Advances in Stroke Health Policy/Outcomes Research 2013 Barbara G. Vickrey, MD, MPH; Amanda G. Thrift, PhD
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venues for risk factor reduction or increasing local medical care facilities and providers. One study of patients with stroke in the province of Ontario, Canada, found that patients with stroke from the highest quintile of median neighborhood income had lower 1-year mortality than those from the lowest quintile (adjusted hazard ratio, 1.18; 95% confidence interval, 1.03–1.29), even after accounting for age, sex, comorbidities, stroke type and severity, type of hospital, provider specialty, and whether cared for on an acute stroke unit.4 Analysis of Cardiovascular Health Study data, which had the advantage of including both individual household income and a composite measure of neighborhood socioeconomic status based on 6 census tract variables, demonstrated that higher neighborhood socioeconomic disadvantage was associated with higher 1-year poststroke mortality (adjusted hazard ratio, 1.77; 95% confidence interval, 1.17–2.68), after accounting for a range of clinical and demographic characteristics, including household income.5 Future research should aim to elucidate the factors and causal pathway behind this association, so that policy interventions are appropriately targeted.
ince the last advances article on health policy and outcomes,1 selected developments include new knowledge on long-term outcomes after stroke and their policy relevance, associations of neighborhood disadvantage with stroke mortality, growth and effect of regionalized systems of stroke care, and preliminary research relevant to policies on early stroke mortality as a hospital performance measure.
Long-Term Outcome After Stroke The South London Stroke Register of incident strokes across a multiethnic, urban population reported that long-term survival gradually improved in consecutive cohorts of patients with stroke from 1995 to 2010, and higher survival was associated with stroke unit admission (hazard ratio, 0.75; P98% adherence across 4 evidence-based measures. All but 1 death occurred after a patient or family decision to withdraw or withhold life-sustaining mechanical ventilation or artificial hydration/nutrition. Taken together, these findings suggest that early acute stroke mortality could primarily be because of patient and family preferences rather than because of quality of care deficiencies.
Disclosures Dr Thrift was supported by a Senior Research fellowship from the National Health & Medical Research Council (Australia). Dr Vickrey reports no conflicts.
References 1. Thrift AG, Vickrey BG. Advances in health policy and outcome 20102011. Stroke. 2012;43:300–301. 2. Wang Y, Rudd AG, Wolfe CD. Trends and survival between ethnic groups after stroke: the South London Stroke Register. Stroke. 2013;44:380–387. 3. Ayerbe L, Ayis S, Crichton S, Wolfe CD, Rudd AG. The natural history of depression up to 15 years after stroke: the South London Stroke Register. Stroke. 2013;44:1105–1110. 4. Kapral MK, Fang J, Chan C, Alter DA, Bronskill SE, Hill MD, et al. Neighborhood income and stroke care and outcomes. Neurology. 2012;79:1200–1207. 5. Brown AF, Liang LJ, Vassar SD, Merkin SS, Longstreth WT Jr, Ovbiagele B, et al. Neighborhood socioeconomic disadvantage and mortality after stroke. Neurology. 2013;80:520–527. 6. Song S, Saver J. Growth of regional acute stroke systems of care in the United States in the first decade of the 21st century. Stroke. 2012;43:1975–1978. 7. Kapral MK, Fang J, Silver FL, Hall R, Stamplecoski M, O’Callaghan C, et al. Effect of a provincial system of stroke care delivery on stroke care and outcomes. CMAJ. 2013;185:E483–E491. 8. Moynihan B, Paul S, Markus HS. User experience of a centralized hyperacute stroke service: a prospective evaluation. Stroke. 2013;44:2743–2747. 9. Switzer JA, Demaerschalk BM, Xie J, Fan L, Villa KF, Wu EQ. Costeffectiveness of hub-and-spoke telestroke networks for the management of acute ischemic stroke from the hospitals’ perspectives. Circ Cardiovasc Qual Outcomes. 2013;6:18–26. 10. National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. 2nd ed. Pittsburgh, PA: National Consensus Project for Quality Palliative Care; 2009:80. 11. Kelly AG, Hoskins KD, Holloway RG. Early stroke mortality, patient preferences, and the withdrawal of care bias. Neurology. 2012;79:941–944. Key Words: mortality ◼ point-of-care systems ◼ quality of healthcare
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venues for risk factor reduction or increasing local medical care facilities and providers. One study of patients with stroke in the province of Ontario, Canada, found that patients with stroke from the highest quintile of median neighborhood income had lower 1-year mortality than those from the lowest quintile (adjusted hazard ratio, 1.18; 95% confidence interval, 1.03–1.29), even after accounting for age, sex, comorbidities, stroke type and severity, type of hospital, provider specialty, and whether cared for on an acute stroke unit.4 Analysis of Cardiovascular Health Study data, which had the advantage of including both individual household income and a composite measure of neighborhood socioeconomic status based on 6 census tract variables, demonstrated that higher neighborhood socioeconomic disadvantage was associated with higher 1-year poststroke mortality (adjusted hazard ratio, 1.77; 95% confidence interval, 1.17–2.68), after accounting for a range of clinical and demographic characteristics, including household income.5 Future research should aim to elucidate the factors and causal pathway behind this association, so that policy interventions are appropriately targeted.
ince the last advances article on health policy and outcomes,1 selected developments include new knowledge on long-term outcomes after stroke and their policy relevance, associations of neighborhood disadvantage with stroke mortality, growth and effect of regionalized systems of stroke care, and preliminary research relevant to policies on early stroke mortality as a hospital performance measure.
Long-Term Outcome After Stroke The South London Stroke Register of incident strokes across a multiethnic, urban population reported that long-term survival gradually improved in consecutive cohorts of patients with stroke from 1995 to 2010, and higher survival was associated with stroke unit admission (hazard ratio, 0.75; P98% adherence across 4 evidence-based measures. All but 1 death occurred after a patient or family decision to withdraw or withhold life-sustaining mechanical ventilation or artificial hydration/nutrition. Taken together, these findings suggest that early acute stroke mortality could primarily be because of patient and family preferences rather than because of quality of care deficiencies.
Disclosures Dr Thrift was supported by a Senior Research fellowship from the National Health & Medical Research Council (Australia). Dr Vickrey reports no conflicts.
References 1. Thrift AG, Vickrey BG. Advances in health policy and outcome 20102011. Stroke. 2012;43:300–301. 2. Wang Y, Rudd AG, Wolfe CD. Trends and survival between ethnic groups after stroke: the South London Stroke Register. Stroke. 2013;44:380–387. 3. Ayerbe L, Ayis S, Crichton S, Wolfe CD, Rudd AG. The natural history of depression up to 15 years after stroke: the South London Stroke Register. Stroke. 2013;44:1105–1110. 4. Kapral MK, Fang J, Chan C, Alter DA, Bronskill SE, Hill MD, et al. Neighborhood income and stroke care and outcomes. Neurology. 2012;79:1200–1207. 5. Brown AF, Liang LJ, Vassar SD, Merkin SS, Longstreth WT Jr, Ovbiagele B, et al. Neighborhood socioeconomic disadvantage and mortality after stroke. Neurology. 2013;80:520–527. 6. Song S, Saver J. Growth of regional acute stroke systems of care in the United States in the first decade of the 21st century. Stroke. 2012;43:1975–1978. 7. Kapral MK, Fang J, Silver FL, Hall R, Stamplecoski M, O’Callaghan C, et al. Effect of a provincial system of stroke care delivery on stroke care and outcomes. CMAJ. 2013;185:E483–E491. 8. Moynihan B, Paul S, Markus HS. User experience of a centralized hyperacute stroke service: a prospective evaluation. Stroke. 2013;44:2743–2747. 9. Switzer JA, Demaerschalk BM, Xie J, Fan L, Villa KF, Wu EQ. Costeffectiveness of hub-and-spoke telestroke networks for the management of acute ischemic stroke from the hospitals’ perspectives. Circ Cardiovasc Qual Outcomes. 2013;6:18–26. 10. National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. 2nd ed. Pittsburgh, PA: National Consensus Project for Quality Palliative Care; 2009:80. 11. Kelly AG, Hoskins KD, Holloway RG. Early stroke mortality, patient preferences, and the withdrawal of care bias. Neurology. 2012;79:941–944. Key Words: mortality ◼ point-of-care systems ◼ quality of healthcare
