Regional variation in acute stroke care organisation

Venturelli, Paula Muñoz; Robinson, Thompson G.; Lavados, Pablo M.; Olavarría, Verónica V.; Arima, Hisatomi; Billot, Laurent; Hackett, Maree L.; Lim, Joyce; Middleton, Sandy; Pontes-Neto, Octávio M.; Peng, Bin; Song, Lily; Mead, Gillian; Watkins, Caroline L; Lin, Ruey‐Tay; Lee, Tsong‐Hai; Pandian, Jeyaraj Durai; Silva, H. Asita de; Anderson, Craig S.

doi:10.1016/j.jns.2016.10.026

Cited by 13 publications

(14 citation statements)

References 18 publications

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“…Previous studies have shown large variations in the organisation of stroke care across hospitals which may compromise effective ourcomes, as significant associations between receipt of evidence-based care and clinical outcomes were reported in our international, multicentre, Head Positioning in acute Stroke Trial (HeadPoST) [7,14]. Despite acknowledging variations in stroke care pathways, access to ASU, and other aspects of stroke care [14,15], few studies have systematically quantified how the specific components of ASU care may differ across regions of the world [16]. Herein, we quantify the components of ASU care, within and across hospitals, in four participating income-grouped geographical regions for patients who participated in the HeadPoST.…”

Section: Introductionmentioning

confidence: 98%

“…While ASU care is relatively well-defined in high resource settings, less attention has been given to its availability and appropriateness in low-and middle-income countries (LMICs), where most of the global burden of stroke occurs [12,13]. Previous studies have shown large variations in the organisation of stroke care across hospitals which may compromise effective ourcomes, as significant associations between receipt of evidence-based care and clinical outcomes were reported in our international, multicentre, Head Positioning in acute Stroke Trial (HeadPoST) [7,14]. Despite acknowledging variations in stroke care pathways, access to ASU, and other aspects of stroke care [14,15], few studies have systematically quantified how the specific components of ASU care may differ across regions of the world [16].…”

Section: Introductionmentioning

confidence: 99%

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Quantifying regional variations in components of acute stroke unit (ASU) care in the international HeadPoST study

Ouyang

Zhang

Wang

et al. 2020

Journal of the Neurological Sciences

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Access to acute stroke unit (ASU) care is known to vary worldwide. We aimed to quantify regional variations in the various components of ASU care. Method: Secondary analysis of the Head Positioning in acute Stroke Trial (HeadPoST), an international, multicentre, cluster crossover trial of head-up versus head-down positioning in 11,093 acute stroke patients at 114 hospitals in 9 countries. Patients characteristics and 11 standard components of processes of care were described according to ASU admission within and across four economically-defined regional groups (Australia/UK, China [includes Taiwan], India/Sri Lanka, and South America [Brazil/Chile/Colombia]). Variations in process of ASU care estimates were obtained in hierarchical mixed models, with adjustment for study design and potential patient-and hospital-level confounders. Results: Of 11,086 patients included in analyses, 59.7% (n = 6620) had an ASU admission. In China, India/Sri Lanka and South America, ASU patients were older, had greater neurological severity and more premorbid conditions than non-ASU patients. ASU patients were more likely to receive reperfusion therapy and multidisciplinary care within regions, but the components of care varied across regions. With Australia/UK as reference, patients in other regions had a lower probability of receiving reperfusion therapy, especially in India/Sri Lanka (adjusted odds ratio [aOR] 0.27, 95% confidence interval [CI] 0.12-0.63) and multidisciplinary care (mainly in formal dysphagia assessment, physiotherapy and occupational therapy). Conclusion:There is significant variation in the components of stroke care across economically-defined regions of the world. Ongoing efforts are required to reduce disparities and optimise health outcomes, especially in resource poor areas. Clinical trial registration: HeadPoST is registered at ClinicalTrials.gov (NCT02162017).

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Section: Introductionmentioning

confidence: 98%

Section: Introductionmentioning

confidence: 99%

Quantifying regional variations in components of acute stroke unit (ASU) care in the international HeadPoST study

Ouyang

Zhang

Wang

et al. 2020

Journal of the Neurological Sciences

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“…29,30 Having organized local stroke care protocols, established goals and quality improvement strategies, all have an important role in stroke care. 31 Unfortunately, considerable regional differences remain in optimal stroke care, including access to stroke units, 32 particularly in low resource settings. Such disparities require further urgent attention to reduce the burden of stroke, in particular in low and middle-income countries where fewer resources are available and stroke rates are increasing.…”

Section: Improving Stroke Systems Of Carementioning

confidence: 99%

Acute Treatment of Stroke (Except Thrombectomy)

Venturelli

Appleton

Anderson

et al. 2018

Curr Neurol Neurosci Rep

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Large definitive trials have provided insight into acute stroke care including broadening the therapeutic window for thrombolysis, alternatives to standard dose alteplase, the use of dual antiplatelet therapy early after minor ischemic stroke, and treating elevated blood pressure in intracerebral hemorrhage. Further ongoing and future trials are eagerly awaited in this ever-expanding area. Although definitive trials have led to improvements in acute stroke care, there remains a need for further research to improve our understanding of pathophysiological mechanisms underlying different stroke types with the potential for treatments to be tailored to the individual.

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“…22 Conversely, in low-income countries, where most of the global stroke burden exists, the lying flat position (and more prolonged immobilization) is widely applied due to use of simple non-mechanical beds. Taken together with other geographical variations in nursing practices and hospital care policies, 23 the manner in which acute stroke patients are nursed could be highly relevant to variable outcomes and adverse events from this critical illness across the world.…”

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confidence: 99%

“…The aim is to determine the comparative effectiveness (and safety) of the lying flat versus sitting up head position in patients with acute stroke. 23 Given uncertainty over the relevance of any treatment effects on a surrogate measure, such as increased CBF after AIS, 25,26 the study has been powered to determine effects on hard clinical endpoints assessed by trained personnel blind to treatment allocation. The use of broad inclusion criteria will allow an assessment of any heterogeneity of potential benefits (and harms) between AIS and ICH, and across particular subtypes of AIS, e.g.…”

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confidence: 99%

Statistical analysis plan for the Head Position in Stroke Trial (HeadPoST): An international cluster cross-over randomized trial

Billot

Woodward

Arima

et al. 2017

International Journal of Stroke

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Background There is evidence to indicate that the lying flat head position increases cerebral blood flow and oxygenation in patients with acute ischemic stroke, but how these physiological effects translate into clinical outcomes is uncertain. The Head Position in Stroke Trial aims to determine the comparative effectiveness of lying flat (0°) compared to sitting up (≥30°) head positioning, initiated within 24 h of hospital admission for patients with acute stroke. Design An international, pragmatic, cluster-randomized, crossover, open, blinded outcome assessed clinical trial. Each hospital with an established acute stroke unit (cluster) site was required to recruit up to 140 consecutive cases of acute stroke (one phase of head positioning before immediately crossing over to the other phase of head positioning), including both acute ischemic stroke and intracerebral hemorrhage, in each randomized head position as a 'business as usual' policy. Objective To outline in detail the predetermined statistical analysis plan for the study. Methods All accumulated data will be reviewed and formally assessed. Information regarding baseline characteristics of patients, their process of care and management will be outlined, and for each item, statistically relevant descriptive elements will be described. For the trial outcomes, the most appropriate statistical comparisons are described. Results A statistical analysis plan was developed that is transparent, verifiable, and predetermined before completion of data collection. Conclusions We developed a predetermined statistical analysis plan for Head Position in Stroke Trial to avoid analysis bias arising from prior knowledge of the findings, in order to reliably quantify the benefits and harms of lying flat versus sitting up early after the onset of acute stroke. Trial registration ClinicalTrials.gov identifier NCT02162017; ANZCTR identifier ACTRN12614000483651.

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Regional variation in acute stroke care organisation

Abstract: Background: Few studies have assessed regional variation in the organisation of stroke

Cited by 13 publications

References 18 publications

Quantifying regional variations in components of acute stroke unit (ASU) care in the international HeadPoST study

Quantifying regional variations in components of acute stroke unit (ASU) care in the international HeadPoST study

Acute Treatment of Stroke (Except Thrombectomy)

Statistical analysis plan for the Head Position in Stroke Trial (HeadPoST): An international cluster cross-over randomized trial

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