The Effect of Transient Ischemic Attack Clinical Pathway Xiaoqin Huang, Ph.D. Chunqiu Fan, M.D. Jianping Jia, Ph.D. Lihong Wang, M.S. Xiaoying Li, M.S. Yingfeng Wu, Ph.D. Yingmei Deng, M.S. Jian Wu, M.D., Ph.D. Background: Clinical pathway (CP) of transient ischemic attack (TIA) is an interdisciplinary, comprehensive, standardized management model for medical care of TIA. It aims to standardize the procedure, reduce the cost, and improve the quality of medical care. However, its effect is still unclear. Objective: To evaluate the effect of TIA CP and provide evidence for control of medical care cost, optimize the structure of hospital cost, and make best use of medical resource. Methods: 112 patients in the CP group and 179 patients in the nonclinical pathway (NCP) group were included in this nonconcurrent cohort study. Results: The average length of stay was 9.5563.89 days in the NCP group, and it was 7.2662.09 days in the CP group. The average length of stay was significantly shortened by 2.29 days. Hospital cost in the CP group significantly increased by 7.9% (868 yuan) compared with that in the NCP group. The proportion of medication cost significantly decreased by 5%, while the proportion of examination cost significantly increased by 8%. As for the clinical outcomes of patients with TIA, 98.21% of the patients in the CP group were discharged in a good condition, while the proportion was 97.77% in the NCP group, and no significant difference was found between the improvement rate of the two groups. Eight patients (4%)
386
http://neuro.psychiatryonline.org
in the NCP group were admitted to the hospital because of a 30-day recurrent TIA or cerebral infarction; four of them had cerebral infarction, whereas no recurrent TIA or cerebral infarction was found in the CP group at the 30-day follow-up. Conclusions: Implementation of TIA CP could reduce the length of stay, the proportion of medication cost, and optimize the structure of hospital expense, thus making best use of medical resources and improve the quality of TIA medical care. (The Journal of Neuropsychiatry and Clinical Neurosciences 2014; 26:386–391)
T
ransient ischemic attack (TIA) is a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction. TIA is one of the major risk factors for acute cerebral infarction.1 In China, the annual incidence rate of TIA is about 180/100,000 accounting for 40% of ischemic stroke, which has been increasing per year and has become one of the major diseases that seriously impacts both human health and quality of life. Nowadays, many domestic and international clinical guidelines for TIA have provided the basis of clinical practice for the treatment of TIA stratification, antiplatelet therapy, or diagnostic imaging.2–4 An important research direction of TIA is how to more effectively transform TIA clinical guidelines into clinical practice. The implementation strategy based on the standardized clinical practice has provided a fundamental approach to transform medicine. The emergence of clinical pathway (CP) management supplies opportunities for the implementation and evaluation of developing the management for ischemic stroke. As a new standardized management model of clinical diagnosis and a standard treatment modality and procedure,
Received July 30, 2013; accepted October 23, 2013. From the Dept. of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China (XH, CF, JJ, LW, JW); Dept. of Medical Affair, Xuan Wu Hospital, Capital Medical University, Beijing, China (XL, YW); and Medical Records and Statistic Office, Xuan Wu Hospital, Capital Medical University, Beijing, China (YD). Send correspondence to Dr. Wu; e-mail: [email protected] Copyright © 2014 American Psychiatric Association
J Neuropsychiatry Clin Neurosci 26:4, Fall 2014
HUANG et al. which have strict requirements of the work order and time, CP is made up by a team of professional staff (including physicians, clinical specialists, nurses, and hospital administrators, etc.), according to a need of clinical intervention of a particular disease. CP is conducive to implement standardized treatment, shorten average length of stay in hospitals, promote the rational use of medical resources, and ensure quality of care.5–7 Foreign research showed the implementation of CP in the treatment of acute cerebral infarction can significantly shorten hospitalization time and hospital costs, promote efficient use of medical resources, decline the readmission rate, and improve clinical outcomes.8–11 Today, there are fewer studies about the efficiency for organization management of TIA. Most studies pay attention to the stratified evaluation and referral processing mode.12,13 In China, the implementation of CP is at the beginning stage. Surgical diseases by surgical treatment are the major disease in view of implement of CP, and the management of CP for TIA patients is just beginning at 2010. The aim of this study was to assess the effectiveness, quality, and safety of implementation of CP for hospitalized TIA patients. The aim was also to determine whether a clear understanding of the medical duties and the implementation of a standardized treatment program could shorten the length of stay in hospitals, control medical costs, improve clinical efficiency of TIA, make rational use of medical resources, and improve medical quality.
METHODS Study Population Xuanwu Hospital Capital Medical University is one of the first-class general hospitals and includes a neurology department. Xuanwu Hospital has more than 1,500 beds and about 2,000 patients with acute cerebral infarction are admitted to the neurology department, accounting for 45%250% of the inpatients. As a pilot hospital of CP management, Xuanwu Hospital began to apply CP for TIA patients. All participants were TIA patients from the neurology department during 2009 March to 2011 December and were managed with TIA CP. Inclusion criteria were 1) the principal diagnosis of TIA, including vertebralbasilar syndrome (ICD-10: G45.0) and carotid syndrome (cerebral hemisphere) (ICD-10: G45.1); and 2) treatment of patients according to CP when other diagnosis does not
J Neuropsychiatry Clin Neurosci 26:4, Fall 2014
require special treatment or disrupt CP implementation. TIA patients before implication of CP (2008 May to 2010 February) were enrolled as controls. TIA CP TIA CP was designed by the Clinical Pathway Committee from the Ministry of Health prior to this study.14 The Clinical Pathway Committee involved experts of multidisciplinary, including neurologists, neurosurgery scientists, nursing scientists, clinical pharmacists, experts in rehabilitation medicine, evidence-based medicine, hospital management, health economics and medical information, and other experts.10,15–17 The Committee referred to the latest diagnosis and treatment guidelines and developed this evidence-based CP, including the Standard Admission Procedure and Clinical Pathways Document (Appendix I/II). CP was included in the routine clinical work of the neurology department as an element of medical quality improvement project. The leader of this CP implementation team is the director of neurology department. The team members include doctors, nurses, and other related medical staffs. Each participant gave written informed consent and agreed to receive standard medical care including major medical advice, detail diagnosis, and treatment information within 1 week after admission. Detail diagnosis and treatment information were recorded using structured the TIA CP form (Appendix II) and entered into the database of the medical record statistics office. Nonconcurrent cohort method was used in this study. TIA information before and after implication of CP was collected from the medical record registration database and analyzed retrospectively. Outcomes The indicators for effect and safety of TIA CP included 1) length of stay; 2) hospital cost; and 3) indicators for safety (improvement rate, cerebral infarction, mortality, readmission rate (1 week, 2 weeks, 30 days because of cerebrovascular events, including TIA, cerebral infarction). Statistical Analysis Categorical variables were expressed as number (%) and continuous variables were expressed as mean6SD or median and quartiles. For comparison between groups, x2/Fisher exact test and independent t-test/rank sum test were used for categorical and continuous variables, respectively. As nonconcurrent cohort method was used in this study, propensity score method was employed to
http://neuro.psychiatryonline.org
387
TRANSIENT ISCHEMIC ATTACK CLINICAL PATHWAY
TABLE 1.
Baseline Characteristics
Characteristics Male (%) Age Risk factor Cerebrovascular disease Hypertension Coronary heart disease Atrial fibrillation Diabetes mellitus Hyperlipidemia Smoking Drinking ABCD2 score Risk level Low(1–3) Medium (4–5) High (6–7) Way of admission Outpatient Emergency
Clinical Pathway (N5179)
Non-Clinical Pathway (N5112)
p*
p1
124 (69.27%) 62.11612.64
86 (76.79%) 60.72613.03
0.1609 0.3684
0.988 0.9955
32 (17.88%) 98 (54.75%) 35 (19.55%) 20 (11.17%) 57 (31.84%) 49 (27.37%) 97 (54.19%) 58 (32.40%) 3.6261.12
26 (23.21%) 70 (62.50%) 16 (14.29%) 9(8.04%) 32 (28.57%) 24 (21.43%) 69 (61.61%) 33 (29.46%) 3.6161.30
88 (49.16%) 77 (43.02%) 14 (7.82%)
55 (49.11%) 48 (42.86%) 9 (8.04%)
42 (23.46%) 137 (76.54%)
35 (31.25%) 77 (68.75%)
0.2705 0.1916 0.245 0.7756 0.5546 0.2516 0.2126 0.5981 0.9516 0.9978 — — — 0.1452 — —
0.5526 0.1916 0.9848 0.7756 0.9995 0.9918 0.2126 0.9993 0.9955 0.9999 .0.05 .0.05 .0.05 0.9705 .0.05 .0.05
p*: p value without adjustment. p1: p value with adjustment.
avoid potential imbalance between the two groups. The variables included in the propensity score model were gender, age, cerebrovascular disease, hypertension, coronary heart disease, atrial fibrillation, diabetes, hyperlipidemia, smoking, drinking, ABCD2 score, risk classification, and method of admission. Adjusted baseline indicators were compared using logistic (qualitative indicators) and covariance analysis (quantitative indicators) between the groups, and propensity score was adjusted in the model as a continuous variable. Data analyses were performed by the SAS 9.13 (SAS Institute, Inc., Cary, NC). Significance was defined as p ,0.05 (two-sided).
RESULTS Baseline Characteristics of Patients with Transient Ischemic attack As shown in Table 1, 284 patients with TIA were included in this study with 112 patients in the CP group and 179 patients in the NCP group. The mean age was 60.726 13.03 years and 62.11612.64 years in the CP group and the NCP group, respectively. Both groups were similar with respect to mean age, gender proportion, and risk factors for angiosis (p .0.05). ABCD2 score was not statistically different between the CP group and the NCP group with mean score of 3.6261.12 and 3.6161.30 in both groups, respectively (p .0.05). Seventy-seven patients (68.75%) in the CP group were admitted to the
388
http://neuro.psychiatryonline.org
hospital from the emergency department, and 35 (31.25%) from the outpatient department, whereas in the NCP group, 76.54% from emergency department and 23.46% from outpatient department. The proportion was not statistically significant (p .0.05). Comparison of Cost and Medical Efficiency Indicators Before and After CP Implementation The average length of stay was 9.5563.89 days in the NCP group, and it was 7.2662.09 days in the CP group. The average length of stay was significantly shortened by 2.29 days (p ,0.001). Hospital cost in the CP group increased significantly by 7.9% (868 yuan) compared with that in NCP group (p ,0.05). The median medication cost (P25, P75) was 4262.7(2856.7–5804.1) and 4200.0(3528.4– 5179.1) in the CP group and the NCP group, respectively. The proportion of medication cost significantly decreased by 5% (p ,0.05), whereas the proportion of examination cost significantly increased by 8% (p ,0.001). In addition, examination cost using expensive machines also significantly increased by 4% (p ,0.01). As for the clinical outcomes of patients with TIA, 98.21% of the patients in the CP group was discharged in a good condition, whereas it was 97.77% in the NCP group; no significant difference was found between the improvement rate of the two groups (p .0.05). As shown in Table 2, eight patients (4%) in the NCP group were admitted to the hospital because of a 30-day recurrent TIA or cerebral infarction, and four among them
J Neuropsychiatry Clin Neurosci 26:4, Fall 2014
HUANG et al.
TABLE 2.
Effect and Safety of TIA Clinical Pathway
Length of stay Hospital cost Medication cost Examination cost Examination cost using expensive machines Proportion of medication cost Proportion of examination cost Proportion of examination cost using expensive machines Improvement rate Cerebral infarction Death Two-week readmission Thirty-day readmission
Clinical Pathway (N5179)
Nonclinical pathway (N5112)
9.5563.89 9300.6 (7081.8–12924) 1088267284.7 4262.7 (2856.7–5804.1) 3259.5 (2306.5–4283.5) 1665 (1100.0–2980.0) 0.4460.16 0.3560.12 0.2060.10
7.2662.09 11737 (9551.1–13452) 1175063179.6 4200.0 (3528.4–5179.1) 5072.5 (3962.8–6008.3) 2980 (1985.0–3747.5) 0.3960.10 0.4360.07 0.2460.07
175 (97.77%) 0 0 0 0
110 (98.21%) 4 0 5 3
p* ,0.001 ,0.001 ,0.001 0.9322 ,0.001 ,0.001 0.0005 ,0.001 0.0002 1.0000 — — — —
p1 ,0.001 0.0029 ,0.001 — ,0.001 ,0.001 — ,0.001 0.0083 — — — — —
p*: p value without adjustment. p 1: p value with adjustment.
had cerebral infarction, whereas no recurrent TIA or cerebral infarction was found in the CP group at the 30-day follow-up.
DISCUSSION Increasing number of patients with cerebral infarction has been an important problem in China, and exploring better treatment has been a great challenge. Updated clinical guidelines have provided evidence for the transformation of research results on ischemic cerebrovascular disease into clinical practice.19 Effective implementation strategy based on clinical practice is one of the fundamental pathways in translational medicine. The development of CP has provided a good opportunity for the optimal management of patients with ischemic stroke. It has been illustrated by other studies that the implementation of CP will reduce the length of stay, medication cost, examination cost, and the incidence of complications in hospital. In addition, it will also improve patients’ activities of daily living and medical quality.11,19–21 TIA is a critical and dangerous warning event of ischemic stroke, and it is also a major risk factor for cerebral infarction. Therefore, the prevention and treatment of TIA is very important. CP for patients with TIA is a good treatment model if expected results could be achieved. The feasibility assessment of emergency department-based TIA CP, which is reported by Brown, has shown that implementation of a CP is feasible and safe in an emergency department setting. However, the effect of CP in hospitalized patients with TIA has not been consistent.
J Neuropsychiatry Clin Neurosci 26:4, Fall 2014
As a pilot hospital of CP management in 2010, Xuanwu Hospital implemented CP management on patients with TIA in the neurology department. The objective of this project is to evaluate the effectiveness of TIA CP as a new medical care management pattern. The results have demonstrated that the length of stay has been reduced by 2.29 days, and the turnover rate has increased after the implementation of TIA CP. Therefore, the operational efficiency of the hospital has been improved, and the average waiting time of admission has been shortened. More patients could be better diagnosed and treated. The hospital cost increased by 7% after implementation of TIA CP. However, the average medication cost decreased, and the increment of hospital cost was mainly due to the increasing proportion of examination cost (increased by 8%). Xuanwu Hospital is one of the first-class general hospitals and includes a neurology department. Because of the complex condition of patients in Xuanwu hospital, it is difficult to determine the treatment strategy of patients with TIA. Therefore, based on the Standard Admission Procedure of Transient Ischemic Attack Clinical Pathways published by Health Ministry, the specific TIA CP of Xuanwu Hospital has been formulated after numerous discussions and expert debates. This evidencebased CP refers to the latest diagnosis and treatment guidelines of other countries16–18 and includes some new examinations and treatment strategies. For example, transesophageal echocardiography and color Doppler flow imaging foaming test have become important examinations due to the relationship between patent foramen ovale and TIA. In addition, more and more patients need cerebral vascular
http://neuro.psychiatryonline.org
389
TRANSIENT ISCHEMIC ATTACK CLINICAL PATHWAY angiography because of frequent TIA accompanied by cerebrovascular stenosis or cerebrovascular occlusion. The improvement of new technologies in medicine has offered not only more benefits but increased cost to patients. Therefore, examination costs increased after implementation of TIA CP. CP substantially improves clinical practice guidelines and offers detailed procedures on treatment, examination, and medical order after admission. Physicians will not determine the diagnosis and treatment of TIA relying only on their own experiences. The implementation of TIA CP has indeed shortened length of stay, standardized clinical medication, and adjusted the distribution of hospital cost. The assessment of TIA CP effectiveness suggested that the examination cost should be further reduced. In general, the implementation of CP controlled the rapid growth of hospital cost to some extent and produced more reasonable distribution of hospital cost. TIA, as an unstable high-risk state, is risk factor for early stroke. Many researches have shown that 8%212% patients with TIA underwent cerebral infarction in 7 days, 9.2% patients in 30 days, and 10%220% in 90 days.23,24 Because TIA most likely progresses to cerebral infarction in the initial days after TIA, early standard treatment will prevent the recurrence of stroke at best. Does the implementation of TIA CP reduce the risk of cerebral infarction? This study has found that the improvement
rate of TIA in the CP group is similar with that in the NCP group; no recurrent TIA or cerebral infarction was found in the CP group, whereas eight patients (4%) in the NCP group were admitted to the hospital after a 14-day or a 30-day follow-up. It is possible that clinical effectiveness could not be observed because of short follow-up duration. In conclusion, CP has standardized and normalized the diagnosis and treatment procedure of TIA. On one hand, the implementation of TIA CP will reduce unnecessary or unreasonable diagnosis and treatment, and improve the treatment result of physicians in different levels. On the other hand, it will also standardize the duration of fulfilling the diagnosis and treatment. CP not only provides a standard procedure for physicians to offer medical care, but also provides the best tool for diagnosis and treatment of TIA. Therefore, overtreatment will be controlled effectively, and medical resources will be better utilized. Xiaoqin Huang and Chunqiu Fan contributed equally to this work. The authors report no financial relationships with commercial interests. The study was funded by the Ministry of Science and Technology Support Program 2009BAI77B06 and National Key Technology R&D Program of the Ministry of Science and Technology of Beijing D111107003111006.
References 1. Easton JD, Saver JL, Albers GW, et al: American Heart Association; American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Interdisciplinary Council on Peripheral Vascular Disease: Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke 2009; 40:2276–2293 2. Rothwell PM, Giles MF, Chandratheva A, et al: Early use of Existing Preventive Strategies for Stroke (EXPRESS) study: Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet 2007; 370:1432–1442 3. Giles MF, Albers GW, Amarenco P, et al: Addition of brain infarction to the ABCD2 Score (ABCD2I): a collaborative analysis
390
http://neuro.psychiatryonline.org
4. 5.
6.
7.
8. 9.
10.
11.
of unpublished data on 4574 patients. Stroke 2010; 41:1907– 1910 Carpentier N, Edjlali M, Bouhafs F, et al: Serial brain MRI in TIA patients. J Neuroradiol 2012; 39:137–141 Caminiti C, Scoditti U, Diodati F, et al: How to promote, improve and test adherence to scientific evidence in clinical practice. BMC Health Serv Res 2005; 5:62 Every NR, Hochman J, Becker R, et al: Committee on Acute Cardiac Care, Council on Clinical Cardiology, American Heart Association. Critical pathways: a review. Circulation 2000; 101:461–465 Grimshaw JM, Russell IT: Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342:1317–1322 Kwan J, Sandercock P: In-hospital care pathways for stroke. Cochrane Database Syst Rev 2004; 18:CD002924 [Review] Wee AS, Cooper WB, Chatham RK, et al: The development of a stroke clinical pathway: an experience in a medium-sized community hospital. J Miss State Med Assoc 2000; 41:648–653 Martínez-Sánchez P, Fuentes B, Medina-Báez J, et al: [Development of an acute stroke care pathway in a hospital with stroke unit]. Neurologia 2010; 25:17–26 Panella M, Marchisio S, Brambilla R, et al: A cluster randomized trial to assess the effect of clinical pathways for patients with
J Neuropsychiatry Clin Neurosci 26:4, Fall 2014
HUANG et al.
12.
13.
14.
15. 16.
17.
stroke: results of the clinical pathways for effective and appropriate care study. BMC Med 2012; 10:71 Lavallée PC, Meseguer E, Abboud H, et al: A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol 2007; 6:953–960 Sanders LM, Srikanth VK, Jolley DJ, et al: Monash transient ischemic attack triaging treatment: safety of a transient ischemic attack mechanism-based outpatient model of care. Stroke 2012; 43:2936–2941 Ministry of Health: Guiding principles of clinical path management (trail)[OL] http://www.moh.gov.cn/publicfiles/business/ htmlfiles/mohylfwjgs/s3582/200910/43181.htm,2009-10-16. Hydo B: Designing an effective clinical pathway for stroke. Am J Nurs 1995; 95:44–50, quiz 51 Adams RJ, Albers G, Alberts MJ, et al: American Heart Association; American Stroke Association: Update to the AHA/ ASA recommendations for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke 2008; 39: 1647–1652 Acute ischemic stroke treatment guidelines writing group from cerebrovascular disease neuropathy study group, Chinese Medical Association. China acute ischemic stroke treatment guidelines. 2010. Chin J Neurol 2010; 43:146–153
J Neuropsychiatry Clin Neurosci 26:4, Fall 2014
18. National Stroke Foundation: Clinical guidelines for stroke management.2010. Melbourne, National Stroke Foundation, 2010 19. Taylor WJ, Wong A, Siegert RJ, et al: Effectiveness of a clinical pathway for acute stroke care in a district general hospital: an audit. BMC Health Serv Res 2006; 6:16 20. Lanska DJ: The role of clinical pathways in reducing the economic burden of stroke. Pharmacoeconomics 1998; 14:151– 158 21. Kwan J: Care pathways for acute stroke care and stroke rehabilitation: from theory to evidence. J Clin Neurosci 2007; 14: 189–200 22. Brown MD, Reeves MJ, Glynn T, et al: Implementation of an emergency department based transient ischemic attack clinical pathway: a pilot study in knowledge translation. Acad Emerg Med 2007; 14:1114–1119 23. Chandratheva A, Mehta Z, Geraghty OC, et al: Oxford Vascular Study: Population-based study of risk and predictors of stroke in the first few hours after a TIA. Neurology 2009; 72:1941–1947 24. Giles MF, Rothwell PM: Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol 2007; 6:1063–1072
http://neuro.psychiatryonline.org
391
386
http://neuro.psychiatryonline.org
in the NCP group were admitted to the hospital because of a 30-day recurrent TIA or cerebral infarction; four of them had cerebral infarction, whereas no recurrent TIA or cerebral infarction was found in the CP group at the 30-day follow-up. Conclusions: Implementation of TIA CP could reduce the length of stay, the proportion of medication cost, and optimize the structure of hospital expense, thus making best use of medical resources and improve the quality of TIA medical care. (The Journal of Neuropsychiatry and Clinical Neurosciences 2014; 26:386–391)
T
ransient ischemic attack (TIA) is a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction. TIA is one of the major risk factors for acute cerebral infarction.1 In China, the annual incidence rate of TIA is about 180/100,000 accounting for 40% of ischemic stroke, which has been increasing per year and has become one of the major diseases that seriously impacts both human health and quality of life. Nowadays, many domestic and international clinical guidelines for TIA have provided the basis of clinical practice for the treatment of TIA stratification, antiplatelet therapy, or diagnostic imaging.2–4 An important research direction of TIA is how to more effectively transform TIA clinical guidelines into clinical practice. The implementation strategy based on the standardized clinical practice has provided a fundamental approach to transform medicine. The emergence of clinical pathway (CP) management supplies opportunities for the implementation and evaluation of developing the management for ischemic stroke. As a new standardized management model of clinical diagnosis and a standard treatment modality and procedure,
Received July 30, 2013; accepted October 23, 2013. From the Dept. of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China (XH, CF, JJ, LW, JW); Dept. of Medical Affair, Xuan Wu Hospital, Capital Medical University, Beijing, China (XL, YW); and Medical Records and Statistic Office, Xuan Wu Hospital, Capital Medical University, Beijing, China (YD). Send correspondence to Dr. Wu; e-mail: [email protected] Copyright © 2014 American Psychiatric Association
J Neuropsychiatry Clin Neurosci 26:4, Fall 2014
HUANG et al. which have strict requirements of the work order and time, CP is made up by a team of professional staff (including physicians, clinical specialists, nurses, and hospital administrators, etc.), according to a need of clinical intervention of a particular disease. CP is conducive to implement standardized treatment, shorten average length of stay in hospitals, promote the rational use of medical resources, and ensure quality of care.5–7 Foreign research showed the implementation of CP in the treatment of acute cerebral infarction can significantly shorten hospitalization time and hospital costs, promote efficient use of medical resources, decline the readmission rate, and improve clinical outcomes.8–11 Today, there are fewer studies about the efficiency for organization management of TIA. Most studies pay attention to the stratified evaluation and referral processing mode.12,13 In China, the implementation of CP is at the beginning stage. Surgical diseases by surgical treatment are the major disease in view of implement of CP, and the management of CP for TIA patients is just beginning at 2010. The aim of this study was to assess the effectiveness, quality, and safety of implementation of CP for hospitalized TIA patients. The aim was also to determine whether a clear understanding of the medical duties and the implementation of a standardized treatment program could shorten the length of stay in hospitals, control medical costs, improve clinical efficiency of TIA, make rational use of medical resources, and improve medical quality.
METHODS Study Population Xuanwu Hospital Capital Medical University is one of the first-class general hospitals and includes a neurology department. Xuanwu Hospital has more than 1,500 beds and about 2,000 patients with acute cerebral infarction are admitted to the neurology department, accounting for 45%250% of the inpatients. As a pilot hospital of CP management, Xuanwu Hospital began to apply CP for TIA patients. All participants were TIA patients from the neurology department during 2009 March to 2011 December and were managed with TIA CP. Inclusion criteria were 1) the principal diagnosis of TIA, including vertebralbasilar syndrome (ICD-10: G45.0) and carotid syndrome (cerebral hemisphere) (ICD-10: G45.1); and 2) treatment of patients according to CP when other diagnosis does not
J Neuropsychiatry Clin Neurosci 26:4, Fall 2014
require special treatment or disrupt CP implementation. TIA patients before implication of CP (2008 May to 2010 February) were enrolled as controls. TIA CP TIA CP was designed by the Clinical Pathway Committee from the Ministry of Health prior to this study.14 The Clinical Pathway Committee involved experts of multidisciplinary, including neurologists, neurosurgery scientists, nursing scientists, clinical pharmacists, experts in rehabilitation medicine, evidence-based medicine, hospital management, health economics and medical information, and other experts.10,15–17 The Committee referred to the latest diagnosis and treatment guidelines and developed this evidence-based CP, including the Standard Admission Procedure and Clinical Pathways Document (Appendix I/II). CP was included in the routine clinical work of the neurology department as an element of medical quality improvement project. The leader of this CP implementation team is the director of neurology department. The team members include doctors, nurses, and other related medical staffs. Each participant gave written informed consent and agreed to receive standard medical care including major medical advice, detail diagnosis, and treatment information within 1 week after admission. Detail diagnosis and treatment information were recorded using structured the TIA CP form (Appendix II) and entered into the database of the medical record statistics office. Nonconcurrent cohort method was used in this study. TIA information before and after implication of CP was collected from the medical record registration database and analyzed retrospectively. Outcomes The indicators for effect and safety of TIA CP included 1) length of stay; 2) hospital cost; and 3) indicators for safety (improvement rate, cerebral infarction, mortality, readmission rate (1 week, 2 weeks, 30 days because of cerebrovascular events, including TIA, cerebral infarction). Statistical Analysis Categorical variables were expressed as number (%) and continuous variables were expressed as mean6SD or median and quartiles. For comparison between groups, x2/Fisher exact test and independent t-test/rank sum test were used for categorical and continuous variables, respectively. As nonconcurrent cohort method was used in this study, propensity score method was employed to
http://neuro.psychiatryonline.org
387
TRANSIENT ISCHEMIC ATTACK CLINICAL PATHWAY
TABLE 1.
Baseline Characteristics
Characteristics Male (%) Age Risk factor Cerebrovascular disease Hypertension Coronary heart disease Atrial fibrillation Diabetes mellitus Hyperlipidemia Smoking Drinking ABCD2 score Risk level Low(1–3) Medium (4–5) High (6–7) Way of admission Outpatient Emergency
Clinical Pathway (N5179)
Non-Clinical Pathway (N5112)
p*
p1
124 (69.27%) 62.11612.64
86 (76.79%) 60.72613.03
0.1609 0.3684
0.988 0.9955
32 (17.88%) 98 (54.75%) 35 (19.55%) 20 (11.17%) 57 (31.84%) 49 (27.37%) 97 (54.19%) 58 (32.40%) 3.6261.12
26 (23.21%) 70 (62.50%) 16 (14.29%) 9(8.04%) 32 (28.57%) 24 (21.43%) 69 (61.61%) 33 (29.46%) 3.6161.30
88 (49.16%) 77 (43.02%) 14 (7.82%)
55 (49.11%) 48 (42.86%) 9 (8.04%)
42 (23.46%) 137 (76.54%)
35 (31.25%) 77 (68.75%)
0.2705 0.1916 0.245 0.7756 0.5546 0.2516 0.2126 0.5981 0.9516 0.9978 — — — 0.1452 — —
0.5526 0.1916 0.9848 0.7756 0.9995 0.9918 0.2126 0.9993 0.9955 0.9999 .0.05 .0.05 .0.05 0.9705 .0.05 .0.05
p*: p value without adjustment. p1: p value with adjustment.
avoid potential imbalance between the two groups. The variables included in the propensity score model were gender, age, cerebrovascular disease, hypertension, coronary heart disease, atrial fibrillation, diabetes, hyperlipidemia, smoking, drinking, ABCD2 score, risk classification, and method of admission. Adjusted baseline indicators were compared using logistic (qualitative indicators) and covariance analysis (quantitative indicators) between the groups, and propensity score was adjusted in the model as a continuous variable. Data analyses were performed by the SAS 9.13 (SAS Institute, Inc., Cary, NC). Significance was defined as p ,0.05 (two-sided).
RESULTS Baseline Characteristics of Patients with Transient Ischemic attack As shown in Table 1, 284 patients with TIA were included in this study with 112 patients in the CP group and 179 patients in the NCP group. The mean age was 60.726 13.03 years and 62.11612.64 years in the CP group and the NCP group, respectively. Both groups were similar with respect to mean age, gender proportion, and risk factors for angiosis (p .0.05). ABCD2 score was not statistically different between the CP group and the NCP group with mean score of 3.6261.12 and 3.6161.30 in both groups, respectively (p .0.05). Seventy-seven patients (68.75%) in the CP group were admitted to the
388
http://neuro.psychiatryonline.org
hospital from the emergency department, and 35 (31.25%) from the outpatient department, whereas in the NCP group, 76.54% from emergency department and 23.46% from outpatient department. The proportion was not statistically significant (p .0.05). Comparison of Cost and Medical Efficiency Indicators Before and After CP Implementation The average length of stay was 9.5563.89 days in the NCP group, and it was 7.2662.09 days in the CP group. The average length of stay was significantly shortened by 2.29 days (p ,0.001). Hospital cost in the CP group increased significantly by 7.9% (868 yuan) compared with that in NCP group (p ,0.05). The median medication cost (P25, P75) was 4262.7(2856.7–5804.1) and 4200.0(3528.4– 5179.1) in the CP group and the NCP group, respectively. The proportion of medication cost significantly decreased by 5% (p ,0.05), whereas the proportion of examination cost significantly increased by 8% (p ,0.001). In addition, examination cost using expensive machines also significantly increased by 4% (p ,0.01). As for the clinical outcomes of patients with TIA, 98.21% of the patients in the CP group was discharged in a good condition, whereas it was 97.77% in the NCP group; no significant difference was found between the improvement rate of the two groups (p .0.05). As shown in Table 2, eight patients (4%) in the NCP group were admitted to the hospital because of a 30-day recurrent TIA or cerebral infarction, and four among them
J Neuropsychiatry Clin Neurosci 26:4, Fall 2014
HUANG et al.
TABLE 2.
Effect and Safety of TIA Clinical Pathway
Length of stay Hospital cost Medication cost Examination cost Examination cost using expensive machines Proportion of medication cost Proportion of examination cost Proportion of examination cost using expensive machines Improvement rate Cerebral infarction Death Two-week readmission Thirty-day readmission
Clinical Pathway (N5179)
Nonclinical pathway (N5112)
9.5563.89 9300.6 (7081.8–12924) 1088267284.7 4262.7 (2856.7–5804.1) 3259.5 (2306.5–4283.5) 1665 (1100.0–2980.0) 0.4460.16 0.3560.12 0.2060.10
7.2662.09 11737 (9551.1–13452) 1175063179.6 4200.0 (3528.4–5179.1) 5072.5 (3962.8–6008.3) 2980 (1985.0–3747.5) 0.3960.10 0.4360.07 0.2460.07
175 (97.77%) 0 0 0 0
110 (98.21%) 4 0 5 3
p* ,0.001 ,0.001 ,0.001 0.9322 ,0.001 ,0.001 0.0005 ,0.001 0.0002 1.0000 — — — —
p1 ,0.001 0.0029 ,0.001 — ,0.001 ,0.001 — ,0.001 0.0083 — — — — —
p*: p value without adjustment. p 1: p value with adjustment.
had cerebral infarction, whereas no recurrent TIA or cerebral infarction was found in the CP group at the 30-day follow-up.
DISCUSSION Increasing number of patients with cerebral infarction has been an important problem in China, and exploring better treatment has been a great challenge. Updated clinical guidelines have provided evidence for the transformation of research results on ischemic cerebrovascular disease into clinical practice.19 Effective implementation strategy based on clinical practice is one of the fundamental pathways in translational medicine. The development of CP has provided a good opportunity for the optimal management of patients with ischemic stroke. It has been illustrated by other studies that the implementation of CP will reduce the length of stay, medication cost, examination cost, and the incidence of complications in hospital. In addition, it will also improve patients’ activities of daily living and medical quality.11,19–21 TIA is a critical and dangerous warning event of ischemic stroke, and it is also a major risk factor for cerebral infarction. Therefore, the prevention and treatment of TIA is very important. CP for patients with TIA is a good treatment model if expected results could be achieved. The feasibility assessment of emergency department-based TIA CP, which is reported by Brown, has shown that implementation of a CP is feasible and safe in an emergency department setting. However, the effect of CP in hospitalized patients with TIA has not been consistent.
J Neuropsychiatry Clin Neurosci 26:4, Fall 2014
As a pilot hospital of CP management in 2010, Xuanwu Hospital implemented CP management on patients with TIA in the neurology department. The objective of this project is to evaluate the effectiveness of TIA CP as a new medical care management pattern. The results have demonstrated that the length of stay has been reduced by 2.29 days, and the turnover rate has increased after the implementation of TIA CP. Therefore, the operational efficiency of the hospital has been improved, and the average waiting time of admission has been shortened. More patients could be better diagnosed and treated. The hospital cost increased by 7% after implementation of TIA CP. However, the average medication cost decreased, and the increment of hospital cost was mainly due to the increasing proportion of examination cost (increased by 8%). Xuanwu Hospital is one of the first-class general hospitals and includes a neurology department. Because of the complex condition of patients in Xuanwu hospital, it is difficult to determine the treatment strategy of patients with TIA. Therefore, based on the Standard Admission Procedure of Transient Ischemic Attack Clinical Pathways published by Health Ministry, the specific TIA CP of Xuanwu Hospital has been formulated after numerous discussions and expert debates. This evidencebased CP refers to the latest diagnosis and treatment guidelines of other countries16–18 and includes some new examinations and treatment strategies. For example, transesophageal echocardiography and color Doppler flow imaging foaming test have become important examinations due to the relationship between patent foramen ovale and TIA. In addition, more and more patients need cerebral vascular
http://neuro.psychiatryonline.org
389
TRANSIENT ISCHEMIC ATTACK CLINICAL PATHWAY angiography because of frequent TIA accompanied by cerebrovascular stenosis or cerebrovascular occlusion. The improvement of new technologies in medicine has offered not only more benefits but increased cost to patients. Therefore, examination costs increased after implementation of TIA CP. CP substantially improves clinical practice guidelines and offers detailed procedures on treatment, examination, and medical order after admission. Physicians will not determine the diagnosis and treatment of TIA relying only on their own experiences. The implementation of TIA CP has indeed shortened length of stay, standardized clinical medication, and adjusted the distribution of hospital cost. The assessment of TIA CP effectiveness suggested that the examination cost should be further reduced. In general, the implementation of CP controlled the rapid growth of hospital cost to some extent and produced more reasonable distribution of hospital cost. TIA, as an unstable high-risk state, is risk factor for early stroke. Many researches have shown that 8%212% patients with TIA underwent cerebral infarction in 7 days, 9.2% patients in 30 days, and 10%220% in 90 days.23,24 Because TIA most likely progresses to cerebral infarction in the initial days after TIA, early standard treatment will prevent the recurrence of stroke at best. Does the implementation of TIA CP reduce the risk of cerebral infarction? This study has found that the improvement
rate of TIA in the CP group is similar with that in the NCP group; no recurrent TIA or cerebral infarction was found in the CP group, whereas eight patients (4%) in the NCP group were admitted to the hospital after a 14-day or a 30-day follow-up. It is possible that clinical effectiveness could not be observed because of short follow-up duration. In conclusion, CP has standardized and normalized the diagnosis and treatment procedure of TIA. On one hand, the implementation of TIA CP will reduce unnecessary or unreasonable diagnosis and treatment, and improve the treatment result of physicians in different levels. On the other hand, it will also standardize the duration of fulfilling the diagnosis and treatment. CP not only provides a standard procedure for physicians to offer medical care, but also provides the best tool for diagnosis and treatment of TIA. Therefore, overtreatment will be controlled effectively, and medical resources will be better utilized. Xiaoqin Huang and Chunqiu Fan contributed equally to this work. The authors report no financial relationships with commercial interests. The study was funded by the Ministry of Science and Technology Support Program 2009BAI77B06 and National Key Technology R&D Program of the Ministry of Science and Technology of Beijing D111107003111006.
References 1. Easton JD, Saver JL, Albers GW, et al: American Heart Association; American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Interdisciplinary Council on Peripheral Vascular Disease: Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke 2009; 40:2276–2293 2. Rothwell PM, Giles MF, Chandratheva A, et al: Early use of Existing Preventive Strategies for Stroke (EXPRESS) study: Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet 2007; 370:1432–1442 3. Giles MF, Albers GW, Amarenco P, et al: Addition of brain infarction to the ABCD2 Score (ABCD2I): a collaborative analysis
390
http://neuro.psychiatryonline.org
4. 5.
6.
7.
8. 9.
10.
11.
of unpublished data on 4574 patients. Stroke 2010; 41:1907– 1910 Carpentier N, Edjlali M, Bouhafs F, et al: Serial brain MRI in TIA patients. J Neuroradiol 2012; 39:137–141 Caminiti C, Scoditti U, Diodati F, et al: How to promote, improve and test adherence to scientific evidence in clinical practice. BMC Health Serv Res 2005; 5:62 Every NR, Hochman J, Becker R, et al: Committee on Acute Cardiac Care, Council on Clinical Cardiology, American Heart Association. Critical pathways: a review. Circulation 2000; 101:461–465 Grimshaw JM, Russell IT: Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342:1317–1322 Kwan J, Sandercock P: In-hospital care pathways for stroke. Cochrane Database Syst Rev 2004; 18:CD002924 [Review] Wee AS, Cooper WB, Chatham RK, et al: The development of a stroke clinical pathway: an experience in a medium-sized community hospital. J Miss State Med Assoc 2000; 41:648–653 Martínez-Sánchez P, Fuentes B, Medina-Báez J, et al: [Development of an acute stroke care pathway in a hospital with stroke unit]. Neurologia 2010; 25:17–26 Panella M, Marchisio S, Brambilla R, et al: A cluster randomized trial to assess the effect of clinical pathways for patients with
J Neuropsychiatry Clin Neurosci 26:4, Fall 2014
HUANG et al.
12.
13.
14.
15. 16.
17.
stroke: results of the clinical pathways for effective and appropriate care study. BMC Med 2012; 10:71 Lavallée PC, Meseguer E, Abboud H, et al: A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol 2007; 6:953–960 Sanders LM, Srikanth VK, Jolley DJ, et al: Monash transient ischemic attack triaging treatment: safety of a transient ischemic attack mechanism-based outpatient model of care. Stroke 2012; 43:2936–2941 Ministry of Health: Guiding principles of clinical path management (trail)[OL] http://www.moh.gov.cn/publicfiles/business/ htmlfiles/mohylfwjgs/s3582/200910/43181.htm,2009-10-16. Hydo B: Designing an effective clinical pathway for stroke. Am J Nurs 1995; 95:44–50, quiz 51 Adams RJ, Albers G, Alberts MJ, et al: American Heart Association; American Stroke Association: Update to the AHA/ ASA recommendations for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke 2008; 39: 1647–1652 Acute ischemic stroke treatment guidelines writing group from cerebrovascular disease neuropathy study group, Chinese Medical Association. China acute ischemic stroke treatment guidelines. 2010. Chin J Neurol 2010; 43:146–153
J Neuropsychiatry Clin Neurosci 26:4, Fall 2014
18. National Stroke Foundation: Clinical guidelines for stroke management.2010. Melbourne, National Stroke Foundation, 2010 19. Taylor WJ, Wong A, Siegert RJ, et al: Effectiveness of a clinical pathway for acute stroke care in a district general hospital: an audit. BMC Health Serv Res 2006; 6:16 20. Lanska DJ: The role of clinical pathways in reducing the economic burden of stroke. Pharmacoeconomics 1998; 14:151– 158 21. Kwan J: Care pathways for acute stroke care and stroke rehabilitation: from theory to evidence. J Clin Neurosci 2007; 14: 189–200 22. Brown MD, Reeves MJ, Glynn T, et al: Implementation of an emergency department based transient ischemic attack clinical pathway: a pilot study in knowledge translation. Acad Emerg Med 2007; 14:1114–1119 23. Chandratheva A, Mehta Z, Geraghty OC, et al: Oxford Vascular Study: Population-based study of risk and predictors of stroke in the first few hours after a TIA. Neurology 2009; 72:1941–1947 24. Giles MF, Rothwell PM: Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol 2007; 6:1063–1072
http://neuro.psychiatryonline.org
391
