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The impact of organizational and temporal factors on acute stroke care in Sweden
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.ORCID iD: 0000-0002-5917-0384
2020 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Acute stroke carries a high risk of morbidity and death, but early treatment can improve outcomes. Intravenous stroke thrombolysis (IVT) is one such treatment, it is however time-sensitive and show better outcomes the sooner it is given. Most studies on time to IVT so far have looked at fixed time-intervals, and studies of short delays in clinical practice are relatively scarce. Another well-established treatment is managing acute stroke patients in stroke units (SU). Admission rates to a SU as first destination of hospital care have improved over time in Sweden. In the past decade however, the rates have leveled out at around 75-80% without further improvement. A hypothesis is that in-hospital overcrowding contributes. Previous studies have shown that outcomes after stroke differ between hospital types, and also vary depending on time of admission, with higher mortality seen for off-hours, weekend and winter admissions. The reasons behind temporal variations are not fully understood, but it has been proposed that environmental, patient-related and organizational factors contribute. The overall aim of this thesis was to study the effect of organizational factors on quality of care and outcomes after stroke, primarily focusing on the role of in-hospital overcrowding, in-hospital time to IVT and time of admission, while also studying differences between hospitals.

Methods: All papers in this thesis were based on data from the Swedish stroke register (Riksstroke), a national quality register that holds data on patient related factors, acute care and outcomes. Paper I included 13,955 patient admissions from 14 hospitals in Region Norrbotten and Region Skåne from 2011-2014, enriched with data on in-hospital bed occupancy. Papers II-IV included all 72 Swedish hospitals caring for patients with acute stroke. Paper II included data from 2011-2015 (N=113,862), paper III from 2011-2016 (N=132,744) and paper IV from 2010-2017 (N=14,132). Analyses included descriptive statistics, unadjusted analyses and multivariable adjusted analyses.

Results: We found that each percent increase in in-hospital bed occupancy above 85% decreased admission rates to a SU as first destination of hospital care by 1.5% (odds ratio (OR) 0.985, 95% confidence interval (CI) 0.978-0.992), with significant differences between hospitals. Admission rates were also lower off-hours, compared to on-hours (OR 0.73, 95% CI 0.70-0.75). Over time, admission rates to a SU as first destination of hospital care decreased in university hospitals, while they increased in specialized non-university hospitals and community hospitals. Each minute delay in door-to-needle time (DNT) decreased the odds of 90-day survival by 0.6% (OR 0.994, 95% CI 0.992-0.996), increased the odds of ICH within 36 hours by 0.3% (OR 1.003, 95% CI 1.000-1.006), and led to significantly higher odds of a worsening in functional outcomes at 3 months by 0.3-0.4%. DNT within 30 minutes was most likely daytime, and varied between hospital types. 90-day survival was lowest for patients admitted in January (81.5%), and highest for those admitted in May (84.1%) (OR 1.28, 95% CI 1.17-1.40).

Conclusion: We found that in-hospital overcrowding decrease admission rates to a SU as first destination of hospital care, and that even short delays in DNT decreases survival, increases ICH complications and leads to a worsening in functional outcomes in routine clinical practice. We also found that quality of care varied depending on time of admission and between hospitals, indicating unequal care. Organizational differences should be accessible through quality improvement efforts aiming to implement robust local guidelines for in-hospital stroke treatment.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2020. , p. 60
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2073
Keywords [en]
in-hospital bed occupancy, stroke unit, The Swedish Stroke Register, organizational factors, temporal variation, stroke thrombolysis, door-to-needle time, quality of care, outcomes
National Category
Other Clinical Medicine
Research subject
Medicine
Identifiers
URN: urn:nbn:se:umu:diva-168619ISBN: 978-91-7855-213-9 (print)ISBN: 978-91-7855-214-6 (electronic)OAI: oai:DiVA.org:umu-168619DiVA, id: diva2:1411292
Public defence
2020-04-03, Hörsal B, Unod T9, Norrlands Universitetssjukhus, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2020-03-13 Created: 2020-03-03 Last updated: 2020-03-27Bibliographically approved
List of papers
1. Patients with acute stroke are less likely to be admitted directly to a stroke unit when hospital beds are scarce: a Swedish multicenter register study
Open this publication in new window or tab >>Patients with acute stroke are less likely to be admitted directly to a stroke unit when hospital beds are scarce: a Swedish multicenter register study
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2017 (English)In: European Stroke Journal, ISSN 2396-9873, E-ISSN 2396-9881, Vol. 2, no 2, p. 178-186Article in journal (Refereed) Published
Abstract [en]

Introduction: It is well established that managing patients with acute stroke in dedicated stroke units is associated with improved functioning and survival. The objectives of this study are to investigate whether patients with acute stroke are less likely to be directly admitted to a stroke unit from the Emergency Department when hospital beds are scarce and to measure variation across hospitals in terms of this outcome.

Patients and methods: This register study comprised data on patients with acute stroke admitted to 14 out of 72 Swedish hospitals in 2011-2014. Data from the Swedish stroke register were linked to administrative daily data on hospital bed occupancy (measured at 6 a.m.). Logistic regression analysis was used to analyse the association between bed occupancy and direct stroke unit admission.

Results: A total of 13,955 hospital admissions were included; 79.6% were directly admitted to a stroke unit from the Emergency Department. Each percentage increase in hospital bed occupancy was associated with a 1.5% decrease in odds of direct admission to a stroke unit (odds ratio = 0.985, 95% confidence interval = 0.978-0.992). The best-performing hospital exhibited an odds ratio of 3.8 (95% confidence interval = 2.6-5.5) for direct admission to a stroke unit versus the reference hospital.

Discussion and conclusion: We found an association between hospital crowding and reduced quality of care in acute stroke, portrayed by a lower likelihood of patients being directly admitted to a stroke unit from the Emergency Department. The magnitude of the effect varied considerably across hospitals.

Place, publisher, year, edition, pages
Sage Publications, 2017
Keywords
Stroke, stroke unit, hospital bed occupancy, hospital admission, stroke care, emergency care, emergency department, bed crisis, The Swedish stroke register
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-153857 (URN)10.1177/2396987317698328 (DOI)000446624400010 ()
Funder
Norrbotten County Council
Available from: 2018-12-05 Created: 2018-12-05 Last updated: 2020-03-03Bibliographically approved
2. Diurnal variations in the quality of stroke care in Sweden
Open this publication in new window or tab >>Diurnal variations in the quality of stroke care in Sweden
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2019 (English)In: Acta Neurologica Scandinavica, ISSN 0001-6314, E-ISSN 1600-0404, Vol. 140, no 2, p. 123-130Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: A recent study of acute stroke patients in England and Wales revealed several patterns of temporal variation in quality of care. We hypothesized that similar patterns would be present in Sweden and aimed to describe these patterns. Additionally, we aimed to investigate whether hospital type conferred resilience against temporal variation.

MATERIALS & METHODS: We conducted this nationwide registry-based study using data from the Swedish Stroke Register (Riksstroke) including all adult patients registered with acute stroke between 2011 and 2015. Outcomes included process measures and survival. We modeled time of presentation as on/off hours, shifts, day of week, 4h and 12 h time blocks. We studied hospital resilience by comparing outcomes across hospital types.

RESULTS: 113862 stroke events in 72 hospitals were included. The process indicators and survival all showed significant temporal variation. Door-to-needle (DTN) time within 30 minutes was less likely during nighttime than daytime (OR 0.50; 95% CI 0.41-0.60). Patients admitted during off-hours had lower odds of direct stroke unit (SU) admission (OR 0.72; 95% CI 0.70-0.75). 30-day survival was lower in nighttime versus daytime presentations (OR 0.90, 95% CI 0.84-0.96). The effects of temporal variation differed significantly between hospital types for DTN time within 30 minutes and direct SU admission where university hospitals were more resilient than specialized non-university hospitals.

CONCLUSIONS: Our study shows that variation in quality of care and survival is present throughout the whole week. We also found that university hospitals were more resilient to temporal variation than specialized non-university hospitals.

Place, publisher, year, edition, pages
John Wiley & Sons, 2019
Keywords
Off hours, Quality of care, Stroke, Temporal variation, Weekend effect, Weekly variation
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-158646 (URN)10.1111/ane.13112 (DOI)000474934000006 ()31046131 (PubMedID)
Available from: 2019-05-06 Created: 2019-05-06 Last updated: 2020-03-03Bibliographically approved
3. Time Trends and Monthly Variation in Swedish Acute Stroke Care
Open this publication in new window or tab >>Time Trends and Monthly Variation in Swedish Acute Stroke Care
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2019 (English)In: Frontiers in Neurology, ISSN 1664-2295, E-ISSN 1664-2295, Vol. 10, article id 1177Article in journal (Refereed) Published
Abstract [en]

Background and Purpose: Studies of monthly variation in acute stroke care have led to conflicting results. Our objective was to study monthly variation and longitudinal trends in quality of care and patient survival following acute stroke.

Methods: Our nationwide study included all adult patients (≥18 years) with acute stroke (ischemic or hemorrhagic), admitted to Swedish hospitals from 2011 to 2016, and that were registered in The Swedish Stroke Register (Riksstroke). We studied how month of admission and longitudinal trends affected acute stroke care and survival. We also studied resilience to this variation among hospitals with different levels of specialization.

Results: We included 132,744 stroke admissions. The 90-day survival was highest in May and lowest in January (84.1 vs. 81.5%). Thrombolysis rates and door-to-needle time within 30 min increased from 2011 to 2016 (respectively, 7.3 vs. 12.8% and 7.7 vs. 28.7%). Admission to a stroke unit as first destination of hospital care was lowest in January and highest in June (78.3 vs. 80.5%). Stroke unit admission rates decreased in university hospitals from 2011 to 2016 (83.4 vs. 73.9%), while no such trend were observed in less specialized hospitals. All the differences above remained significant (p < 0.05) after adjustment for possible confounding factors.

Conclusion: We found that month of admission and longitudinal trends both affect quality of care and survival of stroke patients in Sweden, and that the effects differ between hospital types. The observed variation suggests an opportunity to improve stroke care in Sweden. Future studies ought to focus on identifying the specific factors driving this variation, for subsequent targeting by quality improvement efforts.

Place, publisher, year, edition, pages
Frontiers Media S.A., 2019
Keywords
longitudinal trends, monthly variation, quality of care, stroke, survival
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-166707 (URN)10.3389/fneur.2019.01177 (DOI)000498557000001 ()31787926 (PubMedID)
Funder
Norrbotten County CouncilSwedish Heart Lung FoundationVisare Norr
Available from: 2019-12-20 Created: 2019-12-20 Last updated: 2020-03-03Bibliographically approved
4. In-hospital delays in stroke thrombolysis - Every minute counts
Open this publication in new window or tab >>In-hospital delays in stroke thrombolysis - Every minute counts
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(English)Manuscript (preprint) (Other academic)
National Category
Clinical Medicine
Identifiers
urn:nbn:se:umu:diva-168612 (URN)
Available from: 2020-03-03 Created: 2020-03-03 Last updated: 2020-03-05

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