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.

The authors report a primary finding of a reduction in length of hospital stay from 5 days to 2 days, which was attributed to the use of the outpatient clinic. However, the total length of stay (acute hospitalization and rehabilitation) did not change. Therefore, the centralized units may have just been faster in getting patients to rehabilitation, but not in reducing disability or speeding recovery. Typical daily cost of acute hospitalization as compared with rehabilitation daily cost in Denmark was not reported, and a future formal cost effectiveness analysis is planned. Data was not reported on the use of the outpatient clinic, so the impact of that clinic is not clear. The authors also report a significant improvement in the quality of care, however this improvement mirrored that also seen in the other areas of Denmark. Finally, the analysis did not suggest a significant increase in use of thrombolysis, decrease in mortality, or decrease in readmission. We look forward to the results of the cost analysis – which should include all the costs involved in planning and implementing the consolidation, as well as transportation costs for patients and their family members.

  1. Sidsel Hastrup, Soren P. Johnsen, Thorkild Terkelsen, et al. Effects of centralizing acute stroke services: A prospective cohort study. Neurology 2018;91:e236-e248

 

Kevin A. Kerber, MD, MS

Kevin A. Kerber, MD, MS

Dr. Kevin Kerber is Associate Professor and health services researcher in the Department of Neurology at the University of Michigan Health System. He is the principal investigator on NIH and AHRQ funded studies that involve a variety of methodologies including clinical epidemiology, clinical decision rule (risk stratification) development, interventional implementation science, and patient-oriented behavioral science. The clinical focus of his PI work is vestibular and cerebellar disorders. This work identified gaps between our evidence-base and current practice, and defined subsequent targets leading to his current interventional work. His team is now developing and implementing interventions at the physician and patient levels using rigorous scientific methods. The long-term goal is to achieve efficient, effective, and sustainable processes with optimal patient outcomes. In recognition of his work, he was awarded the Derek Denny-Brown Young Neurological Scholar Award from the American Neurological Association. He is fellowship trained in Neuro-Otology under Robert W. Baloh, MD, at UCLA. He also completed a Masters Degree in Health and Health Care Research, which is the U-M Health Services Research training program, and a healthcare policy fellowship at the Center for Healthcare Research and Transformation (CHRT). He collaborates broadly on health services research in neurology and other specialty areas including headache, stroke, neurologic practice patterns, and payment policy. He also serves as a co-Advisor for the American Academy of Neurology’s Team RUC (Relative Value Unit Update Committee).

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