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2 1996 rtpa benchmarking Abstract Stroke has been the second leading cause of death in Taiwan since 1983, with ischemic stroke accounting for about 70%. Stroke, requiring costly acute hospitalization care and continuing inpatient/outpatient rehabilitation, consequently has a significant social and economic impact on patients, their families, and society as a whole. With an aging population, the number of strokes is projected to increase. That is to say, the enormous burden of stroke is likely to increase further in the future. Health care research is clearly warranted for a disease like stroke. Little treatment existed for ischemic stroke until 1996, when the use of recombinant tissue plasminogen activator (rtpa) for the treatment of patients with acute stroke got approved in the United States. Following the approval granted by the European Union in 2002, the use of rtpa in patients with acute stroke becomes legitimately available in Taiwan after November At the turning point in the acute stroke health care, however, little is known about the status quo of acute stroke care and quality of diagnosis and therapy. The 1

3 purpose of this study is to fill this gap by analyzing the treatment outcome of acute hospitalization in patients with first-ever ischemic stroke. Through this observational study, we are able to provide a benchmark for the recovery outcome of acute hospitalization of patients with first-ever ischemic stroke. In addition, we identify the extent of stroke severity on admission to be predictive of outcome of acute hospitalization, and to clarify the relationships between patient age and early recovery outcome. Keywords: outcome study, ischemic stroke, stroke severity, acute hospitalization 2

4 The main results of this study are summarized as follows. Tseng MC., Chang KC (2005), Acute Care of First-Ever Ischemic Stoke in Taiwan: Outcomes and Implications for Healthcare Resource Utilization, presented at the 2005 ihea World Congress in Barcelona, Spain. Background and Purpose - To evaluate the effectiveness and the utilization of healthcare resource of acute care in first-ever ischemic stroke. Methods A prospective study of 368 first-ever ischemic stroke patients consecutively admitted to a medical center in Taiwan was conducted. Neurologic improvement was defined as an improvement of the NIH Stroke Scale (NIHSS) by 4 points or NIHSS 1 at discharge. Good functional outcome was defined as modified Barthel Index (BI) 19 (20=normal) at discharge. We analyzed the data using univariate methods and a logistic regression with the dependent variable of neurological improvement and good functional outcome, respectively. Results - Of 360 patients (mean age, 64.9±12.5 years; 43% women; median NIHSS, 6; median LOS, 7 days; median costs per patient, US$841), neurological improvement was observed in 150 (42%) patients, and good functional outcome in 126 (35%). Patients with neurologic improvement had shorter LOS (median, 6 vs. 8 days, P=0.017) and lower hospital charges (median, US$769 vs. $872, P=0.056), so did patients with good functional outcome (median, 5 vs. 9 days, P<0.001; US$639 vs. $1,050, P<0.001). In multivariable models, age (odds ratio [OR] = 0.97 per year; 95% CI, 0.95 to 0.99) and initial BI (OR = 1.08 per point; 95% CI, 1.02 to 1.15) were significantly associated with neurological improvement, while age (OR = 0.97 per year; 95% CI, 0.95 to 1.00), initial NIHSS (OR = 0.86 per point; 95% CI, 0.77 to 0.95) and initial BI (OR = 1.22 per point, 95% CI 1.12 to 1.33) were significantly associated with good functional outcome. Conclusions - This study reported clinical outcomes and the extent of effectiveness of acute care for first-ever ischemic stroke. Chang KC, Tseng MC, Tan TY, YH, Liou CW (2005), Acute Hospitalization for First-Ever Ischemic Stroke What Are the Data for Outcome at Discharge? Background and purpose - Evaluating the potential utility of acute hospitalization after stroke is valuable, but difficult. We sought to explore the outcomes of first-ever ischemic stroke patients during acute hospitalization, in terms of changes of neurological deficits and functional status during the period. 3

5 Methods - Data of first-ever ischemic stroke patients were prospectively collected. Patients whose NIH Stroke Scale (NIHSS) score at discharge was 4 points less than at admission or was 0-1 were classified as neurologically improved, within 3 points of baseline was considered neurologically unchanged, and 4 additional points or death was rated as neurological worsened. Our primary analysis regarding functional outcome, measured by Barthel Index (BI), at discharge was based on three categories: good (BI 95), moderate (60-90), and poor (0-55 or dead). We also explored the extent of change in BI over the period of acute hospitalization. Results - There were 207 men and 153 women with mean age 64.9 ± 12.5 years. Mean score of the initial NIHSS was 9.4 ± 9.4 (median 6.0). Median score of the initial BI was 60. Median length of stay was 7 days (mean 11 ± 14). In-hospital death was 8%. Overall, 41.7% of patients improved on the NIHSS, 41.4% remained unchanged, and 17% worsened or died during acute hospitalization. Good functional outcome was seen in 35% patients, moderate in 26.9%, and poor in 30.3%. Patients admitted with severe stroke seldom had good or moderate functional outcome at discharge. Conclusions - Based on data from daily practice, our study provides a reference for recovery of acute care of ischemic stroke, and may offer the fundamental step of evaluating the effectiveness of acute hospitalization of stroke patients. (TIA) transient ischemic attack TIA TIA TIA TIA TIA Self-Evaluation of the study To the best of our knowledge, this was the first study in Taiwan to explore outcomes of acute care in patients with first-ever ischemic stroke. Our analysis therefore provides valuable information to healthcare decision-makers regarding clinical outcomes of acute hospitalization of first-ever ischemic stroke. However, a great many things in outcomes and effectiveness research of stroke remain to be done so as to guide multiple healthcare stakeholders to properly respond to the escalation of healthcare costs related to stroke and 4

6 other diseases. References 1. Adams HP Jr, Davis PH, Leira EC, Chang KC, Bendixen BH, Clarke WR, Woolson RF, Hansen MD. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: a report of the Trial of Org in Acute Stroke Treatment (TOAST). Neurology 1999;53: Adams HP Jr, Leclerc JR, Bluhmki E, Clarke W, Hansen MD, Hacke W. Measuring Outcomes as a Function of Baseline Severity of Ischemic Stroke. Cerebrovasc Dis. 2004;18: Adams HP Jr. Emergent use of anticoagulation for treatment of patients with ischemic stroke. Stroke. 2002;33: Appelros P, Nydevik I, Viitanen M. Poor outcome after first-ever stroke: predictors for death, dependency, and recurrent stroke within the first year. Stroke. 2003;34: Bereczki D, Liu M, Prado GF, Fekete I. Cochrane report: a systematic review of mannitol therapy for acute ischemic stroke and cerebral parenchymal hemorrhage. Stroke 2000;31: Bereczki D, Mihalka L, Szatmari S, Fekete K, Di Cesar D, Fulesdi B, Csiba L, Fekete I. Mannitol use in acute stroke: case fatality at 30 days and 1 year. Stroke 2003;34: Bhalla A, Dundas R, Rudd AG, Wolfe CD. Does admission to hospital improve the outcome for stroke patients? Age Ageing. 2001;30: Cavallini A, Micieli G, Marcheselli S, Quaglini S. Role of monitoring in management of acute ischemic stroke patients. Stroke. 2003;34: Chang KC, Tseng MC, Weng HH, Lin YH, Liou CW, Tan TY. Prediction of length of stay of first-ever ischemic stroke. Stroke 2002;33: Chang KC, Tseng MC. Costs of acute care of first-ever ischemic stroke in Taiwan. Stroke. 2003;34:e219-e DeGraba TJ, Hallenbeck JM, Pettigrew KD, Dutka AJ, Kelly BJ. Progression in acute stroke: value of the initial NIH stroke scale score on patient stratification in future trials. Stroke 1999;30: Evans A, Perez I, Harraf F, Melbourn A, Steadman J, Donaldson N, Kalra L. Can differences in management processes explain different outcomes between stroke unit and stroke-team care? Lancet. 2001;358: Faxon DP, Schwamm LH, Pasternak RC, Peterson ED, McNeil BJ, Bufalino V, Yancy CW, Brass LM, Baker DW, Bonow RO, Smaha LA, Jones DW, Smith SC Jr, Ellrodt G, Allen J, Schwartz SJ, Fonarow G, Duncan P, Horton K, Smith R, Stranne S, Shine K, American Heart Association's Expert Panel on Disease Management. Improving quality 5

7 of care through disease management: principles and recommendations from the American Heart Association's Expert Panel on Disease Management. Stroke. 2004;35: Goldstein LB, Matchar DB, Hoff-Lindquist J, Samsa GP, Horner RD. VA Stroke Study: neurologist care is associated with increased testing but improved outcomes. Neurology 2003;61: Gordon NF, Gulanick M, Costa F, Fletcher G, Franklin BA, Roth EJ, Shephard T. Physical activity and exercise recommendations for stroke survivors: an American Heart Association scientific statement from the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council. Stroke 2004;35: Hacke W, Bluhmki E, Steiner T, Tatlisumak T, Mahagne MH, Sacchetti ML, Meier D. Dichotomized efficacy end points and global end-point analysis applied to the ECASS intention-to-treat data set: post hoc analysis of ECASS I. Stroke 1998;29: Hacke W, Kaste M, Fieschi C, von Kummer R, Davalos A, Meier D, Larrue V, Bluhmki E, Davis S, Donnan G, Schneider D, Diez-Tejedor E, Trouillas P. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet 1998;352: Jorgensen HS, Reith J, Nakayama H, Kammersgaard LP, Raaschou HO, Olsen TS. What determines good recovery in patients with the most severe strokes? The Copenhagen Stroke Study. Stroke 1999;30: Kalra L, Evans A, Perez I, Knapp M, Donaldson N, Swift CG. Alternative strategies for stroke care: a prospective randomised controlled trial. Lancet 2000;356: Lees KR, Asplund K, Carolei A, Davis SM, Diener HC, Kaste M, Orgogozo JM, Whitehead J. Glycine antagonist (gavestinel) in neuroprotection (GAIN International) in patients with acute stroke: a randomised controlled trial. GAIN International Investigators. Lancet 2000;355: Leira EC, Chang KC, Davis PH, Clarke WR, Woolson RF, Hansen MD, Adams HP Jr. Can we predict early recurrence in acute stroke? Cerebrovasc Dis 2004;18: Micieli G, Cavallini A, Quaglini S; Guideline Application for Decision Making in Ischemic Stroke (GLADIS) Study Group. Guideline compliance improves stroke outcome: a preliminary study in 4 districts in the Italian region of Lombardia. Stroke 2002;33: Sandercock P, Gubitz G, Foley P, Counsell C. Antiplatelet therapy for acute ischaemic stroke. Cochrane Database Syst Rev 2003;(2):CD Sulter G, Steen C, De Keyser J. Use of the Barthel index and modified Rankin scale in acute stroke trials. Stroke 1999;30:

8 25. Tei H, Uchiyama S, Ohara K, Kobayashi M, Uchiyama Y, Fukuzawa M. Deteriorating ischemic stroke in 4 clinical categories classified by the Oxfordshire Community Stroke Project. Stroke 2000;31: The National Institute of Neurologicalal Disorders and Stroke rt-pa Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333: The Publications Committee for the Trial of ORG in Acute Stroke Treatment (TOAST) Investigators. Low molecular weight heparinoid, ORG (danaparoid), and outcome after acute ischemic stroke: a randomized controlled trial. JAMA 1998;279: Weimar C, Kurth T, Kraywinkel K, Wagner M, Busse O, Haberl RL, Diener HC, German Stroke Data Bank Collaborators. Assessment of functioning and disability after ischemic stroke. Stroke 2002;33: Young FB, Lees KR, Weir CJ, for the Glycine Antagonist in Neuroprotection International Trial Steering Committee and Investigators. Strengthening acute stroke trials through optimal use of disability end points. Stroke 2003;34:

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