Published online before print January 10, 2008, doi: 10.1161/STROKEAHA.107.510875
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(Stroke. 2008;39:264.)
© 2008 American Heart Association, Inc.
Advances in Stroke 2007 |
Advances in Health Policy 2007
From the Atlantic Health Promotion Research Centre (R.F.L.), Dalhousie University, Halifax NS Canada; Clinical Effectiveness and Evaluation Unit (A.G.R.), Royal College Physicians, London, Stroke Physician, Guy’s and St. Thomas’ Hospital, London, UK; Atlantic Health Promotion Research Centre (C.A.), Dalhousie University, Halifax NS Canada.
Correspondence to Renée F. Lyons, Atlantic Health Promotion Research Centre, Dalhousie University, Halifax NS Canada B3J 3T1. E-mail Rlyons{at}dal.ca
Key Words: advances • health policy • knowledge translation • outcomes
Notable advances have been made in stroke policy and outcomes research over the past year. Policy-relevant gray and published research is included in this review. The advances selected are organized under 3 areas: stroke policy and related evidence, predictive modeling, and quality improvement.
Stroke Policy and Related Evidence
The Role of Evidence in Stroke Policy Investments
Different types of evidence are required at each stage in the development and implementation of large scale stroke strategies. The role of evidence was examined in the development of the Ontario Stroke System (a $30 million per year health policy initiative to improve stroke care in Ontario, Canada). Researchers identified key stages in the implementation process and the various types of evidence mobilized at each stage.1 The value of this research for stroke knowledge translation and policy is that evidence can be systematically organized and shared strategically to achieve policy commitments.
Strategies for Improving Stroke Care
The Helsingborg Declaration 2006 on European Stroke Strategies2 is a consensus document with substantial potential for influencing stroke policy in Europe. The Declaration states that by 2015 all persons in Europe with stroke should have access to a continuum of care in the acute phase including rehabilitation and secondary prevention. Clear goals for improving outcomes, the means to achieve them, and evaluation are outlined. The document also calls for a system to be established to incorporate new research into stroke care.
In Canada, work continues on implementing the Canadian Stroke Strategy. The Canadian Stroke Network, a national center of excellence, has been a major contributor in developing research and knowledge translation toward improved policy and care.3 The policy challenge for Canada is that health is a provincial responsibility with substantially different health resources and commitments to stroke in each province. During 2007, several gains were made. For example, the Alberta Provincial Stroke Strategy was developed and a commitment of $1.1 million CDN was made to improve tele-stroke for remote areas.4 In addition, the Province of Ontario committed $5 million CDN for a Centre for Stroke Recovery.5
The National Health Service in Britain developed a comprehensive consultation document on stroke to stimulate debate on how best to prevent and treat stroke.6 This document provides considerable detail about components of integrated care written in language that is understandable by policy-makers and the public. It provides useful frameworks that outline elements of care including poststroke care (see page 34), discussion questions, and stories that accompany the evidence-informed draft recommendations.
Development and Implementation of Stroke Guidelines
The generation and implementation of priority-setting guidelines for practice is an important step in operationalizing evidence.7 Sweden appears to be the first country to have developed a transparent, evidence-based mechanism to set priorities for stroke care. The guidelines consider need, effect size and evidence.8 The guidelines are presented in 2 versions: 1 for policy-makers and 1 for healthcare providers.
The need for stroke guidelines to include additional elements of care has been documented in a number of areas including emergency medical services9 and intensive care discharge.10 In addition, there has been a call to link national stroke policy more strategically to regional uptake. For instance, Lavados called for more specific details related to uptake at the regional level after an analysis of stroke incidence and service in Latin America and the Caribbean.11
Research on guideline utilization indicates that having written policy and practice guidelines can improve compliance with best practice for therapeutic anticoagulation.12 Another study demonstrated the effectiveness of best practice utilization in poststroke depression.13 The research cited above provides increased knowledge about what stroke policy needs to include such as guidelines on a substantial number of detailed elements in addition to dedicated funds for healthcare systems remodeling. Change requires resources.14
Access to, Need for, and Efficacy of Stroke Prevention and Treatment
Advances have been made in identifying determinants of stroke burden and outcome such as stroke belt research and other studies that examine regional, socioeconomic and ethnocultural variations in stroke prevalence and outcome.15 Stroke belt (areas of high incidence and mortality) analyses and other population health approaches to the epidemiology of stroke contribute to identifying where stroke-related policy should be directed. The stroke belt work suggests that early life exposures where one lives as a child are important in explaining stroke mortality.16,17 A study on urbanization and poverty levels suggests a relation between inner city slums and stroke.18
Are those who need care getting it, especially those in low socioeconomic groups? A WHO study found that 87% of the 5.7 million people who die annually from stroke live in low or middle income countries. These people are often unable to access stroke units or new drugs. Primary prevention and adequate stroke treatment are essential.19 Following a study to quantify the socioeconomic gap in long-term health outcomes after stroke and related healthcare utilization, it was concluded that greater clarity is needed in policy decisions about access, eg, coordinated care investments and disadvantaged groups.20 A study by Feigin,21 for example, provides increased understanding about stroke program and policy needs in the Maori and Pacific peoples.
Components of Integrated Care
Stroke units were found to be important in the prevention of complications.22 A systematic review of comparative stroke outcomes indicated that the benefits of stroke units in routine care were comparable to that seen in clinical trials.23 A study of weekday versus weekend mortality suggested that mortality increases over the weekend in both rural and urban hospitals in Canada. It was recommended that policy relating to specialists and weekend coverage be reviewed.24 Improvements to access to imaging facilities for stroke patients were recommended from an imaging service study in Scotland.25
A study of stroke units in 886 hospitals in 25 European countries provided valuable insights into the current status of acute care. Less than 10% of hospitals had optimal facilities and in 40% the minimal level of service was not available.26 Access to stroke care units in public hospitals in Australia was compared with 1999 levels. Findings showed that although progress had been made, the percentage of people accessing stroke units was approximately 20% as compared with 70% in Sweden. Policy to improve access to stroke units was recommended.27
Poststroke Outcome and Rehabilitation
Research has pointed to the need for greater attention to poststroke outcome and its determinants with studies showing high observed death and readmission.28 These authors call for more stroke-related health services research to clarify determinants of long-term stroke outcomes and to systematically evaluate targeted interventions in this area. Although there have been major advances in acute care for stroke in the Province of Ontario, deficiencies were reported in poststroke services such as depression.29 Correspondingly, a rehabilitation consensus conference was held in Canada. Priority areas for programs and research were identified including multimodal programs for reintegration, rehabilitation for severe stroke, cognitive rehabilitation, and research on the timing and intensity for 2 areas: aphasia therapy and therapy after mild to moderate stroke events.30 Posthospital care was the theme of a study of 7 hospitals in Taipei.31 These authors argue that our aging society must establish improved stroke service as a healthcare priority.
Prevention and Public Health
The first systematic review of articles on public education and policy for stroke prevention was published. The review examined stroke documents published since 1999. Using evaluation criteria and a data abstraction instrument, only 4 evidence-based policy articles on prevention were identified: 2 on prevention guidelines and 2 on recommendations for changes in health systems.32 Several studies published over the past year examined the effectiveness of intervention research on early warning signs of stroke, which contain implications for how this preventive measure might be improved.33,34 Also, there has been some important work on cultural considerations in treatment-seeking that has policy implications related to interaction between patients and providers.35
Predictive Modeling
Accurate estimates of the burden of the target problem coupled with the likely outcome of policy options are valuable contributors to stroke policy decision-making.36 These estimates involve collecting, synthesizing, and communicating complex data. Thus, predictive modeling has considerable potential for influencing stroke policy. We found 3 notable articles published this past year that used predictive modeling related to stroke policy. In the first article, economic predictive modeling was used to demonstrate the "invest to save" approach in building an economic argument for funding public health prevention to reduce cardiovascular disease risk.37 In the second article, a multivariate risk prediction equation using the Duke Stroke Model was developed to estimate stroke admissions and financial impact.36 The resultant simulation model was used to produce a legislative document reporting on the potential health and economic impact of improved stroke services in Mississippi. The style of the report appears to be understandable at the policy level, and the approach used to communicate these data may be of value to other jurisdictions aiming to identify optimal investments in stroke. In the third article predictive modeling was used to examine the potential effectiveness of combining multiple interventions in secondary prevention of stroke. It was shown that at least 80% of recurrent cerebrovascular events might be prevented by incorporating 5 proven clinical strategies: dietary modification, exercise, aspirin, a statin, and a hypertensive agent. Additional therapies such as smoking cessation increase effectiveness.38,39
Quality Improvement
Quality improvement in care based on a policy agenda requires changed individual and group behaviors. Clarifying barriers and facilitators to change is a key element of this process, although some conditions are context specific.40 A mixed methods approach was used to examine readiness for quality improvement from the perspectives of staff, patients, and administrators in acute care.41 Factors influencing the climate of change included the nature of past efforts to use evidence in organizational change, working environment, team climate and organizational stability. The data informed the development of an implementation strategy. This approach may be of value to stroke health systems examining the climate for change and working to improve it. In addition, a review was conducted to determine organizational barriers to the delivery of thrombolysis.42
Examples of practical methods for health system quality improvement are important to policy-makers, administrators and clinicians. A framework and collaborative process was developed by LaBresh for diagnosing barriers to acute stroke care, system redesign, implementation, and outcome assessment. Several tools (eg, GWTG-Stroke) to support system change were developed through this project.43 In another article, stroke was used to illustrate the importance of linking healthcare policy to education policy. Academic and medical training must include methods for translation of research into clinical delivery.44
The examples of policy-relevant research on stroke given above demonstrate the breadth of research questions and approaches being used to understand and act on stroke. This work has yielded policy-relevant outcomes, as well as outputs such as new research approaches related to stroke strategies and elements of care, optimizing policy investments in stroke, and knowledge translation. Despite the data on stroke mortality and morbidity that compels policy-makers to act, clarity about effective solutions and policy-maker roles in these solutions is needed. In particular, how can we focus research and policy on prevention and treatment of underserved people and regions? Given data on the heavy burden of cardiovascular disease in developing countries, how can evidence be used to make the case that it receive greater attention in global health?45 Lastly, in order to advance the quality of care and improve outcome, how can policy include commitments to research as a key component of stroke strategies?21
Acknowledgments
Disclosures
None.
Received November 23, 2007; revision received December 4, 2007; accepted December 5, 2007.
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