miércoles, 8 de diciembre de 2010

Acute Stroke and Myocardial Infarction, Transition of Care: Review Protocol


Acute Stroke and Myocardial Infarction, Transition of Care
Full Title: Transition of Care for Acute Stroke and Myocardial Infarction Patients from Hospitalization to Rehabilitation, Recovery, and Secondary Prevention
Evidence-based Practice Center Systematic Review Protocol

Expected Release Date: mid 2011


Contents

Background and Objectives
Key Questions
Analytic Framework
Methods
References
Abbreviations
Summary of Protocol Amendments

I. Background and Objectives for the Systematic Review

The Centers for Disease Control and Prevention (CDC) has requested the AHRQ Evidence-based Practice Center (EPC) Program to systematically review the evidence for transitional services and programs that improve the posthospitalization quality of care for patients who have suffered heart attacks and strokes. The results of the review will be used by CDC to guide development of a post-acute quality-of-care program for stroke and myocardial infarction (MI). State health departments that are engaged in developing comprehensive systems will be able to implement the program at hospitals working to improve the quality of acute stroke and MI care.

The mission of the Division for Heart Disease and Stroke Prevention (DHDSP) at the CDC is to provide public health leadership to improve cardiovascular health, reduce the burden, and eliminate disparities associated with heart disease and stroke. Heart disease and stroke are among the most widespread and costly health problems facing our nation today even though they are also among the most preventable. Heart disease and stroke are the first and third (respectively) leading causes of death for both women and men.1 They are also major causes of illness and disability and are estimated to cost the nation hundreds of billions of dollars annually in health care expenditures and lost productivity.

A Public Health Action Plan to Prevent Heart Disease and Stroke helps the CDC to promote and achieve national goals for preventing heart disease and stroke, through 2020 and beyond, through collaboration with public health agencies, interested partners, and the public at large.

Improving the transition of care for heart attack and stroke patients from hospitalization through rehabilitation, recovery, and secondary prevention aligns with one of the major goals of the DHDSP and the Paul Coverdell National Acute Stroke Registry. This is also an area where states working with and funded by DHDSP are requesting guidance.

Despite the lack of a recent literature review encompassing transitions in care, we find that there are some consistencies and inconsistencies in the early literature on transitional care models depending on the focus of the study and the driving force (nursing, medicine, rehabilitation).2 Over the more recent years, it has become increasingly evident that transitional care (defined as "a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location")3 is a multidisciplinary issue. This suggests that a broad and multidisciplinary review will be required to adequately explore the key questions of transitional care for patients diagnosed with stroke or MI.

The primary challenge of this systematic review is the scope and understanding of transitions. First, it is important to consider the pathways for these transitions. Transitions may include those that are direct to the outpatient environment as well as those to and from intermediate care environments. In addition, components of transitional services may occur separately or in aggregate, which makes it important how the components are categorized and described within a clear taxonomy. The second challenge will be to dissect those data relevant to our disease states of interest. The incidence of stroke and MI increases with age, as does the presence of other chronic conditions that may be driving downstream outcomes. Also, stroke and MI are not exclusively diseases of the elderly, so it is fundamental to explore stroke and MI transitions within the population as a whole as well as in the older or chronically ill population.

While both stroke and MI result from disorders of the vascular system, and as such share many common risk factors, each medical condition presents unique challenges regarding transitions across care settings. Stroke patients more often transition from hospital to inpatient rehabilitation facilities, nursing homes for rehabilitation or palliative care, or home health services. In addition, patients with stroke have more long-term physical disability and cognitive impairments that may require rehabilitative services or long-term institutional support. In contrast, MI patients are more likely to be discharged directly home and receive outpatient transitional services. Furthermore, patients with stroke tend to be older, are more often female, and are at a higher proportion African American than patients with MI. 1 As part of this review, we will explore features of transitional care that are common to both vascular disorders as well as features that are unique to disease-specific needs.

Furthermore, we will review literature that explores the opportunities and limitations of existing models, such as patient resource management, available for patients as they navigate from acute hospital care to rehabilitation services and eventually to long-term independent or dependent living. Each step in the transition process will be evaluated on its own merits as well as how it integrates the care of patients as they move through health care system(s).

As recommended by the proposed key questions, we will review the available published literature to assess whether evidence exists supporting a beneficial role for coordinated transition services for the long-term maintenance period of medical, rehabilitative, and nursing care services. Metrics of successful application of transitional services will include hospital readmission rates, second events (MI or stroke), resource utilization (cardiac or stroke rehabilitation, medical followup), functional status, medication adherence, and compliance with health care programs aimed at secondary prevention.


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Acute Stroke and Myocardial Infarction, Transition of Care: Review Protocol

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Acute Stroke and Myocardial Infarction, Transition of Care: Review Protocol


Current as of December 2010

Internet Citation:

Acute Stroke and Myocardial Infarction, Transition of Care, Review Protocol. December 2010. Agency for Healthcare Research and Quality, Rockville, MD.
http://www.ahrq.gov/clinic/tp/strokecaretp.htm



Summary of Protocol Amendments

In the event of protocol amendments, the date of each amendment will be accompanied by a description of the change and the rationale.

Note: The following protocol elements are standard procedures for all protocols.

Review of Key Questions

For Comparative Effectiveness reviews the key questions were posted for public comment and finalized after review of the comments. For other systematic reviews, key questions submitted by partners are reviewed and refined as needed by the EPC and the Technical Expert Panel (TEP) to assure that the questions are specific and explicit about what information is being reviewed.

Technical Expert Panel (TEP)

A TEP panel is selected to provide broad expertise and perspectives specific to the topic under development. Divergent and conflicted opinions are common and perceived as health scientific discourse that results in a thoughtful, relevant systematic review. Therefore study questions, design and/or methodological approaches do not necessarily represent the views of individual technical and content experts. The TEP provides information to the EPC to identify literature search strategies, review the draft report and recommend approaches to specific issues as requested by the EPC. The TEP does not do analysis of any kind nor contribute to the writing of the report.

Peer Review (Standard Language)

Approximately five experts in the field will be asked to peer review the draft report and provide comments. The peer reviewer may represent stakeholder groups such as professional or advocacy organizations with knowledge of the topic. On some specific reports such as reports requested by the Office of Medical Applications of Research, National Institutes of Health there may be other rules that apply regarding participation in the peer review process. Peer review comments on the preliminary draft of the report are considered by the EPC in preparation of the final draft of the report. The synthesis of the scientific literature presented in the final report does not necessarily represent the views of individual reviewers. The dispositions of the peer review comments are documented and will, for Comparative Effectiveness Reviews (CERs) and Technical Briefs, be published three months after the publication of the Evidence Report.

It is our policy not to release the names of the peer reviewers or TEP panel members until the report is published so that they can maintain their objectivity during the review process.

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