Impact on Clinical and Cost Outcomes of a Centralized Approach to Acute Stroke Care in London: A Comparative Effectiveness Before and After Model

被引：64

作者：

Hunter, Rachael Maree ^{[1
]}

Davie, Charles ^{[2
]}

Rudd, Anthony ^{[3
,4
]}

Thompson, Alan ^{[5
]}

Walker, Hilary ^{[6
]}

Thomson, Neil ^{[7
]}

Mountford, James ^{[8
]}

Schwamm, Lee ^{[9
]}

Deanfield, John ^{[10
]}

Thompson, Kerry ^{[2
]}

Dewan, Bikash ^{[2
]}

Mistry, Minesh ^{[11
]}

Quoraishi, Sadik ^{[11
]}

Morris, Stephen ^{[12
]}

机构：

[1] UCL, Res Dept Primary Care & Populat Hlth, London, England

[2] Royal Free London NHS Fdn Trust, Dept Clin Neurosci, London, England

[3] Kings Coll London, Div Hlth & Social Care Res, London, England

[4] Guys & St Thomas NHS Fdn Trust, Natl Inst Hlth Res, Comprehens Biomed Res Ctr, London, England

[5] UCL, Inst Neurol, London, England

[6] North Cent London CardioVasc & Stroke Network, London, England

[7] London Ambulance Serv NHS Trust, London, England

[8] UCLPartners, London, England

[9] Massachusetts Gen Hosp, Dept Neurol, Boston, MA 02114 USA

[10] UCL, Ctr Cardiovasc Prevent & Outcomes, London, England

[11] UCL, UCL Med Sch, London, England

[12] UCL, Dept Appl Hlth Res, London, England

来源：

PLOS ONE | 2013年 / 8卷 / 08期

关键词：

D O I：

10.1371/journal.pone.0070420

中图分类号：

O [数理科学和化学]; P [天文学、地球科学]; Q [生物科学]; N [自然科学总论];

学科分类号：

07 ; 0710 ; 09 ;

摘要：

Background: In July 2010 a new multiple hub-and-spoke model for acute stroke care was implemented across the whole of London, UK, with continuous specialist care during the first 72 hours provided at 8 hyper-acute stroke units (HASUs) compared to the previous model of 30 local hospitals receiving acute stroke patients. We investigated differences in clinical outcomes and costs between the new and old models. Methods: We compared outcomes and costs 'before' (July 2007-July 2008) vs. 'after' (July 2010-June 2011) the introduction of the new model, adjusted for patient characteristics and national time trends in mortality and length of stay. We constructed 90-day and 10-year decision analytic models using data from population based stroke registers, audits and published sources. Mortality and length of stay were modelled using survival analysis. Findings: In a pooled sample of 307 patients 'before' and 3156 patients 'after', survival improved in the 'after' period (age adjusted hazard ratio 0.54; 95% CI 0.41-0.72). The predicted survival rates at 90 days in the deterministic model adjusted for national trends were 87.2% 'before' % (95% CI 86.7%-87.7%) and 88.7% 'after' (95% CI 88.6%-88.8%); a relative reduction in deaths of 12% (95% CI 8%-16%). Based on a cohort of 6,438 stroke patients, the model produces a total cost saving of 5.2 pound million per year at 90 days (95% CI 4.9- pound 5.5 pound million; 811 pound per patient). Conclusion: A centralized model for acute stroke care across an entire metropolitan city appears to have reduced mortality for a reduced cost per patient, predominately as a result of reduced hospital length of stay.

引用

页数：9