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和主要单一残疾原因。估计2008年中风的直接和间接费用约为650亿美元。从先前的研究中得知，早期识别和治疗可降低与中风相关的发病率和成本。静脉注射组织纤溶酶原激活剂（IV t-PA）溶栓仍然是症状发作3小时内出现的急性缺血性卒中的唯一经证实的治疗方法，无明确禁忌症。然而，还已知缺血性卒中患者中t-PA的使用率仅为2- 3%。大规模研究表明，溶栓率低是由于患者缺乏对卒中症状的认识，延迟获得紧急医疗服务（EMS）和院内延迟，如缺乏快速分诊。因此，科学上众所周知，需要多学科方法来提高合格急性卒中患者中t-PA的使用率。除了提高社区对早期卒中识别的认识外，脑卒中联盟（BAC）还决定建立两个级别的卒中护理，即初级和综合卒中中心，以改善卒中的急诊和其他类型的临床护理。随着认证的初级中风中心的建立和初级中风中心护理质量提高的证据，县当局和EMS机构制定了政策，绕过最近的急诊室，将中风患者运送到初级中风中心。虽然多个县正在采用这一变化，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，关于院前提供者卒中识别准确性的研究表明，卒中识别有相当大的改进空间。为了解决这些问题，我建议进行一项研究，主要目标是研究区域化和非区域化卒中系统中患者结局的比较。次要目标是评估区域化护理的成本效益和系统区域化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.