Did consolidating acute stroke services in Denmark help?

Getting acute stroke patients to appropriate clinical care setting as fast as possible is very important. Hastrup et al report results of an initiative to centralize stroke care in 2012 in the Central Denmark Region (CDR). CDR has a population of 1.3million and area of 5040 square miles1. The purpose of the centralization was a) to ensure all stroke patients would receive care in designated areas and b) to reduce overall costs. The design of the study was pre/post with contemporaneous comparisons to the rest of Denmark. The centralization involved consolidating acute stroke care to 2 designated hospitals from a total of 6 hospitals in the region. These hospitals both offered thrombolysis, but endovascular therapy was only offered at one. A neurologist was on call 24 hours a day for calls from outside the acute stroke units. In addition, an outpatient clinic was established for minor stroke and TIA.

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Caution in Using Pre/Post Research Designs to Inform Changes in Care Delivery

IV-tPA is an established treatment for acute stroke based on randomized control trials showing beneficial effects on 90-day functional outcomes typically measured by the modified Rankin scale. Could there be additional benefits to IV-tPA? This is the question posed by Chen et al in Association between implementation of a code stroke system and poststroke epilepsy, who sought to assess if a concerted effort to promote IV-tPA use – the Code Stroke System – impacts the development of post-stroke epilepsy. This is an important outcome to consider since seizures negatively influence overall quality of life. It certainly seems plausible that less brain injury – a theoretical benefit from the Code Stroke System – lowers the risk for seizures. Chen et al conclude that the Code Stroke System was indeed associated with lower odds of post-stroke epilepsy and state the next steps are to identify the contributions of its individual components.

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Comparing aspects of care delivered by the integrated neurologist

A challenge for the primary care medical home model (PCMH) is incorporating care from specialties. In this study, Elrashidi et al explored the impact of integrating a neurologist into the Mayo Clinic PCMH by comparing aspects of care delivered by the integrated neurologist with matched visits from the pre-integration time period. The integrated neurologist worked 0.6 FTE, had a staff of 3 FTE registered nurses, 3 clinical assistants, and a specified work plan — 3-4 scheduled patients per half day, in addition to curbsides, e-consults, follow-up, and additional acute same-day consults. Over a 12-month period of patient follow-up, patients seen by the integrated neurologist had fewer subsequent neurologist visits (0.62, p=0.001), EMGs (OR 0.64, p=0.009), and brain MRIs (0.60, p<0.001), but not total subsequent outpatient visits (0.92, p=0.21), ED visits (0.83, p=0.20), or hospitalizations (0.96, p=0.83) compared with the pre-integration visits. The integrated neurologist also did not lower the time to neurologist appointment (p=0.83), despite presumably reducing referrals because of curbsides and e-consults.

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Dr. Lyell K. Jones Answers Our Questions on the Axon Registry

In Introducing the Axon Registry, Sigsbee et al outline the rationale, structure, function, and challenges related to the AAN’s development of its own clinical quality data registry: the Axon Registry. Dr. Lyell K. Jones, co-author, answers some questions we had after reading the report.

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