Impact of Regionalization of Care in Acute Stroke Patients

描述（由申请人提供）：中风是美国第三大死亡原因，也是导致残疾的主要原因。2008年中风的直接和间接费用估计约为650亿美元。从先前的研究中可以得知，早期识别和治疗可以降低与中风相关的发病率和费用。静脉溶栓组织型纤溶酶原激活剂（IV t-PA）仍然是唯一被证实的治疗急性缺血性卒中症状出现3小时内无明确禁忌症的治疗方法。然而，我们也知道，t-PA在缺血性脑卒中患者中的使用率仅为2-3%。大规模研究表明，低溶栓率是由于患者缺乏对中风症状的认识，获得紧急医疗服务（EMS）的延误以及缺乏快速分诊等院内延误。因此，科学上众所周知，需要多学科的方法来提高符合条件的急性脑卒中患者t-PA的使用率。除了提高社区对早期中风识别的认识外，脑攻击联盟（BAC）还决定创建两个级别的中风护理，即初级和综合中风中心，以改善中风的急诊和其他类型的临床护理。随着经过认证的初级卒中中心的建立和初级卒中中心护理质量改善的证据，县当局和EMS机构制定了绕过最近的急诊科并将卒中患者运送到初级卒中中心的政策。虽然多个国家正在采取这一改变，但政策变化对区域患者结局的影响尚未通过科学证据确定。此外，院前提供者对卒中识别准确性的研究表明，卒中识别还有相当大的改进空间。为了解决这些问题，我建议开展一项研究，其主要目标是研究区域化和非区域化卒中系统中患者预后的比较。次要目标将是评估区域化护理的成本效益和区域化系统前后院前卒中识别的准确性。

DESCRIPTION (provided by applicant): Stroke is the third leading cause of death and leading single cause of disability in the United States. The estimated direct and indirect costs of stroke for 2008 are about $65 billion. It is known from prior research that early recognition and treatment reduces the morbidity and costs associated with stroke. Thrombolysis with intravenous tissue plasminogen activator (IV t-PA) remains the only proven treatment for acute ischemic stroke who present within three hours of symptom onset with no established contraindication. However, it is also known that the rate of t-PA use in ischemic stroke patients is only 2-3%. Large scale studies have shown that poor rates of thrombolysis are due to lack of patient recognition of stroke symptoms, delay in accessing Emergency Medical Services (EMS) and in-hospital delays like lack of expedited triage. Therefore, it is well known scientifically that a multi-disciplinary approach is necessary to improve the rate of t-PA use in eligible acute stroke patients. In addition to improving knowledge on early stroke recognition in the community, the Brain Attack Coalition (BAC) determined that two levels of stroke care i.e. primary and comprehensive stroke centers be created to improve emergency and other types of clinical care for stroke. With establishment of certified primary stroke centers and evidence for improved quality of care at primary stroke centers, county authorities and EMS agencies created policies to bypass the nearest emergency department and transport stroke patients to primary stroke centers. Although multiple counties are adopting the change, the impact of the policy change on regional patient outcomes has not yet been established through scientific evidence. In addition, studies on accuracy of stroke recognition by prehospital providers have shown that there is considerable scope for improvement in stroke recognition. To address these issues, I propose to conduct a study with the primary goal of studying comparative patient outcomes in regionalized and non-regionalized stroke systems. The secondary goals will be to assess the cost-effectiveness of regionalized care and accuracy of prehospital stroke recognition before and after regionalization of systems.