Published online before print March 19, 2009, doi: 10.1161/STROKEAHA.108.531053
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(Stroke. 2009;40:1793.)
© 2009 American Heart Association, Inc.
Original Contributions |
Regional Implementation of the Stroke Systems of Care Model
Recommendations of the Northeast Cerebrovascular Consortium
From the Long Island College Hospital (T.G.), Brooklyn, NY; American Stroke Association (Z.M.-I., D.D., S.M.), Dallas, Tex; and Massachusetts General Hospital (L.H.S.), Boston, Mass.
Correspondence to Toby Gropen, MD, Chairman, Department of Neurology and Director, Stroke Center, Long Island College Hospital, 339 Hicks Street, Brooklyn, NY 11201. E-mail tgropen{at}chpnet.org
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Abstract |
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Background and Purpose— The Northeast Cerebrovascular Consortium was established to examine regional disparities and recommend strategies to improve stroke care based on the Stroke Systems of Care Model.
Methods— An annual summit was first held in 2006, bringing together public health officials, researchers, physicians, nurses, health professionals, state legislators, and advocacy organizations. Best practices and evidence-based interventions within each of the Stroke Systems of Care Model components were presented. Six writing groups were tasked with cataloging each state’s current activities and identifying goals for the region.
Results— There were significant variations in the delivery of stroke care, particularly in urban versus rural areas, as evidenced by the availability of designated stroke centers and neurologists, and stroke-related death rates. Recommendations to address variations in care delivery included the use of a common stroke data collection system, unified community education criteria, improvements to emergency medical services dispatch and training, adoption of prehospital care measures, creation of a web-based central repository of acute stroke protocols and order sets, a regional atlas of stroke resources and capabilities, a stroke patient "report card" to promote adherence to secondary prevention strategies, and explicit standards for rehabilitation services.
Conclusions— Significant disparities in the delivery of stroke care across the 8 state-region have been identified. Northeast Cerebrovascular Consortium demonstrates that multistate regional collaboration is a viable process for developing specific regional recommendations to address those disparities. Northeast Cerebrovascular Consortium is assessing the usefulness of the Stroke Systems of Care Model as a framework for implementing a regional approach to stroke across the continuum of care.
Key Words: regional implementation • stroke • stroke systems
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Introduction |
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More efficient and tightly integrated systems for stroke care are needed. In 2002, a task force sponsored by the National Institutes of Neurological Disorders and Stroke of the National Institutes of Health published recommendations calling for greater coordination and better support mechanisms for the various components and professionals involved in both prehospital and acute stroke care.1 In 2005, an American Heart Association task force on the development of stroke systems described the fragmentation of stroke care, defined the key components of a stroke system, and recommended methods for encouraging the implementation of stroke systems of care.2 The task force defined 7 key components of the Stroke Systems of Care Model (SSCM): primordial and primary prevention; community education; notification and response of emergency medical services; acute stroke treatment; subacute stroke treatment and secondary prevention; rehabilitation; and continuous quality improvement activities.
The northeastern United States has the lowest stroke incidence and age-adjusted stroke mortality rate in the country.3 However, there is considerable geographic, demographic, and economic diversity across the Northeast along with variability in stroke care resources and delivery. Increasing access to high-quality stroke care for all patients is one of the central goals of the SSCM. To date, initiatives to improve care delivery in the Northeast have included grass roots education and health screening campaigns; stroke center designation through legislative action or public health regulation; and emergency medical service (EMS) stroke-specific training and triage.
Although stroke system oversight and accountability can be coordinated at the state or national level, regional coordination may contribute significantly to system improvement. The Northeast Cerebrovascular Consortium (NECC) was established as an independent organization in 2006 to bring together key stakeholders in the Northeast states (Connecticut, Massachusetts, Maine, New Hampshire, New Jersey, New York, Rhode Island, Vermont) to (1) identify regional variations in systems of stroke care delivery; (2) develop a series of recommendations based on the SSCM framework; (3) implement the recommendations; and (4) assess the impact of implementation of the SSCM in the Northeast.4 This initial report focuses on the results of the first 2 phases.
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Methods |
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Key aspects of NECC methodology include local participation and ownership of decisions with an emphasis on stroke care policy and system changes, consensus-building, regional sharing of experiences and collaboration, and continuous quality improvement. Local participation and ownership of decisions in NECC is modeled after prior efforts of the American Stroke Association (ASA). From 1997 to 2002, the ASA’s "Operation Stroke" program focused on bringing together hospitals, healthcare professionals, and emergency medical systems professionals in the large metropolitan US markets to improve the quality of care for patients with acute stroke. In 2003, as focus shifted from local initiatives to regional efforts to address systems change, the ASA supported a coalition of volunteers from Massachusetts, Maine, New Hampshire, Upstate New York, Vermont, and Rhode Island in creating the "Northeast Stroke Task Force" (NEST). NEST provided the foundation and the necessary framework for the ultimate establishment of NECC.
NECC aspires to develop partnerships among stroke volunteers, state governments, and public and nonprofit agencies. In 2005, a 4-year blueprint was developed using the SSCM framework to increase collaboration across the Northeast to improve patient outcomes in the prevention, treatment, and rehabilitation of stroke (see supplemental Appendix I, available online at http://stroke.ahajournals.org). From the inception, it was envisioned that NECC would bring together key stakeholders from each of the 8 Northeast states to affect policy and system changes in stroke care (see supplemental Appendix II).
Regional sharing of experiences and collaboration is fostered by a number of activities, including annual regional conferences and regional representation on NECC committees. The Inaugural Summit of NECC was entitled "Envisioning an Integrated, Multi-State, Regional Stroke System of Care: Designing the Blueprint." Representatives from all 8 NECC states met in Boston on September 13, 2006.4 The Summit was jointly sponsored by the ASA and the National Stroke Association in collaboration with the Massachusetts Department of Public Health. Each NECC state presented a stroke care "state-of-the-state" address organized according to the SSCM framework. For many states, this was the first time that the state department of health had systematically reviewed their stroke care delivery methods and had the opportunity to share experiences and learn from their neighbors.
As the fiscal agent of NECC, the ASA led the effort to secure external funds in support of the Summit and has assisted in the coordination of NECC and its 4 main committees comprised of invited representatives from across the region and spanning the components of the SSCM. These committees are governed by consensus and include a NECC Advisory Council to guide overall strategic direction, a Planning Committee to develop and approve the conference agendas, a Grant Review Committee to judge proposals and award funds, and a NECC Writing Committee to develop and document recommendations (see supplemental Appendix II). Committee members were invited and chairs were chosen all by consensus, and the membership has evolved over time.
A Grant Award program, supported by the NECC through unrestricted funding of $20 000 annually from corporate sponsors, solicits 1-year proposals that help further the goals of the NECC in any of the defined areas of the SSCM. It is designed to promote collaboration and best practice-sharing and to build relationships across the NECC member states. Proposals that involve interagency collaboration are favored as well as projects that involve collaboration or mentorship relationships with another state that is part of the NECC. Strong consideration is given to projects that address stroke in regions where stroke initiatives and resources are limited. All funded recipients present a summary of their project at the subsequent Annual NECC Summit.4
Writing Committee groups were asked to develop specific recommendations for each of the content areas in the SSCM for regional or multistate collaboration. Best practices and evidence-based interventions within each of the SSCM domains were presented by local and regional experts. Six writing groups were tasked with cataloging each state’s current activities and identifying goals for the region. Publicly available healthcare data files were integrated with geospatial data to create geographical information systems (GIS) maps of the distribution of stroke care resources across the NECC region (see Figures 1 to 3
).5 Data on state-certified stroke centers were obtained from respective NECC state departments of health (G. Palmeri, Massachusetts Department of Public Health, personal communication, April 15, 2008; N. Barhydt, New York State Department of Health, personal communication). Data on Joint Commission Primary Stroke Centers was obtained from the Joint Commission and data on hospitals participating in the American Heart Association’s Get With The Guidelines–Stroke program was obtained from the American Heart Association (Z. Magdon-Ismail, American Heart Association, personal communication, April 15, 2008).6 For a county to be considered within 30 miles of a designated stroke center, at least a portion of the county needed to be covered by at least one Joint Commission or state-designated stroke center. Counties were classified as urban or rural according to Office of Management and Budget categories. Counties were defined as urban if they were classified as metro and defined as rural if they were classified as nonmetro based on the 9-part county codification. Stroke mortality per 100 000 persons aged 35+ by quintile (1, 61 to 113; 2, 114 to 123; 3, 124 to 133; 4, 134 to 146; 5, 147 to 241), neurologist per 10 000 persons age 65+ by quintile (1, 0; 2, 0.3 to 1.5; 3, 1.6 to 2.5; 4, 2.6 to 4.2; 5, 4.3 to 84.9), and short-term general hospitals with rehabilitation care services by quartile (1, 0; 2, 1; 3, 2 to 3; 4, 4 to 29) were recorded according to the 2002 Atlas of Stroke Mortality published by the Centers for Disease Control and Prevention. Population data, index of racial and ethnic diversity (range, 0 to 100 with 100 most diverse), and median household income by quartile in dollars (1, $30 117 to $45 243; 2, $45 244 to $55 931; 3, $55 932 to $73 535; 4, $73 536 to $100 485) were 2007 estimates from ESRI, Inc (Redlands, Calif) based on the 2000 US Census. Univariate analysis of continuous variables was by independent t test, ordinal, or rank order variables by 
2 or Wilcoxon rank sum. Multivariable analysis included 3 characteristics (median household income, diversity index, and urban/rural classification) that were all significant in univariate analyses and was performed by logistic regression for dichotomous outcome variables and linear regression for continuous outcome variables. Multivariable results are reported as ORs with 95% CIs (lower, upper limit).
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After each NECC Summit, each state’s current stroke care activities in the SSCM were catalogued. Continuous quality improvement methods were applied to the implementation goals as well as the structure of NECC itself based on feedback from the states and stakeholders, and new goals were identified. After the Summit, the Writing Committee groups met and developed recommendations for regional implementation to address variations in care delivery.
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Results |
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At the NECC 2006 Summit, best practices and current evidence-based guidelines were presented.4 The different organizational structures within each state relevant to stroke care were compared, and current efforts in stroke systems of care development were catalogued. In addition, cross-border opportunities for care and common criteria for stroke center designation were discussed as well as prior experiences with "pay for performance" in cardiovascular and cerebrovascular disease and challenges related to collection of outcomes data in a Health Insurance Portability and Accountability Act-constrained environment. At the NECC 2007 Summit, presentations included the national trauma system as an example of a disease-specific systems of care model, the impact of reimbursement on patterns of acute stroke care, novel approaches to primary prevention in white and minority populations, and updated guidelines on the treatment of intracerebral hemorrhage.4 Methods for common data collection were reviewed, and data on disparities in care were presented. Many of these presentations are available for review by the public on the NECC web site (www.thenecc.org).
After the 2006 NECC Summit, significant regional variations in baseline (before September 13, 2006) stroke care delivery were identified in each component of the SSCM as detailed in each subsequent subsection. Examples of disparity in the distribution of stroke care resources across NECC as a function of population demographics are displayed in Table 1 and in Figures 1 to 3
with respect to stroke center availability. Writing Committee group recommendations for regional implementation to address these variations in care delivery were finalized in February 2008 and are presented in Table 2 as a set of overarching recommendations followed by SSCM component-specific items.
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Primordial and Primary Prevention
Baseline Activities
Quantitative data are not available. All NECC states had primordial prevention programs focused on obesity, exercise, and nutrition and risk factor education programs focused on hypertension, diabetes, and smoking cessation. Most NECC states and cities have legislation aimed at reducing exposure to secondhand smoke.7 Throughout the Northeast, nonprofit agencies such as the ASA, National Stroke Association, and others were working to educate primary care providers and at-risk patients about stroke prevention. Only some states (Connecticut, Massachusetts, New Jersey, and New York) had education or intervention programs specifically targeting minorities.
Recommendations
The SSCM states that a stroke system should develop support mechanisms and tools to assist communities, patients, and providers in initiating and adhering to prevention regimens applicable to the population as a whole with a focus on educational programs to target high-risk populations. Primary care providers can play a critical role in providing individualized education to their patients about risk of stroke and therapeutic lifestyle changes that can be made to reduce the risk. The 3 key interventions are listed in Table 2.
Community Education
Baseline Activities
Quantitative data are not available. Traditional hospital- and community-based educational programs were present throughout the region. These programs often relied on educational resources and materials created by third parties such as federal agencies or advocacy organizations and generally did not include an evaluation component. All hospitals receiving Stroke Center Designation from the Joint Commission or state-based programs in New York, New Jersey, or Massachusetts were required to provide community stroke prevention education programs at least twice per year; however, frequently these did not include an evaluation component.8–11 Regional variability in community education is also suggested by the initial presence of the American Heart Association’s Power to End Stroke program in only 4 of the 8 states (Connecticut, Massachusetts, New Jersey, and New York)12 and presence in only 4 states (Connecticut, Massachusetts, Maine, New York) of warning sign and EMS activation media campaigns. Additionally, a 1400-person randomized clinical trial was launched in New York City in 2005 to test the efficacy of an intensive behavioral intervention to decrease time from stroke onset to emergency treatment.13
Recommendations
Community-based outreach programs need to develop and implement culturally appropriate strategies that increase awareness of stroke risk and warning signs, the importance of timely action in calling 911, and the role of therapeutic lifestyle changes to reduce stroke risk. This is especially important among populations in which disparities in healthcare delivery currently exist. Every NECC state and local media market has specific challenges and populations that need to be addressed. The 5 key recommendations are listed in Table 2.
Notification and Response of EMSs
Baseline Activities
There are limited data regarding the type (eg, emergency medical technicians, fire, police, volunteer) and level (basic life support, advanced life support) of EMS response to stroke. Few states or cities within the NECC region currently had a unified regional EMS response to acute stroke, and the organization of EMS agencies and providers was fragmented and highly variable with 2 notable exceptions. As part of the New York State Stroke Center Designation Project, EMS triaged patients with acute stroke to state-based designated stroke centers in the boroughs of Brooklyn and Queens starting in May 2003.14 This program was expanded to New York State in 2004. The Boston Operation Stroke Study laid the groundwork for the State-based Primary Stroke Service designation program, which began in July 2005, that required EMS diversion to stroke centers for selected patients with acute stroke throughout the state.
Recommendations
A recent ASA policy statement recommended a series of implementation strategies for EMS within the SSCM to increase access to facilities capable of treating acute stroke.15 The NECC recommendations define specific actions consistent with these general recommendations to increase the likelihood that patients will be transported to the nearest stroke center for evaluation and care provided a stroke center is located within a reasonable transport distance and transport time. The 9 key interventions are listed in Table 2.
Acute Stroke Treatment
Baseline Activities
All 8 NECC states had conducted a formal or informal hospital stroke capacity survey addressing available hospital services, including specialist coverage. Three states (Massachusetts, Maine, and New York) had taken steps to address the shortage of neurologists in rural areas by supporting increased access to care through telemedicine-enabled stroke consultation. This had been accomplished through telemedicine grants to rural hospitals (Massachusetts, New York) and collaboration with nonprofit hospitals (Massachusetts and Maine) or for-profit telemedicine companies (Massachusetts, New York). Three of the states had state-based primary stroke center designation programs; the Massachusetts and New York programs used regulatory approaches and in New Jersey a legislative approach was used with legislation passed in May 2004 with implementation in 2006. Massachusetts is the one NECC state that participated in the Centers for Disease Control and Prevention’s Paul Coverdell National Acute Stroke Registry.16 New Jersey is the only NECC state to have developed criteria for Comprehensive Stroke Center designation.9
Significant variations in access to acute stroke care across the region were identified and are shown in Table 1 and GIS Figures 1 to 3. In univariate analyses (Table 1), major differences between urban and rural counties existed in diversity index, household income, stroke death rates, access to neurologists, access to at least one designated stroke center (all P<0.001), and numbers of designated stroke centers per 100 000 persons (P=0.03). In univariate analyses, compared with counties without access to a designated stroke center, counties with a designated stroke center within 30 miles had mortality in the lowest quintile more often (79.1% versus 52.5%, P=0.001) and had a significantly higher median household income (P<0.0001). In multivariable analysis, independent predictors of living within 30 miles of a designated stroke center were greater diversity index (OR, 1.15 [1.07 to 1.25] per incremental point; P<0.001) and rural location (OR, 0.29 [0.10 to 0.91]; P=0.04) with a trend toward median household income (OR, 1.20 [0.91 to 4.36]; P=0.08). Rural location, median income, and diversity index were not independent predictors of stroke mortality.
Figure 1 depicts access to a designated stroke center within a 30-mile radius versus population. In September 2006, 177 hospitals had been certified as a stroke center either as a Joint Commission Primary Stroke Center or as a formal stroke center by state-based criteria. The map also shows those hospitals that implemented the Get With The Guidelines–Stroke quality improvement program. Although 90% of the population in 2006 was within 30 miles of a certified stroke center, there were vast areas of the region, including the populations of whole states, that were not. Figure 2 depicts access to a designated stroke center within a 30-mile radius versus quintiles of stroke mortality by county according to the Centers for Disease Control and Prevention Atlas of Stroke Mortality. Figure 3 depicts access to a designated stroke center within a 30-mile radius versus median household income.
Recommendations
A regional stroke system organized according to the SSCM maintains a transparent inventory of the acute stroke treatment capabilities and limitations of all hospitals in the region and makes this information available to providers and the public. It also ensures that all hospitals and facilities that could be involved in the care of patients with acute stroke (including those without stroke center status) have action plans for the triage and treatment or transport of patients with stroke as appropriate. The 5 key interventions are listed in Table 2.
Subacute Care and Secondary Prevention
Baseline Activities
Stroke units have been shown to reduce morbidity and mortality of stroke.17 In 2006, however, the actual numbers and composition of these stroke units across NECC was unknown, except those required as part of national and most state-based stroke center designation programs (see Figures 1 to 3). State and national stroke center designation programs as well as quality improvement programs were also measuring aspects of subacute hospital-based stroke care. There was, however, little published data on the details of their implementation, process and outcome measures, or data collection and case ascertainment methodology with the exception of data on the implementation process and performance of state-based stroke centers designated in Brooklyn and Queens.14 Furthermore, few states had an organized statewide plan for stroke quality improvement, and there was little attention paid to developing systems to link acute inpatient hospital care to postdischarge care at rehabilitation facilities or residential environments.
Some NECC states with state-based stroke center designation programs had built-in secondary prevention guidelines in accordance with the ASA Guidelines. Many hospitals across the region also participated in Get With The Guidelines–Stroke and/or had sought Joint Commission Primary Stroke Center Certification. In general, however, participation in these programs was highest within the states with active stroke center designation programs (see Figures 1 to 3).
Recommendations
Subacute care not only involves the prevention of in-hospital complications and recurrent stroke and initiation of stroke prevention education, but also is the critical linkage between acute care and postdischarge care environments. It should address modifiable risk factors, patient and family education, transitions to appropriate follow-up care, and strategies to monitor and improve long-term patient adherence to guideline-based risk reduction interventions. The 6 key interventions are listed in Table 2.
Rehabilitation
Baseline Activities
As shown in Table 1, there were no differences in access to short-term general hospitals with rehabilitation care services (although there were more than 50% of counties without available data). In general, inpatient or postacute rehabilitation had not been a required service specified in stroke center certification programs; in fact, only New Jersey had identified plans to require rehabilitation services for the designation of both primary and comprehensive stroke centers.
Recommendations
Results of randomized, controlled trials comparing stroke unit care with general medical ward care suggest that incorporation of rehabilitation into stroke unit care is one of the key components resulting in reduction in disability.17 The SSCM emphasizes the use of standardized screening evaluations of all patients, periodic assessment of rehabilitation services and resources within the stroke system, referral of patients to the most appropriate level and setting of rehabilitation, and appropriate follow-up and primary care for patients discharged to home. The 4 key interventions are listed in Table 2.
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Discussion |
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NECC demonstrates that multistate regional collaboration is a viable process for developing specific regional recommendations for improved stroke care. There are other regional stroke networks in the United States (eg, the Delta States Stroke Consortium, Great Lakes Regional Stroke Network, Stroke Belt Consortium, Greater Cincinnati–Northern Kentucky Stroke System, Tri State Stroke Network, and Northwest Regional Stroke Network) and other countries (eg, the Bavarian and Canadian Stroke Networks18–22). All of the US regional stroke networks rely on local participation and ownership of decisions, collaboration across state lines, and partnership among state governments and public and nonprofit agencies. NECC, like other stroke networks, leverages the expertise of individuals and state entities to focus on changes in stroke care.
However, unlike the other consortia, the NECC has chosen to focus more on system and policy changes to accelerate the growth of regional collaboration rather than on patient and provider education. In addition, leveraging the high density of hospitals in the region participating in national stroke quality improvement initiatives, NECC is poised to be the first US stroke network to implement a uniform regional data collection and performance measurement system. A recent review of stroke systems of care reinforces that harmonization of efforts by the major healthcare organizations to collect data on hospital-based stroke care and to improve care will lead to broader implementation of these programs and better patient outcomes. Health policy changes are needed at the state, regional, and federal level to increase funding for stroke education and provider reimbursement, improve provider capabilities, and address shortages of acute stroke expertise nationwide.23
NECC has identified variations in the delivery of stroke care across the 8-state region in almost every component of the SSCM. Rural populations throughout the region had significantly less access to neurologists and designated stroke centers and higher stroke-related death rates. Although we acknowledge the lack of quantitative data for stroke care activities related to primary and primordial prevention, community education, and notification and response of EMS as a limitation, the qualitative data suggest significant heterogeneity in available services and resources. In addition, the variation in distribution of designated stroke centers is important, because it is likely that stroke center designation impacts on multiple components of the SSCM. The variation in distribution of designated stroke centers is amply demonstrated by use of GIS maps. However, our results also highlight the lack of accurate and current data on stroke care delivery in the northeastern United States. In the future, NECC will create metrics for each Stroke System of Care Recommendation and generate GIS maps to track system progress.
NECC is the first organized effort to attempt regional implementation of the SSCM. Translating the general recommendations of the SCCM into specific actionable goals and working across the region to implement these changes is a formidable task. It is anticipated that successful implementation of the NECC recommendations will create a standardized regional approach to stroke in the prehospital, inpatient, and outpatient domains that will help reduce the disparities in stroke care that have been identified. The leadership of the NECC believes that the consortium will help facilitate the flow of information across public health departments and other state agencies to catalyze action in states that have been slower in developing and implementing standards for acute stroke care. This is a work in progress and the difficult next steps of defining the most relevant markers of system progress and implementing the consensus recommendations lie ahead. It remains to be seen if this process will lead to synergies across the region and more rapid adoption of strategies shown to be successful in other states within NECC.
Supplemental Appendix 1: NECC Blueprint
NECC Overview
The NECC has a driven purpose that is to design a blueprint for stroke care in the region. We have a vision of an integrated multistate, regional stroke system of care. The 8 states that are part of the Consortium are Connecticut, Massachusetts, Maine, New Hampshire, New Jersey, New York, Rhode Island, and Vermont.
Designing and implementing a Regional Stroke System of Care requires that individuals and groups must first come together and compare the different organizational structures within each state relevant to stroke care, catalog current efforts, review the challenges of outcomes data collection in a Health Insurance Portability and Accountability Act-constrained environment, and outline prior experience with "pay for performance" in cardiovascular and cerebrovascular disease.
Furthermore, identifying cross-border opportunities for care and creating common criteria for primary stroke service designation that will allow for cross-border designation and delivery of care is essential.
NECC Annual Conference Objectives
Inaugural Meeting of The NorthEast Cerebrovascular Consortium: Envisioning an Integrated, Multi-State, Regional Stroke System of Care: Designing the Blueprint, Boston, Mass, September 13 to 15, 2006:
• Compare the different organizational structures within each state relevant to stroke care;
• Catalog current efforts in stroke systems of care;
• Identify cross-border opportunities for care and create common criteria for primary stroke service designation that will allow for cross-border designation and delivery of care;
• Outline prior experience with "pay for performance" in cardiovascular and cerebrovascular disease; and
• Review the challenges of outcomes data collection in a Health Insurance Portability and Accountability Act-constrained environment.
The 2nd Annual Meeting of the NorthEast Cerebrovascular Consortium: Collaborative Data Collection and Quality Improvement: Accelerating Implementation of Individual State-Based Stroke Systems of Care, New York, NY, October 3 to 4, 2007:
• Explore approaches for common data reporting and creating linkages or sharing of one data platform;
• Create a document to map the plan for the coming year; and
• Propose designs for a pilot project initiative in "pay for performance" in cerebrovascular disease.
The 3rd Annual Meeting of the NorthEast Cerebrovascular Consortium, Lessons Learned in Interstate Collaboration and Regional Stroke Care Delivery: Preliminary Data, Boston, Mass, October 29 to 30, 2008:
• Transform published Centers for Disease Control and Prevention guidelines for creation of a state burden document into blueprint for creating a regional burden document (Development of A Public Health Action Plan to Prevent Heart Disease and Stroke, www.cdc.gov/cvh/Action_Plan/full_appendix_d.htm);
• Review available state level administrative data and prospectively collected hospital-level outcomes data sources for inclusion in burden document;
• Identify specific geographic regions adjacent to other states and in neurologically underserved areas for opportunities of cross-border collaboration and telemedicine support;
• Explore other opportunities for cross-border quality improvement;
• Bring together a consensus panel to review regional EMS dispatch and transport protocols;
• Develop a pilot plan for pay for performance based on quality improvement indicators; and
• Propose models for long-term outcomes assessment in quality improvement initiatives using a hybrid of administrative data and clinical follow-up without explicit informed consent.
The 4th Annual Meeting of the NorthEast Cerebrovascular Consortium, Action Plan for the NorthEast Stroke System of Care Model: Successes, Failures and Translation to Other Regions, location/date to be determined:
• Create an action plan for implementation of a Northeast Regional Stroke Systems of Care model;
• Highlight areas of successful collaboration;
• Identify remaining obstacles and analyze barriers; identify opportunities for collaborative efforts and innovative mechanisms to overcome barriers; and
Explore pay for performance in relation to specific components of the action plan for implementing a Northeast Regional Stroke Systems of Care.
Supplemental Appendix II: Advisory, Planning, Writing, Grant Review, and Other Committees
NECC Advisory Group
Nadine Allyn, RD, MPH, American Heart Association, Mass; Matthew Bannister, American Heart Association, Mass; Bernadette Boden-Abala, PhD, Columbia Presbyterian Hospital, NY; Christopher Commichau, MD, Fletcher Allen Health Care, Vt; David Day, BS, American Heart Association, Mass; Brian Glaser, MSW, American Heart Association, NJ; Toby Gropen, MD, FAHA, Long Island College Hospital, NY; John J. Halperin, MD, FAAN, FACP, Overlook Hospital, NJ; David B. Hiltz, NREMT-P, American Heart Association, RI; Tom Kwiatkowski, MD, North Shore–LIJ Health System, NY; Laura Lennihan, MD, Columbia University, NY; Danielle Louder, Maine Cardiovascular Health Program, Maine; Timothy G. Lukovits, MD, Dartmouth Hitchcock Medical Center, NH; Zainab Magdon-Ismail, EdM, MPH, Shannon Melluzzo, BA, American Heart Association, Mass; Peter Moyer, MD, MPH, Boston EMS, Mass; Peter Panagos, MD, Rhode Island Hospital, RI; Lee Schwamm, MD, Massachusetts General Hospital, Mass; Magdy Selim, MD, PhD, Beth Israel Deaconess Medical Center, Mass; Joel Stein, MD, Spaulding Rehabilitation Hospital, Mass; Bill Thompsen, American Heart Association, NJ.
NECC Writing Groups
Co-Chairs—Lee H. Schwamm, MD, FAHA, Massachusetts General Hospital, Mass; Toby Gropen, MD, FAHA, Long Island College Hospital, NY; Health Promotion Community Outreach Writing Group: Chair—Bernadette Boden-Abala, PhD, Columbia Presbyterian Hospital, NY; Vice Chair—Danielle Louder, Maine Cardiovascular Health Program, Maine; Members: Kathy Foell, Massachusetts Department of Public Health, Mass; Debra Wigand, MEd, CHES, Maine Center for Disease Control, Maine; Deborah Spicer, RD, MPH, New York State Department of Health, NY; Bill Thompsen, American Heart Association, NJ; Primary & Seconday Prevention Writing Group: Chair—Magdy Selim, MD, PhD, Beth Israel Deaconess Medical Center, Mass; Members: Marc Fisher, MD, UMASS Memorial Medical Center, Mass; Nancy Pederizini, American Heart Association, NH; Emergency Medical Services Writing Group: Chair—Tom Kwiatkowski, MD, Long Island Jewish Medical Center, NY; Vice Chair—Peter Moyer, MD, MPH, Boston EMS, Mass; Members: Diana Barrett, American Heart Association, NY; David B. Hiltz, NREMT-P, American Heart Association, RI; Christine Rutan, American Heart Association, NY; Hospital Based Acute Stroke Care Writing Group: Chair—Peter Panagos, MD, Rhode Island Hospital, RI; Vice Chair—Christopher Commichau, MD, Fletcher Allen Health Care, Vt; Members: Nadine Allyn, RD, MPH, American Heart Association, Mass; Cathy Blake, New York State Department of Health, NY; Doug DeOrchis, MD, The Miriam Hospital, RI; Toby Gropen, MD, FAHA, Long Island College Hospital, NY; Gail Palmeri, RN, Massachusetts Department of Public Health, Mass; Susanna Horvath, MD, Columbia University, NY; Hospital Based Secondary Prevention Writing Group: Chair—Timothy G. Lukovits, MD, Dartmouth Hitchcock Medical Center, NH; Vice Chair—John J. Halperin MD, FAAN, FACP, Overlook Hospital, NJ; Members: Judy Hinchey, MD, Caritas St Elizabeth’s Medical Center, Mass; Sheree Murphy, MS, American Heart Association, NY; Rehabilitation and Recovery Writing Group: Chair—Laura Lennihan, MD, Columbia University, NY; Vice Chair—Joel Stein, MD, Spaulding Rehabilitation Hospital, Mass; Members: Brian Glaser, MSW, American Heart Association, NJ; Carl V. Granger, MD, University at Buffalo, NY; Randy Marshall, MD, Neurological Institute, NY; Janet Prvu-Bettger, ScD; Massachusetts Department of Public Health, Mass.
2007 Summit Planning and Grant Review Committee
Bernadette Boden-Abala, PhD, Columbia Presbyterian Hospital, NY; Laura Coe, MA, DPH, Mass; Christopher Commichau, MD, Fletcher Allen Health Care, Vt; David Day, BS, American Heart Association, Mass; Mitchell S. V. Elkind, MD, MS, FAAN, Columbia University, NY; Kathy Foell, Massachusetts Department of Public Health, Mass; Carl V. Granger, MD, University at Buffalo, NY; Toby Gropen, MD, Long Island College Hospital, NY; John J. Halperin MD, FAAN, FACP, Overlook Hospital, NJ; Richard Hodosh, MD, Atlantic Brain & Spine Institute, NJ; Betty Jung, RN, MPH, CHES, Connecticut Department of Public Health, Conn; Elsbeth Kalenderian, DDS, American Stroke Association, NY; Tom Kwiatkowski, MD, Long Island Jewish Medical Center, NY; Daniel Labovitz, MD, MS, NYU School of Medicine, NY; Laura Lennihan, MD, Columbia University, NY; Danielle Louder, Maine Cardiovascular Health Program, Maine; Timothy G. Lukovits, MD, Dartmouth Hitchcock Medical Center, NH; Zainab Magdon-Ismail, EdM, MPH, American Stroke Association, NY; Shannon Melluzzo, BA, American Stroke Association, Mass; Susan Moore, RN, Kent Hospital, RI; Peter Moyer, MD, MPH, Boston EMS, Mass; Gail Palmeri, RN, Massachusetts Department of Public Health, Mass; Peter Panagos, MD, Rhode Island Hospital, RI; Lee Schwamm, MD, Massachusetts General Hospital, Mass; Magdy Selim, MD, Beth Israel Deaconess Medical Center, Mass; Judith Spilker, RN, National Stroke Association; Joel Stein, MD, Spaulding Rehabilitation Hospital, Mass; Debra Wigand, MEd, CHES, Maine Center for Disease Control, Maine.
2006 Summit Planning and Grant Review Committee
John Belden, MD, Maine Medical Center, Maine; Curtis Benesch, MD, MPH, University of Rochester, NY; Christopher Commichau, MD, Fletcher Allen Health Care, Vt; Kathy Foell, Massachusetts Department of Public Health, Mass; Richard Hodosh, MD, Atlantic Brain & Spine Institute, NJ; Sharon Januchowski, RN, National Stroke Association; Srinath Kadimi, MD, FRCS, Associated Neurologists of Southern Connecticut, PC, NH; Elsbeth Kalenderian, DDS, American Heart Association, Mass; Timothy G. Lukovits, MD, Dartmouth–Hitchcock Medical Center, NH; Zainab Magdon-Ismail, EdM, MPH, American Heart Association, NY; Shannon Melluzzo, BA, American Heart Association, Mass; Susan Moore, RN, Kent Hospital, RI; John Morely, MD, New York State Department of Health, NY; Peter Moyer, MD, MPH, Boston EMS, Mass; Gail Palmeri, RN, Department of Public Health, Mass; Peter Panagos, MD, Rhode Island Hospital, RI; Janet Prvu, PhD, Massachusetts Department of Public Health, Mass; Adnan Qureshi, MD, UMDNJ–New Jersey Medical School, NJ; Ralph L. Sacco, MS, MD, Neurological Institute; Lee Schwamm, MD, Massachusetts General Hospital; Debra Wigand, MEd, CHES, Maine Center for Disease Control.
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Acknowledgments |
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The NECC thanks the following for their support of the development of the NECC and the genesis of the article: Ralph Sacco, MD, Elsbeth Kalenderian, DDS, MPH, Janet Prvu Bettger, Sc.D, Ben Weittenhiller, MBA, and the American Heart Association.
Sources of Funding
The NECC conferences were supported in part by Centers for Disease Control and Prevention Conference Grant 5 U13 DP001176-02. The following commercial sponsors contributed funds to support the Northeast Cerebrovascular Consortium annual meetings but had no input into the conference planning or manuscript content, preparation or analyses: AstraZeneca Pharmaceuticals, Inc, Forest Research Institute, Genentech, HealthSouth, Innovative Neurotronics, Medivance, National Stroke Association, Novo Nordisk, NuStep, PDL Pharma, and Pfizer.
Disclosures
T.G.: former speaker for Boehringer Ingelheim; L.H.S.: paid consultant on stroke systems of care to the Massachusetts Department of Health.
Received July 8, 2008; revision received October 10, 2008; accepted November 4, 2008.
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