Organization of a United States County System for Comprehensive Acute Stroke Care

Cramer, Steven C.; Stradling, Dana; Brown, David M.; Carrillo-Nunez, Ignacio M.; Ciabarra, Anthony; Cummings, Michael; Dauben, Richard; Lombardi, David; Patel, Nirav J.; Traynor, Elizabeth N.; Waldman, Stephen; Miller, Ken; Stratton, Samuel J.

doi:10.1161/strokeaha.111.635334

Cited by 33 publications

(36 citation statements)

References 11 publications

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“…Only approximately 5.2% of patients receive tissue plasminogen activator for acute stroke across the United States, 1 with higher rates in some stroke systems. 2 In addition, many patients who do receive acute reperfusion therapies nonetheless have significant long-term disability. Additional forms of therapy are needed to improve outcomes.…”

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confidence: 99%

“…The effect size of MSC therapy was determined for the 4 endpoints that appeared most frequently across preclinical MSC studies: (1) modified Neurological Severity Score (mNSS), (2) adhesive removal test, (3) rotarod test, and (4) infarct volume. For each, effect size was defined as the improvement in outcome in MSC-treated animals relative to untreated ischemic controls, and calculated using Hedges' g, which is similar to Cohen d but more appropriate when examining effect size in smaller samples.…”

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confidence: 99%

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Meta-analysis of preclinical studies of mesenchymal stromal cells for ischemic stroke

et al. 2014

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Objectives:To evaluate the quality of preclinical evidence for mesenchymal stromal cell (MSC) treatment of ischemic stroke, determine effect size of MSC therapy, and identify clinical measures that correlate with differences in MSC effects.Methods: A literature search identified studies of MSCs in animal models of cerebral ischemia. For each, a Quality Score was derived, and effect size of MSCs was determined for the most common behavioral and histologic endpoints.Results: Of 46 studies, 44 reported that MSCs significantly improved outcome. The median Quality Score was 5.5 (of 10). The median effect size was 1.78 for modified Neurological Severity Score, 1.73 for the adhesive removal test, 1.02 for the rotarod test, and 0.93 for infarct volume reduction. Quality Score correlated significantly and positively with effect size for the modified Neurological Severity Score. Effect sizes varied significantly with clinical measures such as administration route (intracerebral . intra-arterial . IV, although effect size for IV was nonetheless very large at 1.55) and species receiving MSCs (primate . rat . mouse). Because many MSC mechanisms are restorative, analyses were repeated examining only the 36 preclinical studies administering MSCs $24 hours poststroke; results were overall very similar. Conclusions:In preclinical studies, MSCs have consistently improved multiple outcome measures, with very large effect sizes. Results were robust across species studied, administration route, species of MSC origin, timing, degree of immunogenicity, and dose, and in the presence of comorbidities. In contrast to meta-analyses of preclinical data for other stroke therapies, higher-quality MSC preclinical studies were associated with larger behavioral gains. These findings support the utility of further studies to translate MSCs in the treatment of ischemic stroke in humans.

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Meta-analysis of preclinical studies of mesenchymal stromal cells for ischemic stroke

et al. 2014

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“…This approach might also be useful for other acute stroke care applications such as to find the best locations for remote centers for telemedicine networks by identifying recombinant tissuetype plasminogen activator-ready hospitals as key steps in the regionalization process, 18 or identifying the best centers for a spoke-and-hub comprehensive stroke center network. 19 Geographic computerized methods that find the best location to improve access have been proposed for other services such as nephrology services 20 or flu surveillance. 11 We have made our maximal coverage calculator web-based to allow the system to be used by other states to determine the best locations of PSCs (http://compepi.cs.uiowa.edu/ϳgcfairch/sentinel).…”

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confidence: 99%

Primary Stroke Centers Should Be Located Using Maximal Coverage Models for Optimal Access

Leira¹,

Fairchild²,

Segre³

et al. 2012

Stroke

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Background and Purpose-The current self-initiated approach by which hospitals acquire Primary Stroke Center (PSC) certification provides insufficient coverage for large areas of the United States. An alternative, directed, algorithmic approach to determine near optimal locations of PSCs would be justified if it significantly improves coverage. Methods-Using geographic location-allocation modeling techniques, we developed a universal web-based calculator for selecting near optimal PSC locations designed to maximize the population coverage in any state. We analyzed the current PSC network population coverage in Iowa and compared it with the coverage that would exist if a maximal coverage model had instead been used to place those centers. We then estimated the expected gains in population coverage if additional PSCs follow the current self-initiated model and compared it against the more efficient coverage expected by use of a maximal coverage model to select additional locations. Results-The existing 12 self-initiated PSCs in Iowa cover 37% of the population, assuming a time-distance radius of 30 minutes. The current population coverage would have been 47.5% if those 12 PSCs had been located using a maximal coverage model. With the current self-initiated approach, 54 additional PSCs on average will be needed to improve coverage to 75% of the population. Conversely, only 31 additional PSCs would be needed to achieve the same degree of population coverage if a maximal coverage model is used. Conclusion-Given the substantial gain in population access to adequate acute stroke care, it appears justified to direct the location of additional PSCs or recombinant tissue-type plasminogen activator-capable hospitals through a maximal coverage model algorithmic approach. (Stroke. 2012;43:2417-2422.)

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“…The hub and spoke model has been successfully implemented in rural areas and third world countries to maximize available resources across various health domains and has been integrated within comprehensive stroke centers in the United States 15 and hyperacute SUs in the United Kingdom 16 to improve access to intravenous thrombolysis. 15 In hospitals with low volumes of stroke admissions, a model where a clinical coordinator services potentially a group of hospitals in reasonable geographic proximity, may prove practical and pragmatic, potentially with some economies of scale in terms of planning and some resources.…”

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confidence: 99%

“…15 In hospitals with low volumes of stroke admissions, a model where a clinical coordinator services potentially a group of hospitals in reasonable geographic proximity, may prove practical and pragmatic, potentially with some economies of scale in terms of planning and some resources. This was part of the business rationale used for the RSP.…”

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Evaluation of Rural Stroke Services

Cadilhac

Purvis

Kilkenny

et al. 2013

Stroke

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Furthermore, only 4% to 5% of the 91 rural hospitals that responded to a national survey had an SU or access to neurologists, <50% used a care pathway, and only 32% had a clinical nurse specialist for stroke.3 With ≈7 million residents, New South Wales (NSW) is the most populated state in Australia, 9 and almost a third of this population live in rural areas.11 Similar to many locations, variability in the provisionBackground and Purpose-The quality of hospital care for stroke varies, particularly in rural areas. In 2007, funding to improve stroke care became available as part of the Rural Stroke Project (RSP) in New South Wales (Australia). The RSP included the employment of clinical coordinators to establish stroke units or pathways and protocols, and more clinical staff. We aimed to describe the effectiveness of RSP in improving stroke care and patient outcomes. Methods-A historical control cohort design was used. Clinical practice and outcomes at 8 hospitals were compared using 2 medical record reviews of 100 consecutive ischemic or intracerebral hemorrhage patients ≥12 months before RSP and 3 to 6 months after RSP was implemented. Descriptive statistics and multivariable analyses of patient outcomes are presented. Results-Sample: pre-RSP n=750; mean age 74 (SD, 13) years; women 50% and post-RSP n=730; mean age 74 (SD,13) years; women 46%. Many improvements in stroke care were found after RSP: access to stroke units (pre 0%; post 58%, P<0.001); use of aspirin within 24 hours of ischemic stroke (pre 59%; post 71%, P<0.001); use of care plans (pre 15%; post 63%, P<0.001); and allied health assessments within 48 hours (pre 65%; post 82% P<0.001). After implementation of the RSP, patients directly admitted to an RSP hospital were 89% more likely to be discharged home (adjusted odds ratio, 1.89; 95% confidence interval, 1.34-2.66). Conclusions-Investment in clinical coordinators who implemented organizational change, together with increased clinician resources, effectively improved stroke care in rural hospitals, resulting in more patients being discharged home.

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Organization of a United States County System for Comprehensive Acute Stroke Care

Cited by 33 publications

References 11 publications

Meta-analysis of preclinical studies of mesenchymal stromal cells for ischemic stroke

Meta-analysis of preclinical studies of mesenchymal stromal cells for ischemic stroke

Primary Stroke Centers Should Be Located Using Maximal Coverage Models for Optimal Access

Evaluation of Rural Stroke Services

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