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In Canada, Integrated Stroke Care Systems Were Associated with Declines in Stroke Mortality

ARTICLE IN BRIEF

A new analysis found that organized stroke care systems in Canada reported a decrease in the 30-day unadjusted mortality rates, compared with provinces that did not have organized stroke care systems.

Stroke mortality has declined significantly in Canadian provinces that have implemented integrative stroke care systems. Thirty-day unadjusted mortality rates decreased from 15.8 percent to 12.7 percent over an 11-year period in provinces with stroke systems, while the death rate remained at 14.5 percent in provinces without organized stroke care, according to a new study that analyzed stroke data from throughout Canada.

The study, published online February 5 ahead of the March 8 print edition of Neurology, was not designed to pinpoint why mortality rates were lower in provinces with an organized stroke system, though hospitals in those provinces were more likely to have a dedicated stroke unit and provide patients access to a stroke prevention clinic and telestroke services.

The study offers “pretty compelling evidence that if you get organized, you start to save people's lives,” the study's coauthor, Michael D. Hill, MD, a professor of neurology at the University of Calgary, told Neurology Today.

Indeed, earlier reports have found a correlation between declines in stroke-related mortality in stroke centers in the United States. A 2011 paper in the Journal of the American Medical Association analyzed 30-day all-cause mortality rates for patients admitted to stroke centers in New York, for example, and found that patients who had an acute ischemic stroke had a better chance of surviving if they went to a designated stroke center. (Read the Neurology Today article about the study here: http://bit.ly/strokemortality.)

NATIONWIDE EFFORT IN CANADA

To date, there has been little evidence to say whether organizing stroke care at a regional or state level might result in population-wide benefits. “The differential evolution of stroke systems by province permitted the natural experiment in effectiveness of care in Canada,” the authors of the new study wrote.

The Canadian Stroke Strategy, launched in 2005, included the adoption of best practice recommendations, training programs, EMS transport protocols, quality monitoring, stroke prevention clinics, and public awareness campaigns focused on stroke.

Ontario was first to implement such a system in the early 2000s, and today six of 13 Canadian provinces and territories have integrated stroke systems, according to the study. The configuration of stroke care differs from province to province, but the shared goal is to optimize the delivery of all phases of care — from EMS response to acute treatment, rehabilitation services, community reintegration, and secondary stroke prevention, Dr. Hill said. Stroke centers are designated at the provincial level, and they are accredited nationally by “Accreditation Canada” with the Stroke Distinction Award Designation, he said.

“What we did, and are continuing to try to improve upon, in Canada for stroke is to realize the benefits of the full continuum of care,” Dr. Hill said.

Whether the results in Canada, where the government-run health care system is organized and funded at the provincial level, are replicable in other countries is not clear, he said.

STUDY METHODOLOGY

The researchers analyzed stroke death rates for fiscal years 2003-2004 to 2012-2013 using the Canadian Institute for Health Information's Discharge Abstract Database. During that time, there were 319,972 patients hospitalized with ischemic stroke, hemorrhagic stroke, or transient ischemic attack (TIA). They then computed 30-day in-hospital deaths rates for provinces with integrated systems compared with provinces without an organized system. (Quebec was excluded because data were incomplete.) The vast majority of strokes, including stroke deaths, occurred in hospitals in provinces with stroke-care systems.

The study found that during the last four years of the study there was a sustained 15 percent reduction in 30-day in-hospital mortality in provinces with a stroke care system.

In addition to analyzing mortality rates, the researchers also sent out surveys to hospitals across Canada to inquire about their stroke services.

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DR. MICHAEL HILL said he hoped that the findings would encourage additional Canadian provinces to institute stroke-care systems, and encourage others in the US and elsewhere to do the same.

The surveys indicated that hospitals in provinces with an organized stroke care system were more likely to have a stroke unit and “were far more likely to provide access to stroke prevention clinics within 48-72 hours for patients with acute TIA, and to provide telestroke services,” the researchers reported.

CAUSE AND EFFECT NOT CERTAIN

An editorial that accompanied the study noted that because the study was observational, not a randomized, controlled trial, it is impossible to say that the establishment of stroke care systems caused the reduction in mortality. Stroke mortality in general has been declining in recent years.

“The study design also limits the ability to discern which facets of the stroke system exerted the greatest effect,” wrote Jeffrey J. Fletcher, MD, a clinical assistant professor in the departments of neurosurgery and neurology at the University of Michigan, and Jennifer J. Majersik, MD, an associate professor of neurology at the University of Utah.

The study did not look at factors such as use of thrombolysis, intensity of life-sustaining therapies, or the use of early rehabilitation services; nor did it account for differences in stroke severity. Also, the researchers focused on death rates, not long-term functional outcomes.

Despite those research limitations, “this work shows that enacting full spectrum stroke systems improves stroke mortality. The authors have highlighted an opportunity that may have profound implications for reducing the global burden of stroke,” the commentary noted.

Dr. Hill, the study's senior author, said he hoped that the findings would encourage additional Canadian provinces to institute stroke-care systems, and encourage others in the US and elsewhere to do the same.

“I hope people don't steer clear of the idea because they say their health care system is different from ours,” he said, adding, “I'd like them to say ‘we need to make this happen, and how do we do it?’”

Vladimir Hachinski, MD, FAAN, a professor of neurology and epidemiology at Western University in Ontario, said traditional stroke care is fragmented, with acute care seen as quite separate from stroke prevention and stroke rehabilitation.

“What a stroke strategy does is connect the disconnect,” said Dr. Hachinski, who has done research with some of the authors of the new Canadian study. He said more attention to primary stroke prevention in particular has the potential for another huge payoff — the prevention of dementia.

In December, Dr. Hachinski reported in JAMA Neurology that between 2002 and 2013 in Ontario, the incidence of stroke declined 32.4 percent and the incidence of dementia declined 7.4 percent. Ontario has an organized stroke care system, he noted.

Dr. Hachinski is now studying the incidence of stroke and dementia in Canadian provinces that don't have organized stroke care systems.

US ORGANIZATIONAL PRACTICES

“The question is, ‘Would this apply in a country that does not have national health care?’” said Brian Silver, MD, director of the Comprehensive Stroke Center at Rhode Island Hospital, who was not part of the current study. “My instinct tells me, ‘Yes, it does.’”

Dr. Silver was part of a team that implemented a statewide stroke-care system in Rhode Island last July. He said early data being collected suggest that “we are seeing more patients with better outcomes than we did before, particularly among patients with the most severe strokes in the state.”

Dr. Silver, who is also an associate professor of neurology at the Warren Alpert Medical School of Brown University, said the process to implement a statewide stroke system in Rhode Island went fairly smoothly, probably in part because the state is small and Rhode Island Hospital is the only comprehensive stroke center. Typically, in urban centers, there are multiple hospitals competing for stroke patients, he said.

“What we are trying to do at the state level is to have patients with severe stroke, identified in the field by EMS providers, bypass primary stroke centers and get to the comprehensive stroke center for endovascular therapy,” Dr. Silver said. He added that devising such a system might be more complicated in other states or regions. But he said the new study from Canada, as well as research from England that showed benefits from the establishment of organized stroke care in London and Manchester, should be a catalyst to “bring everyone together at the table and agree to do the right thing for the patient.”

Stroke care has also become increasingly organized throughout the state of Maryland. And that is not necessarily a simple task to accomplish in the US, said Michael Phipps, MD, an assistant professor of neurology and director of the Brain Attack Center at the University of Maryland. “There have to be incentives for hospitals to operate,” he said, “and in a lot of places, there is competition rather than cooperation.”

Dr. Phipps said another reason stroke care has been slow to organize is because until the availability of tPA, and now stent retriever technology, treatments weren't very effective. “Everyone understands that trauma is a matter of life or death, but stroke wasn't viewed with the same sense of urgency,” he said.

Part of Maryland's plan involved statewide EMS transport guidelines for IV tPA “drip-and-ship” and for endovascular therapy, Dr. Phipps said. The state's EMS agency regulates the designation of “stroke center” in the state. A pilot program is almost underway in Baltimore that will involve bypassing primary stroke centers to get to comprehensive stroke centers for suspected large vessel strokes, he said.

“We hope to affect mortality some, but the big thing we are trying to affect is disability,” Dr. Phipps said.

EXPERTS: ON CREATING ORGANIZED STROKE CARE SYSTEMS

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DR. VLADIMIR HACHINSKI said traditional stroke care is fragmented, with acute care seen as quite separate from stroke prevention and stroke rehabilitation. “What a stroke strategy does is connect the disconnect.”

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DR. BRIAN SILVER was part of a team that implemented a statewide stroke-care system in Rhode Island last July. He said early data being collected suggest that “we are seeing more patients with better outcomes than we did before, particularly among patients with the most severe strokes in the state.”

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DR. MICHAEL PHIPPS said stroke care in Maryland has become more organized and that is not necessarily a simple task to accomplish in the US. “There have to be incentives for hospitals to operate, and in a lot of places, there is competition rather than cooperation.”

LINK UP FOR MORE INFORMATION:

•. Ganesh A, Lindsay P, Fang J, et al. Integrated systems of stroke care and reduction in 30-day mortality: A retrospective analysis http://www.neurology.org/content/early/2016/02/04/WNL.0000000000002443.short. Neurology 2016: Epub 2016 Feb. 5.
    •. Fletcher JJ, Majerski JJ. Editorial: Stroke systems of care: The sum is greater than the parts http://www.neurology.org/content/early/2016/02/04/WNL.0000000000002452.short. Neurology 2016: Epub 2016 Feb. 5.
      •. Sposato LA, Kapral MK, Fang J, et al. Declining incidence of stroke and dementia: Coincidence or prevention opportunity http://archneur.jamanetwork.com/article.aspx?articleID=2475253. JAMA Neurol 2015; 72(12): 1529–1531.