w w w . e l s e v i e r . p t / r p s p
Original
Article
Program
“Via
verde
do
AVC”:
analysis
of
the
impact
on
stroke
mortality
Sara
Silva,
Miguel
Gouveia
∗CatolicaLisbonSchoolofBusinessandEconomics,Lisbon,Portugal
a
r
t
i
c
l
e
i
n
f
o
Articlehistory: Received18May2012 Accepted27December2012 Keywords: Stroke Mortalityrates Healthgains Intervention Effectiveness DRGa
b
s
t
r
a
c
t
Theprogram‘ViaverdedoAVC’hasbeenimplementedinPortugalsince2005,withthe objectiveofreducingmortalitybystroke.Mortalityratesfromstrokehavebeendecreasing, butnostudieshavebeendonemeasuringthelinkbetweenthistrendand‘Viaverdedo AVC’.
Thisstudyaimstoassesswhethertheprogramhasachievedsignificanthealthgains.We relyontwodatasources:individuallevelhospitaldataonischemicstrokeadmissionsand regionallevelstrokemortalityrates.
Forbothtypesofdatawefindnoevidencethat‘ViaverdedoAVC’hadastatistically significantimpactonischemicstrokemortality.
©2012EscolaNacionaldeSaúdePública.PublishedbyElsevierEspaña,S.L.Allrights reserved.
Programa
“Via
verde
do
AVC”:
análise
do
impacto
sobre
a
mortalidade
do
AVC
Palavras-chave:
Acidentevascularcerebral Taxasdemortalidade Ganhosdesaúde Intervenc¸ão Efetividade GDH
r
e
s
u
m
o
Oprograma“ViaverdedoAVC”foiimplementadoemPortugaldesde2005,comoobjetivo dereduziramortalidadeporAVC.AstaxasdemortalidadeporAVCtêmvindoadiminuir, masnenhumestudotentoumediraligac¸ãoentreestatendênciaea“ViaverdedoAVC”.
Esteestudopretendeuavaliarseoprogramaconseguiuganhossignificativosdesaúde. Contámoscom2fontesdedados:dadoshospitalaresanívelindividualdeinternamentos porAVCisquémicoetaxasregionaisdemortalidadeporAVC.
Paraambosostiposdedadosnãoencontrámosqualquerevidênciadea“Viaverdedo AVC”terumimpactoestatisticamentesignificativosobreamortalidadedoAVCisquémico. ©2012EscolaNacionaldeSaúdePública.PublicadoporElsevierEspaña,S.L.Todosos direitosreservados.
∗ Correspondingauthor.
E-mailaddress:[email protected](M.Gouveia).
0870-9025/$–seefrontmatter©2012EscolaNacionaldeSaúdePública.PublishedbyElsevierEspaña,S.L.Allrightsreserved. http://dx.doi.org/10.1016/j.rpsp.2012.12.005
Introduction
Stroke
AsdefinedbyWHO,strokeisacerebrovasculardisease(CVD) “causedbytheinterruptionofthebloodsupplytothebrain, usuallybecauseabloodvesselbursts[hemorrhagicstroke]or isblockedbyaclot[ischemicstroke].”1
Thereare 15 million people sufferingfrom stroke every year–atrendthatisexpectedtoholdinthefuture.Ofthose, 5.5milliondieandother5millionareleftpermanently dis-able.ItisthethirdcausethedeathintheWorld(10%),only exceededbycoronaryheartdisease(13%)andcancer(12%).2
Vascular diseases are the number one cause of death also in Portugal. They are responsible for almost 40% of mortality,3 and ofthose, approximately 45% are caused by
stroke.In2004,thestandardizedmortalitybystrokewas97.6/ 100.000inhabitants,withlargeregionalasymmetries.4
Despitethe effortsdevoted tothe developmentofmore effectivedrugs,5intravenousrt-PA(recombinanttissue
plas-minogenactivator)istheonlyapprovedtreatmentforstroke; itisonlyeffectiveforacuteischemia–responsibleforabout 80%ofthetotalstrokeepisodes,andcanonlybeusedwithin 3hafterthebeginningofsymptoms.
Forthisreason– andgiventhefactthatupto70%of mortal-itybystrokeoccursbeforearrivaltothehospital,6theNational
HealthPlanandtheNationalProgramforPreventionand Con-trol of CVD havedefined specific strategies and targets to reduceboththestandardizedmortalityrate,inparticularfor peoplebelow65yearsold,andin-hospitalmortalitybystroke.4
Inordertoachievethesetargets,theprogram‘Viaverdedo AVC’hasbeenimplementedacrossthecountrysince2005and theentireprocessfollowedbypatientswasredesigned.
Theprocessisinitiatedbyaphonecalltotheemergency number(112)andredirectedtoalocalandspecializedcall cen-ter(CODU)thatcoordinatestheoperationsuntilthearrivalof thepatienttothehospital(Pre-hospitalStage).Whenarrived atthehospital,abatteryofexamsaredone,inorderto cer-tifythatthepatientfulfillsallthemedicalrequirementsfor rt-PAadministration(In-hospitalStage).For thosewho sur-vivebutarenotfullyrecoveredfromthestrokeepisode,there isanetofrehabilitationservices,intendedtoprovide assis-tancetothepatientsafterthein-hospitalperiod(Post-hospital Stage/Rehabilitation).Forfurtherdetails,seethereportsfrom the “Coordenac¸ão Nacional para as Doenc¸as Cardiovascu-lares”.Viaverde appliesonlytopatients18or olderandup to80yearsold.
Strokeprogramsworldwide
Inresponsetoprogramsaimedatreducingbloodpressureand smoking,theincidenceofstrokeindevelopedcountrieshas beendecliningintherecentyears.7Nevertheless,theoverall
ratesarestillhigh,andmanycountries(suchasUSA, Den-mark,SpainandNetherlands)havealreadyintroducedstroke programsspecificallytargetedtostrokepatients.
Investments have been made in educational programs toincreaseawarenessofprocedures forinitialassessment, acutetreatment,andtransportofpotentialstrokepatients.8
Intra-hospitalchangeshavealsobeenintroducedduringthe lastdecade,aimedtoreducedelaysinmedicalresponse.9,10
Organizational changes in both pre- and intra-hospital stagesasdoneinSpain,analyzedthroughtime,have trans-lated notonlyinmorepatientstreatedwithrt-PA,butalso inasignificantlylargerpercentageofpatientswho achieve functionalindependenceafter3months.11
Another important aspect is the post-hospital stage of stroke, as rehabilitation can also deliver significant health gains for stroke patients – shorter admission times,greaterindependence,improvementinqualityoflife andgreaterprobabilityofhomedischargeinsteadoflong-tem care.12
Moreover, cost-effectiveness studies carried out in the USA,13Spain,14andinNetherlands15showthatthese
orga-nizationalchangesinstrokeassistancehavetranslatedinto costsavings,whilegeneratinghealthgains.
Inshort,whenproperlyplannedandimplemented,itcan besaidthatorganizationalchangecanfacilitateandsupport scientificadvances,achievingbothhealthgainsandcost sav-ings.Inthissense,thisworkaimstoassesswhetherthe“Via verdedoAVC”(VV-AVC)programinPortugalhasachieved sig-nificanthealthgainsand,ifnot,whatmightbethereasons forsuchresult.
Data
collection
and
methodology
Theanalysiswasperformedbystudyingindividuallevel in-patienthospitaldataonstrokeadmissionsandbystudying regionallevelstrokemortalityrates,inordertosearchfora linkbetweentheexistenceofViaverdeand areductionin strokemortality.
Intheanalysisofin-hospitalmortalityeachobservation correspondstoasinglestrokeepisode,andonlytheepisodes treatedinanhospitalareconsidered,whiletheregional analy-sisisbasedonregionallyaggregateddata,takingintoaccount all the cases in which stroke was stated as the cause of death. Moreover,inthe firstapproachthe clinical outcome issurvivalordeathofstroke patients,whileinthesecond analysistheoutcomevariableisthestrokemortalityrateper 100.000inhabitants.
Inbothcasesthemethodologyusedwillbethe differences-in-differencesapproach.Thisapproachisusedoftenand it ensures that the resultsare valideven ifother factorsare changingmortalityrates overtime. Anexampleofthe use ofdifferencesindifferencesinEconomicscanbeseeninthe workofMeyer.16ThebasicideaisillustratedinFig.1,where
theapproachfiltersoutother changesfromtheanalysisby lookingathowchangesovertimedifferbetweenareasand yearswhereVV-AVCwasinitiatedandareasandyears with-out VV-AVC.Alimitationoftheanalysisisthatit assumes changesovertimewouldbesimilarforbothtypesofareasif therewerenoVV-AVC.
In-hospitalmortality
Clinical informationonstroke patientsforin-hospital mor-talitythisanalysisconsidersonlyHealthRegionsNorthand Algarve, sincethesewere the onlyregions withconsistent
Stroke mortality rate Differences before VV Impact=differences of differences Differences after VV Time Hospital starting VV-AVC between 2004 and 2009 Hospitals not starting VV-AVC
Fig.1–How“differences-in-differences”works.
dataavailableontheVV-AVCstartingdates.Itwascollected fromtheannualDRGdatabases(knownasGDHinPortugal). Dataonthestartingdateoftheprogramineachofthe rele-vanthospitalswerecollectedfromofficialreportsandpress releasespublishedbyARSNorteandAlgarve.Basedonthe opinionofmedicalexperts,therelevantepisodesselectedhad afirstdiagnosis(ICD9CM)withcodes433or434–ischemic stroke,whichare the program’s target.These criteria have been usedpreviouslyin publishedwork.17,18 SinceVV-AVC
startedin2005,and theanalysisrequires datafrom before andaftertheprogram’sintroductionineachhospital(aswell asdatafromhospitalswithoutVV-AVC),thetimeframe con-sideredwasfrom2004to2009.ForotherHealthRegionswe werenotabletofindacomprehensivelistwiththestarting datesofVV-AVCbyhospital.
The criteria specified earlier lead to a selection of 28.837episodes.Thisdatawereanalyzedbylogisticregression performedwithSTATA10.Thehospitalsconsideredandthe VV-AVCstartingdatesaredescribedinTable1.The explana-toryvariablesusedcanbeseeninTable2.
Tocapturethe effectsofVV-AVCalternative approaches werefollowed:
◦ Basecase–asingledummyvariable(VV)isusedtoaccount fortheexistenceoftheprogram.
◦ Breakdownoftheimpactbyyear–Thisapproachismeant tocapturetheeffectofVV-AVCinaspecificyear.Themore peopleareaware,proneandabletousetheprogram,the greater the overall impact it can attain. However, since this process ofchange isgenerallyslow, it ispredictable that,astimepasses,theprogramenlargesitscoverageand, consequently,theaverageimpactonthetargetpopulation increases.
◦ Breakdownoftheimpactbyexpertise–itcapturestheeffect ofexpertiseacquiredwiththepracticeinViaverdedoAVC. Itisexpectedthat,thelongertheexistenceoftheprogram, the better the system performs, which ultimately trans-latesintoagreaterimpactonclinicaloutcomes.Foragiven hospitalasetofdummyvariablescapturethefirstyearof VV-AVCinthathospital,thesecondyear,andsoforth.All dummyvariablessettozeromeanthatahospitalneverhad VV-AVC.
Asimilaranalysiswasalsoperformed,limitingthe sam-ple to 9.014 ischemic stroke episodes ofpatients with age higher than 18 and lower than 65 years old (which is the rangedefinedbytheNationalHealthPlanastheprioritytarget group),insteadofarangefrom18to80(whichisthemaximum rangeforclinicalintervention).
Regionalmortality
This analysis islimited to subregions inthe North Health Region(consideringtheHospitalsmentionedinTable1,except H.Faro andH.Portimão,alsodue todatalimitations).The NorthhealthRegionwasdividedinto24subregionswith aver-agepopulationof152.319(in2001),asdetailedinTable3.The dataconcerningstrokemortality(standardizedmortalityrate – SMR)bysubregion,year,genderandagegroupweremade availablebyARSNorte(theprimarysourceofdatabeingINE). Itwasnotpossibletolimittheanalysistotheprogram’s tar-getpopulationsoalldeathsbycerebrovasculardiseases,for allages,wereincluded.
Dataonpopulationbyregionthroughtimewerecollected fromINEdatabases.Theinformationpreviouslycollected con-cerningthestartingdateofVV-AVCineachhospitalwasalso usedforthisanalysis.Thetimeframeconsideredwasfrom 2001to2009.Regressionanalysiswith216observationswas
Table1–HospitalsunderanalysisandVV-AVCstartingdates.
Hospital Startingdate Hospital Startingdate
H.S.Gonc¸alo – H.S.João 15-11-2005
H.GeralSto.António 15-11-2005 U.H.Lamego –
H.Sta.MariaMaior – U.H.MacedodeCavaleiros –
U.H.Braganc¸a 19-01-2009 H.PedroHispano 01-09-2008
H.S.Marcos 05-02-2007 U.H.Mirandela –
U.H.Chaves – H.SãoMiguel –
U.H.Fafe – H.S.PedrodeVilaReal 03-03-2007
U.H.Famalicão – U.H.Sto.Tirso –
H.S.Sebastião 15-11-2005 H.Pe.Américo,V.Sousa 22-06-2009
H.EduardoSantosSilva 03-03-2008 H.N.Sra.daConceic¸ãodoValongo –
U.H.Guimarães 01-04-2009 U.H.PóvoadoVarzim –
IPOPorto – H.Sta.LuziadeVianadoCastelo 01-09-2009
Table2–Variablesofin-hospitalanalysis.
Mortality Dependentvariable.Dummyvariable,referringthefinaloutcome:‘Dead’(1)or‘Alive’(0) Age Numericalvariable,expressingtheageofthepatient
Gender Dummyvariable:male(0)orfemale(1)
No.ofdiagnoses Numericalvariablecountingthenumberofdiagnoses.Itrangesfrom1(onlystrokediagnosis)upto20(strokeand19 otherdiagnoses)
Hospital Dummyvariables,indicatingthehospitalinwhichthepatientwastreated Year Dummyvariables,indicatingtheyearinwhichtheepisodeoccurred
VV Variabletomeasuretheprograms’impactinthebase-case.Dummyvariable,referringtheexistenceofVV-AVC.Value ‘1represents‘ExistenceofVV-AVC’(ent1>=dateofbeginningoftheprograminaspecifiedhospital),andvalue‘0’ represents‘NonExistenceofVV-AVC’(remainingcases)
VV Yk Dummyvariablesareconstructedtomeasuretheprograms’breakdownimpactbyyear.Dummyvariables(5),referto theexistenceofVV-AVCinagivenyear.VVYkequals“1”fortheobservationsthatoccurredintheyeark[k
Є
(2005; 2009)],inanhospitalwithVVAVC,and0otherwise.VV kYExpert Variablestomeasuretheprograms’breakdownimpactbyexpertise.Dummyvariables(5),referringthelongevityofthe programineachhospital.VVkYExpertequals“1”fortheobservationsthatoccurredwithinthekth[k
Є
{1;5}]yearof theprograminthespecifichospital,and0otherwiseTable3–Subregionsunderanalysis,population(in2001)andHospitalsbysubregion.
Subregion Population(‘01) Hospital Subregion Population(‘01) Hospital
AltoMinho 247.862 Viana Gaia/Espinho 319.905 V.N.Gaia
Gerês/Cabreira 110.058 Braga Gondomar 163.109 Sto.António
Barcelos/Esposende 154.233 Barcelos Valongo 85.417 Valongo
Braga 163.153 Braga ValeSousaNorte 154.250 ValeSousa
TerrasBasto 78.506 Guimarães ValeSousaSul 171.156 ValeSousa
Guimarães/Vizela 180.858 Guimarães Feira/Arouca 159.073 S.M.Feira
SantoTirso/Trofa 108.932 Sto.Tirso AveiroNorte 115.595 S.M.Feira
Famalicão 126.675 Famalicão BaixoTâmega 187.875 ValeSousa
Póvoa/Conde 136.838 P.Varzim DouroSul 79.242 Lamego
Maia 119.939 S.João MarãoeDouroNorte 131.538 VilaReal
Matosinhos 165.583 Matosinhos AltoTâmegaeBarroso 81.451 Chaves
Porto 258.804 S.João+Sto.António Nordeste 155.614 Braganc¸a
performedwithSTATA10,usingmultiplelinearregressions,
intwodifferentapproaches:
• Simplelinearregression
• Linearregressionweightedbyregionalpopulation
Asforin-hospitaldata,asimilaranalysiswasperformed
forregionaldata,includingonlyepisodesbelow65yearsold.
ThevariablesincludedaredescribedinTable4.
Table4–VariablesintheRegionalAnalysis.
StandardMortalityRate Dependentvariable.Numericalvalue, referringthestandardmortalityratein agivenyearandregion
Region Dummyvariables,referringtheregion Year Dummyvariables,indicatingtheyear VV Variablemeanttocapturetheprograms’
impact.VVisequalto“1”for
observationsthatoccurredinayearand regioninwhichthereisVV-AVC.Forthe yearofimplementationoftheprogram inagivenhospital/region,VVequals“1” onlyifsuchimplementationoccurred beforeJune30(morethanhalfayear withVV-AVC)
Population Numericalvalue,expressingthe populationinagivenyearandregion.It isusedtoweighttheregression.
Results
Thein-patientsample
AfterselectingepisodesfromtheDRGdatabase,thedatawere
composedof51.603observations.Byexcludinghemorrhagic
strokethesamplesuffereda15%reduction.Moreover,when
data were restricted evenfurther, in order tocontainonly
thosecaseswhichmettheagecriteriaoftheprogram,only
28.837episodeswereeligibletotheactivationof“VV-AVC”–
whichrepresents56%ofthetotalnumberofstrokeepisodes
duringtheperiodof2004–2009(Fig.2).Intermsofage
distri-bution,thereisacleardominanceofepisodesinpatientswith agesbetween60and90yearsold,asshowninFig.3.
When genderisconsideredwithout agerestrictions,the incidenceofstrokeissimilarformenandwomen(Fig.4),and this characteristicholds over time.For stroke patients, the modalnumberofdiagnosesotherthanstrokeis3,andalmost 80%have5orlesssecondarydiagnosis(Fig.5).
Descriptivestatistics
Forthein-hospitalsample,asdescribedinTable5,mortality ratesofstrokepatientsagedbetween18and80arearound 8%,withastandarddeviationofapproximately3%.Interms ofpatientcharacterization,56%ofthemaremen,andtheir ageis67±10.Moreover,patientsarriveatthehospitalwith anaverageofabout5diagnoses.
Table5–Descriptivestatisticsofdata.
In-hospitalsample Regionalsample
Mortality Sex Age No.diagnostics SMR(simple) SMR(populationweighted)
Mean 0.081 0.436 67.28 5.26 100.04 99.27
Std.Dev 0.273 – 10.27 3.46 27.64 27.67
SMR– standardizedmortalityrate;sex=0(male)1(female);No.diagnostics–numberofdiagnosisforeachepisodeintheDRGdatabase.
Total 51,603 43,807 Number of episodes 28,842 Ischemic Age ]18;80[ 44% 15% 34%
Fig.2–Program’scoveragepotential.
When analyzing regional data, statistics show that the
standardmortalityrateintheNorthregionisapproximately
100/100.000inhabitants,but when theratio isweighted by
thepopulation,itdecreasesslightly–whichmeansthatthe
mortalityrateinthemostpopulatedsubregionsislowerthan
average.
Regressionanalysis
TheresultsoftheregressionsperformedcanbeseeninTable6.
Whenconsideringtheimpactoftheprogramonthebasecase (ischemicstrokepatientswithageabove18andbelow80years
100
Relative frequency, cum. (%)
80 60 40 20 0 10 20 30 40 50 60 70 80 90 100110120 Age 0
Fig.3– Sampledistributionbyage(cum%).
60 4951 49 51 50 50 Relative frequency, 2004-2009 (%) 50 50 51 49 50 50 40 20 0 2004 2005 2006 2007 2008 2009 M W
Fig.4–Sampledistributionbygender(%).
old)aswellastherestrictedgroup(agedbetween18and65), measuredbyasingleVVvariable,thereisnostatistical evi-denceofimpactofVV-AVConmortality.
Usingthebreakdownoftheinterventionvariableby exper-tise,aswellasthebreakdownbyyear,theresultsobtained showsimilarconclusions:thereisnostatisticallysignificant decreaseinmortalityofischemicstrokepatientscapturedin anyofthedummyvariables.
Ontheotherhand,theimpactofthenumberofdiagnoses and ageonmortalityishighlysignificantinall regressions
Relative frequency (%) 20 15 10 5 0 0 3 5 10 15 19 # Sec. diagnoses Cumulative relative frequency ≤ 5=80%
Fig.5–Sampledistributionbynumberofsecond diagnoses.
Table6–TheimpactofViaverdedoAVC:resultsofin-hospitalanalysis.
Scopeofanalysis Variable Coefficient p>|z| PseudoR2 Jointtestoffixedeffects
Ischemic]18;80[ VV No.ofdiagnosis Gender Age 0.099 0.091 0.087 0.042 0.209 0.000 0.049 0.000 4.09% hospid√ Prob>2=0.00 Year
∗
Prob>2=0.33 Ischemic]18;65[ VV 0.031 0.863 4.69% hospid√ Prob>2=0.00 Year∗
Prob>2=0.90BreakdownbyExpertise VV1YExpert VV2YExpert VV3YExpert VV 4YExpert VV 5YExpert 0.109 0.097 −0.003 −0.020 0.165 0.205 0.347 0.984 0.910 0.644 4.10% hospid√ Prob>2=0.00 Year
∗
Prob>2=0.45BreakdownbyYear VVY2005 VVY2006 VVY2007 VVY2008 VVY2009 0.573 0.016 0.202 0.129 −0.027 0.098 0.918 0.101 0.304 0.833 4.12% hospid√ Prob>2=0.00 Year
∗
Prob>2=0.42(althoughonlypresentedinthe base-case)–the largerthe
numberofdiagnosisortheolderthepatient,thehigherthe
probability ofdeath;gender varies betweenborderline
sig-nificant(p-value=0.049)andnon-significant,butalwayswith
apositivebias–whichtranslatesinahigherpropensityfor
womentodieincaseofstroke.
Inalloftheseapproaches,thevectorofhospitaldummies
arejointlysignificantly(p>2=0.00%),whilethereisno
statis-ticalevidencethattimehascontributedforashiftonstroke
mortality(p>2around40%forage]18;80[andhigherthan90%
forage]18;65[).
Ameasureoftheexplanatorypoweroftheseanalyses(the
pseudoR2)isaround4%.
Inconclusion,basedontheseanalyses,itisnotpossible
toconcludethattheprogramwasabletoimprovethehealth
statusofstrokepatientsthroughthedecreaseofin-hospital
mortality,even if the impact isbroken down bydegree of
expertiseoryearofobservation.
TheresultsoftheregionalanalysisareondisplayinTable7.
Accordingtotheresultsobtainedinbothapproaches(simple, andpopulation-weighted),bothforageupper-limitof80and 65,onceagain,thereisnostatisticalevidencethatthe exist-enceof‘VV-AVC’intheregionstranslatesintolowermortality forstrokepatients(p-valuesrangingfrom10%to30%).
On the other hand, there are large differences among regionsandthroughouttheyears,sincethejointtestsshow thattherespectivecoefficientsarestatisticallydifferentfrom zero(p>F=0.00%).
Program’slimitationsthatmightexplaintheresults obtained
Giventhefactthatnoneofthe analysisperformedshowed significanteffectivenessoftheprogramVV-AVCinreducing mortality,itisrelevanttofocusontheprogram’sdesignand implementationstrategy, inorderto betterunderstandthe possiblecausesthatarelimitingitssuccess.
Promotionandreach
Thetriggeroftheprocessisacalltotheemergencyservicesat theoccurrenceofastrokeepisode.Inthissense,informative
campaignstoincreasethepopulation’sawarenessarecritical forthesuccessoftheprogram.However,inPortugal,the pro-gramhasnotbeenheavilypromotedandmanypeoplemight bestillnotawareofitsexistence.
Indeed,whenconsideringtheNorthregion(theonewith thelargestadherencerates,basedonofficialreportsonthe topic,19andthroughtime,asmorehospitalsimplementthe
program,thepopulationcoveredincreasesdramaticallyfrom 25% toaround70% (“hospitalpotentialcoverage”,the ratio ofstrokepatientsinhospitalswithVV-AVCandtotalstroke patientsinhospitalsintheregion).However,thepercentageof patientswhoareactuallyusingit(“programactualcoverage”, percentageoftotalstrokepatientsintheregiontreatedwith rt-PA)–althoughincreasingatasimilarrate–,isonlyabout halfofthepotentialnumberofepisodesthatcouldhaveused theprogram(Fig.6).
Basedonthisfigures,itispossibletoarguethatitisnot enoughtocreatemoreinfrastructurestotackletheproblem: itisalsocriticaltoinvolvethepopulationonthisprogram,to makeitawareofitsexistenceandthus,totranslatepotential impactintoactualimpact.
Trainingandexpertise
Inordertoachievethebestoutcomespossible,itisimportant that everybodyinvolvedinthe processisfully capableand
80
Potential vs. actual coverage (%)
60
Regional potential coverage Hospital potential coverage Program actual coverage
40 20 0 2006 22 25 11 –57% 33 35 17 47 46 23 79 68 34 –50% 2007 2008 2009
Table7–TheImpactofViaverdedoAVC:resultsofregionalanalysis.
Scopeofanalysis Variable Coefficient p>|t| AdjR2 Jointtestoffixedeffects
Simplelinearregression VV]18;80[ 2.7 0.3 88.7% Region√Prob>F<0.01 Year√Prob>F<0.01 VV]18;65[ 1.4 0.2 41.9% Region√Prob>F<0.01 Year√Prob>F<0.01 Population-weightedlinear
regression
VV]18;80[ 4.1 0.1 87.7% hospid√Prob>F<0.01 Year√Prob>F<0.01 VV]18;65[ 1.4 0.1 45.2% hospid√Prob>F<0.01 Year√Prob>F<0.01
knowledgeableaboutit.So,trainingshouldbecontinuously
implemented.4
However, when considering data on the time elapsed sincethebeginningofsymptomsuntilarrivaltothehospital (“onset-to-door”),notmuchimprovementhasbeenachieved sincetheimplementationoftheprogram,andapproximately 50% ofthe patients transported byINEM take longer than 1hourtoarriveatthehospital.22
Alongwiththisgoesthefactthat,ofalltheepisodesthat meettheprogram’s requirements (ischemicstrokepatients withagebetween18and80),onlyasmallfractionhasbeen treated withrt-PA (from 1% in2005 to7%in 2008),which meansthattheultimatepurposeoftheprogram(providingthe strokepatientswithtrombolitictreatment)israrelyachieved andonlyasmallfractionofthetargetpopulationisactually benefitingfromtheprocessinfull(Fig.7).
Post-hospitalcareandrehabilitation
Anotherrelevantstageofthestrokeprocessispost-hospital care. As mentioned before, many countries have adopted programsthat includerehabilitationtreatment, inorder to improvethepatientshealthconditionsandtheirfunctional status,sincemany ofthosewho surviveare stilllimitedin theirphysicalconditions.
InPortugal,inparticular,althoughthereistheintention toincludethisstageintheprocess,thereisnotmuch infor-mationconcerningitsactualimplementationandmonitoring. Also,thereisnosystematictrackofthepatients’health sta-tusafterhospitaldischarge,andthus,noinformationonits evolutionovertime.
Forthisreason,andnowthatthepre-andintra-hospital stages are already implemented, it would be important to focus on this issue and to develop mechanisms that wouldallowstrokepatientstohavecomprehensiveaccessto post-hospital health care services, thus maximizing the
6,000 4,000 2,000 2007 2008 2005 2006 0 4,669
Potential vs actual trombolysis (#)
99% 52 113 272 307 93% 98% 4,743 4,516 94% 4,258
Target episodes Trombolysis
Fig.7–Trombolosisrate.Sources:.21,23
program’sreachthroughoutthewholeprocessofstroke treat-ment.
Conclusions
Sincetheprogram’simplementationin2005untilnowadays, data have shown a sharp and steady decrease of stroke mortalityinPortugal.However,accordingtotheanalysis per-formed,consideringbothin-hospitalobservations,aswellas population-leveldata,thereisnostatisticalevidencethatsuch adecreaseisrelatedtotheimplementationof‘Viaverdedo AVC’.
Inanattempttounderstandthereasonforthisresult,some possibleexplanationswerepresented.Firstofall,theefforts onpromotionandinformationcampaignsabouttheprogram mighthavenotbeenenoughtoreachasmanypeopleasit wouldbepossibleanddesirable.Second,thereisstillavery smallfractionofthetargetpopulationbeingtreatedwithrt-PA drugs.Finally,thepoorimplementationofpost-hospitalcare mightfurtherlimittheresultsoftheoverallprogram.
Theanalysisitselfalsohassomelimitations:asitfocuses onfewregions,itisnotpossibletoreachnationwide conclu-sions;andintheregionalanalysis,itwasnotpossibletofully match thesamplewiththeprogram’srequirements (stroke categoryandagegroups).
Inshort,althoughtheresultsobtaineddonotshowavery positivepicture,theybringtolightsomeimportantinsightsof whatcanbedonedifferently.Inthissense,thisworkshould be interpretedas adriving forceto continuouslystrivefor the developmentofbetterandmoreeffectivemechanisms, inwhichresourcesareproperlyallocatedandused–afterall, “Improvement”isanever-endingprocess.
Conflicts
of
interest
Theauthorshavenoconflictsofinteresttodeclare.
Acknowledgement
Thispaperhasbenefitedfromcommentsandsuggestionsby MargaridaBorges.
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1.WHO.WHOhealthtopics:stroke,cerebrovascularaccident [Online].Geneva:WorldHealthOrganization;2011.Available from:http://www.who.int/topics/cerebrovascular
accident/en/[cited09.10.11].
2. MackayJ,MensahG.Theatlasofhearthdiseaseandstroke. Geneva:WHO;2004.
3. INE.Óbitos(No.)porsexoecausademorte[Online].Lisboa: InstitutoNacionaldeEstatística;2010.Availablefrom: http://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine indicadores&indOcorrCod=0001675&contexto=bd&selTab =tab2[cited12.10.11].
4. MinistériodaSaúde.AltoComissariadodaSaúde. Coordenac¸ãoNacionalparaasDoenc¸asCardiovasculares. DocumentoorientadorsobreviasverdesdoEAMeAVC,2007. 5. GrottaJ,JacobsTP,KoroshetzWJ,MoskowitzMA.Stroke
programreviewgroup:aninterimreport.JAmHeartAssoc Stroke.2008;39:1364–70.
6. GomesRS.Viasverdes:EAMeAVC.Lisboa:Coordenac¸ão NacionalparaasDoenc¸asCardiovasculares;2007. 7. InternetStrokeCenter.Aboutstroke:strokestatistics
[Online].TheInternetStrokeCenter.Availablefrom:
www.strokecenter.org/patients/about-stroke/stroke-statistics [cited24.04.12].
8. OserCS,McNamaraMJ,FogleCC,GohdesD,HelgersonSD, HarwellTS.Educationaloutreachtoimproveemergency medicalservicessystemsofcareforstrokeinMontana. PrehospEmergCare.2010;14:259–64.
9. HeoJH,KimYD,NamHS,HongK,AhnSH,ChoHJ,etal.A computerizedin-hospitalalertsystemforthrombolysis inacutestroke.JAmHeartAssocStroke.2010;41: 1978–83.
10.NamHS,HanSW,AhnSH,LeeJY,ChoiHY,ParkIC,etal. Improvedtimeintervalsbyimplementationofcomputerized physicianorderentry-basedstroketeamapproach.
CerebrovascDis.2007;23:289–93.
11.SimalP,GarcíaA,MasjuanJ,AlonsodeLeci ˜nanaM,Fuentes B,DíazF,etal.TrombólisisenMadrid: ¿cadavezmásymejor? Análisisdeseriestemporalesdurante4a ˜nos.Neurología. 2009;24:804–7.
12.Carod-ArtalFJ,MedeirosMS,HoranTA,BragaLW.Predictive factorsoffunctionalgaininlong-termstrokesurvivors admittedtoarehabilitationprogramme.BrainInj. 2005;19:667–73.
13.DemaerschalkBM,HwangHM,LeungG.Costanalysisreview ofstrokecenters,telestroke,andrt-PA.AmJManageCare. 2010;16:537–44.
14.Leci ˜nana-CasesMA,Gil-Nú ˜nezA,Díez-TejedorE.Relevance ofstrokecode,strokeunitandstrokenetworksin
organizationofacutestrokecare:theMadridacutestroke careprogram.CerebrovascDis.2009;27Suppl.1:140–7. 15.BaetenS,vanExelNJ,DirksM,KoopmanschapMA,Dippel
DW,NiessenLW.Lifetimehealtheffectsandmedicalcostsof integratedstrokeservices:anon-randomizedcontrolled cluster-trialbasedlifetableapproach.CostEffResour Allocation.2010;8:21–31.
16. MeyerB.Naturalandquasi-naturalexperimentsin economics.JBusEconStat.1995;13:151–62.
17.Cortez-PintoH,GouveiaM,dosSantosPinheiroL,CostaJ, BorgesM,VazCarneiroA.Theburdenofdiseaseandthecost ofillnessattributabletoalcoholdrinking-resultsofanational study.AlcoholClinExpRes.2010;34:1442–9.
18.BorgesM,GouveiaM,CostaJ,PinheiroLS,PauloS,Carneiro AV.Cargadadoenc¸aatribuívelaotabagismoemPortugal. PortugueseJPulmonol.2009;6:951–1004.
19.MinistériodaSaúde.AltoComissariadodaSaúde. Coordenac¸ãoNacionalparaasDoenc¸asCardiovasculares. Viasverdescoronáriaedoacidentevascularcerebral: indicadoresdeactividade.Lisboa:Coordenac¸ãoNacionalpara asDoenc¸asCardiovasculares;2010.p.31.
20. INE.ARSN.Mortalidadepordoenc¸avascular-cerebral:ACeS RegiãoNorte2001–2009.Porto:DepartamentodeSaúde PúblicadaARSNorte;2011.
21.ACSS.GDH–GruposdeDiagnósticosHomogéneos2004–2009. Lisboa:ACSS;2009.
22.INEM.Estatísticas:viaverdedoAVC:tempodesdeiníciodos sintomasatéchegadadodoenteaoHospital[Online].Lisboa: INEM;2007–2009.Availablefrom:http://avc.inem.pt/ avc/statsavcsite/stats.asp[cited01.12.11].
23.ARSNorte.Umanodereflexãoemudanc¸a:Comissão RegionaldoDoenteCrítico.Porto:ARSNorte;2009.p.72.
