Organized stroke care.

The firm scientific basis for organized stroke care is relatively short, little more than 10 years. During the past year, existing knowledge has not only been consolidated but also extended in several areas with important implications on clinical practice. Three areas can be identified: (1) organization of prehospital services, (2) hospital treatment, and (3) follow-up care. Progress has been highly variable among the 3 areas and around the world based on local practices and differences in health care systems and resources. Overall, more progress is evident in hospital care, primarily creation and promotion of “stroke units”. Recent studies have supported the effectiveness of inhospital organized (stroke unit) care,1 and that management in a stroke rehabilitation unit confers survival benefits 10 years after stroke, probably because long-term survival is related to early reduction in disability.2 An estimate based on data from the North East Melbourne Stroke Incidence Study showed that although tPA was the most potent intervention, management in stroke units had the greatest population benefit.3 Stroke unit care as provided in routine clinical practice in England, Wales, and Northern Ireland was associated with reduced case fatality by 25%,4 which is in line with previously reported data from the Swedish national registry of stroke care (Riks-Stroke),5,6 and with the figure obtained from systematic analysis of stroke unit trial data. In a Japanese observational study, admission to an acute stroke unit during weekends and holidays, when level of multidisciplinary care and rehabilitation efforts was reduced, was associated with more unfavourable outcomes.7 Organization of prehospital care has received less attention but is recognized as an important component. Included in this domain would be protocols and methods for action by “first responders” and ultimately field triage of suspected stroke to determine the optimal hospital destination. Both Canada8 and the US9 have articulated concepts of integrated “Stroke Systems of Care” that include all 3 components listed above, but these have not been fully implemented. Testing the effectiveness and cost/benefit of such systems will also be a challenge. In the US particularly, the ASA Systems Plan points out that “ . . . the current fragmented approach to stroke care in most regions of the United States provides inadequate linkages and coordination among the fundamental components of stroke care”.9 Although an overarching plan for correcting this problem is a welcome concept, its design and implementation will be a daunting challenge. At the present time the hospital component of an overall “Stroke System of Care” is being better developed in the US. The Brain Attack Coalition has articulated characteristics of both Primary and Comprehensive Stroke Centers.10,11 The concept of a center goes beyond a “stroke unit” to include processes that start at the door with rapid evaluation of the patient for rPA-use and extend to interaction with the local community for stroke education. The American Stroke Association in partnership with the Joint Commission for Accreditation of Health Care Organizations (JCAHO) has developed a certification program for Primary Stroke Centers (PCS), and this program has been highly subscribed and has grown rapidly.12 At present there are 150 certified PSC’s. Whether a comparable program for Comprehensive Centers will be developed is under consideration.13 At least 3 states have developed their own certification for Stroke Centers. No data are yet available on the impact or effectiveness of these programs. Two programs in the US have been developed which focus on poststroke care. UCLA has developed and piloted a program called Stroke PROTECT, which systematically implements 8 evidence-based medication/behavioral interventions in the hospital. High 90-day adherence rates have been reported from this program.14 The American Stroke Association has developed a program called “Get with the Guidelines,” which provides implementation and tracking tools to hospitals aimed at better secondary prevention practices, and ultimately outcomes, after stroke.15 Integrating various components (eg, Primary and Comprehensive Centers, outpatient programs, etc) into a coordinated “system” may be more challenging in the US, with its fragmented system of care, than in countries with a single payer system. This difficult work, which will encounter economic and political obstacles, is just beginning. Canada has been active in the organization of stroke care for several years. A Stroke Strategy for Canada was published in 2003 based on work in the Ontario province that created key partnerships to address stroke care and help insure that knowledge and research advances were more widely implemented to reduce the burden of stroke.16 The Canadian Stroke Consortium is a network of investigators/institutions that