Development and implementation of the Ontario Stroke System: the use of evidence
TL;DR: This study provides guidance to support the development and implementation of evidence-based models of integrated service delivery across the continuum of care in the Ontario Stroke System.
Abstract: Introduction The Ontario Stroke System was developed to enhance the quality and continuity of stroke care provided across the care continuum. Research Objective To identify the role evidence played in the development and implementation of the Ontario Stroke System. Methods This study employed a qualitative case study design. In-depth interviews were conducted with six members of the Ontario Stroke System provincial steering committee. Nine focus groups were conducted with: Regional Program Managers, Regional Education Coordinators, and seven acute care teams. To supplement these findings interviews were conducted with eight individuals knowledgeable about national and international models of integrated service delivery. Results Our analyses identified six themes. The first four themes highlight the use of evidence to support the process of system development and implementation including: 1) informing system development; 2) mobilizing governmental support; 3) getting the system up and running; and 4) integrating services across the continuum of care. The final two themes describe the foundation required to support this process: 1) human capacity and 2) mechanisms to share evidence. Conclusion This study provides guidance to support the development and implementation of evidence-based models of integrated service delivery.
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TL;DR: A scoping review of the literature on stroke transitions was conducted to identify the current areas of research emphasis and highlight stroke survivors’ and family caregivers’ experiences with transitions across care environment and some potential strategies to improve those transitions.
Abstract: Stroke affects many aspects of the lives of stroke survivors and their family caregivers. Supporting long-term recovery and rehabilitation are necessary to help stroke survivors adapt to living wit...
105 citations
TL;DR: The fragmentation of the current poststroke chain of care could benefit from the introduction of case managers or "navigators," discharge planning, electronic medical records, and evidence-based neurorehabilitation guidelines.
Abstract: Stroke is a significant source of death and disability worldwide. The increasing prevalence of stroke survivors forecasts substantial socioeconomic burden and a greater need for comprehensive poststroke rehabilitative services. Despite the rapidly rising burden of cerebrovascular disease, particularly in developing countries, there has been limited implementation of multidisciplinary stroke units, a proven care modality in reducing patient mortality and improving functional outcomes. Transitioning from these acute inpatient settings to in- and outpatient rehabilitation or long-term care environments has consistently been identified as an obstacle to quality stroke rehabilitation. To address the barriers preventing the seamless delivery of poststroke care, an evaluation of patient-caregiver perspectives, treatment challenges, and system-wide shortcomings is presented. The fragmentation of the current poststroke chain of care could benefit from the introduction of case managers or "navigators," discharge planning, electronic medical records, and evidence-based neurorehabilitation guidelines. By aiding in successful care transitions, these proposed efforts could advance post-acute stroke patients along the care continuum to achieve their rehabilitative goals.
94 citations
TL;DR: A concomitant decline in stroke and dementia incidence rates at a whole population level in Ontario, Canada is discovered and trends within demographic subgroups are explored.
Abstract: Introduction We discovered a concomitant decline in stroke and dementia incidence rates at a whole population level in Ontario, Canada. This study explores these trends within demographic subgroups. Methods We analyzed administrative data sources using validated algorithms to calculate stroke and dementia incidence rates from 2002 to 2013. Results For more than 12 years, stroke incidence remained unchanged among those aged 20 to 49 years and decreased for those aged 50 to 64, 65 to 79, and 80+ years by 22.7%, 36.9%, and 37.9%, respectively. Dementia incidence increased by 17.3% and 23.5% in those aged 20 to 49 and 50 to 64 years, respectively, remained unchanged in those aged 65 to 79 years, and decreased by 15.4% in those aged 80+ years. Discussion The concomitant decline in stroke and dementia incidence rates may depict how successful stroke prevention has targeted shared risk factors of both conditions, especially at advanced ages where such risk factors are highly prevalent. We lend support for the development of an integrated system of stroke and dementia prevention.
34 citations
Cites background from "Development and implementation of t..."
...In 2000, Ontario implemented a successful stroke strategy [13], of which primary stroke prevention through the control of risk factors common to stroke and dementia was a core tenet....
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TL;DR: The basis and rationale for the ‘critical care cascade’ concept, which contends that the optimal management of critically ill patients should be a continuum of care through the healthcare system, are discussed.
Abstract: Purpose of review To emphasize the evolving body of evidence that supports the need for a more seamless and interconnected continuum of patient care for a growing compendium of critical care conditions, starting in the prehospital and emergency department (ED) phases of management and continuing through ICU and rehabilitation services. Recent findings The care of critically ill and injured patients has become increasingly complex. It now has been demonstrated that, for a number of such critical care conditions, optimal management not only relies heavily on the talents of highly coordinated, multidisciplinary teams, but it also may require shared responsibilities across a continuum of longitudinal care involving numerous specialties and departments. This continuum usually needs to begin in the prehospital and ED settings with management extending through specialized in-hospital diagnostic and interventional suites to traditional ICU and rehabilitation programs. In recent years, examples of these conditions have included the development of systems of care for trauma, cardiac arrest, myocardial infarction, stroke, sepsis syndromes, toxicology and other critical illnesses. Although the widespread implementation of such multidisciplinary, multispecialty critical care cascades of care has been achieved most commonly in trauma care, current healthcare delivery systems generally tend to employ compartmentalized organization for the majority of other critical care patients. Accordingly, optimal systematic care often breaks down in the management of these complex patients due to barriers such as lack of interoperable communication between teams, disjointed transfers between services, unnecessary time-consuming, re-evaluations and transitional pauses in time-dependent circumstances, deficiencies in cross-disciplinary education and quality assurance loops, and significant variability in patient care practices. Such barriers can lead to adverse outcomes in this fragile patient population. Summary This article discusses the basis and rationale for the 'critical care cascade' concept, which contends that the optimal management of critically ill patients should be a continuum of care through the healthcare system. In the critical care cascade, each patient is enrolled on a 'pathway' of management based on their working diagnosis and each and every healthcare provider engaged along that continuum acts as part of a interconnected coordinated team that ensures a specific endpoint for these patients in a bundled manner that seamlessly extends from the prehospital and ED phases to the ICU and rehabilitation services.
33 citations
TL;DR: The concept of ‘holding the line’ is problematised and the power implications of such managerial approaches in the early phases of health service reconfiguration are explored.
Abstract: Health service reconfigurations are of international interest but remain poorly understood. This article focuses on the use of evidence by senior managerial decision-makers involved in the reconfiguration of stroke services in London 2008–2012. Recent work comparing stroke service reconfiguration in London and Manchester emphasises the ability of senior managerial decision-makers in London to ‘hold the line’ in the crucial early phases of the stroke reconfiguration programme. In this article, we explore in detail how these decision-makers ‘held the line’ and ask what the broader power implications of doing so are for the interaction between evidence, health policy and system redesign. The research combined semi-structured interviews (n = 20) and documentary analysis of historically relevant policy papers and contemporary stroke reconfiguration documentation published by NHS London and other interested parties (n = 125). We applied a critical interpretive and reflexive approach to the analysis of the data. We identified two forms of power which senior managerial decision-makers drew upon in order to ‘hold the line’. Firstly, discursive power, which through an emphasis on evidence, better patient outcomes, professional support and clinical credibility alongside a tightly managed consultation process, helped to set an agenda that was broadly receptive to the overall decision to change stroke services in the capital in a radical way. Secondly, once the essential parameters of the decision to change services had been agreed, senior managerial decision-makers ‘held the line’ through hierarchical New Public Management style power to minimise the traditional pressures to de-radicalise the reconfiguration through ‘top down’ decision-making. We problematise the concept of ‘holding the line’ and explore the power implications of such managerial approaches in the early phases of health service reconfiguration. We highlight the importance of evidence for senior managerial decision-makers in agenda setting and the limitations of clinical research findings in guiding politically sensitive policy decisions which impact upon regional healthcare systems.
29 citations
References
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TL;DR: A new approach to create and manage image-based EPR from actual patient records is given, and a novel method to use Web technology and DICOM standard to build an open architecture for collaborative medical applications is presented.
20 citations
Journal Article•
TL;DR: Differences in diagnostic patterns between the two sources of data, differences between rural and urban areas, and variation across most of the regions reveal that any CBVD surveillance system based on administrative data requires a large-scale and person-oriented approach.
Abstract: The diagnosis of cerebrovascular disease (CBVD) from administrative data has been critically examined by epidemiologists in recent years. Much of the existing literature suggests that hospital discharge diagnoses based on ICD-9-CM codes are an unreliable source of information for determining a diagnosis of stroke, particularly when four- and five-digit codes are used. We examined how diagnoses for CBVD in hospital inpatient and outpatient facilities vary between rural and urban areas and among the 16 administrative health regions. Our analysis revealed differences in diagnostic patterns between the two sources of data, differences between rural and urban areas, and variation across most of the regions. Geographic variation in health service utilization, diagnostic practices, specialty of the physician making the diagnosis, and disease burden may explain our findings. Our results suggest that the diagnosis of patients attending rural facilities are either coded differently (and less precisely) than those of urban residents or are coded more precisely only after the patients attend urban facilities. Regional differences in coding practices show that any CBVD surveillance system based on administrative data requires a large-scale (in this case, province-wide) and person-oriented approach.
13 citations
TL;DR: The recently published national clinical guidelines for stroke patients provide a framework for providing high quality care from the initial diagnosis through to rehabilitation and long-term care, highlighting that after the acute phase, specialist services provided in the hospital or community, yield the same results if care is well coordinated.
Abstract: An estimated 100000 people and their families are affected by a cerebral vascular accident (CVA) every year (Office of Population Census and Surveys, 1993). The recently published national clinical guidelines for stroke patients (Royal College of Physicians (RCP), 2000) provide a framework for providing high quality care from the initial diagnosis through to rehabilitation and long-term care. The message evident throughout the guidelines is clear, namely, that effective care depends on good multidisciplinary teamwork. It is suggested in the core principles that ‘all members of the healthcare team should work with the patient and family using an agreed therapeutic approach’. The guidelines also highlight that, after the acute phase, specialist services provided in the hospital or community, yield the same results if care is well coordinated.
2 citations
Journal Article•
TL;DR: Rational approaches to anticoagulation for neurologic patients are reviewed, with a focus on antiplatelet agents for ischemia secondary to artery-to-artery embolism.
Abstract: Anticoagulant therapy to halt or limit a potentially devastating stroke carries both risk and an unproven benefit. Two case reports highlight potential pitfalls. Antiplatelet agents are indicated for ischemia secondary to artery-to-artery embolism. Anticoagulation should be undertaken only when a demonstrated cardiac embolic source places a patient at ongoing risk of repeated embolic stroke. This article reviews rational approaches to anticoagulation for neurologic patients.
2 citations