of providing this care. 7 The Centers for Medicare and Medicaid Services have led the effort to shift the US health care system to focus on value-based care, with payment models influencing both how care is delivered and how health care systems and providers are paid. 8…”

Efectos de la Terapia en Espejo vs. Ejercicio Terapéutico Cognoscitivo en la mejora de las funciones del miembro superior en pacientes con ictus

“…Así mismo, estos dos grupos se dividen en varios subgrupos como se muestra en la siguiente Figura 7. como AIT o ictus isquémico [34]. Cuando el evento dura menos de 24 nos referimos a un AIT, este evento se resuelve rápidamente originando síntomas transitorios aunque debe ser considerado una señal de advertencia de futuros derrames [35][36][37]. En cambio, el ictus isquémico supera las 24 horas de evolución y provoca necrosis del tejido cerebral [38][39][40], y puede dividirse en cinco subtipos basándose en la clasificación Trial Org-10172…”