Conference News Update—Fifth Canadian Stroke Congress
The investigators excluded all patients who, within 90 days after their discharge, died, had another stroke or TIA, had a heart attack, were hospitalized for any reason, or were admitted to long-term care. More than 10,000 patients (30%) were excluded, which emphasizes why this 90-day period has historically been associated with high risk for people who have a stroke or TIA and why stroke clinics generally provide these people close medical follow-up.
The records for the remaining 24,000 patients were examined during the following years, and the researchers found that 9.3% of the participants had a repeat stroke or TIA, died, had a heart attack, or were admitted to long-term care in the first year after this highest-risk period was over. Death was the most common event, occurring in 5.1% of patients in the first year. Among those who survived the first year, the event rate remained at 5% for each of the following four years.
“We now need to identify ways to determine which people, among those who have made it through the riskiest period, remain most at risk for serious events so we can develop appropriate preventive interventions,” said Dr. Swartz. His team has started new studies to examine the potential effect of risk factors such as depression, obstructive sleep apnea, and cognitive impairment.
The group has already developed and validated a quick test that physicians could use to evaluate cognitive decline in patients with stroke or TIA. “If we determine that cognitive decline is a predictor of greater risk for a subsequent stroke or TIA, a simple tool such as this could allow doctors to easily identify patients at higher risk and take more aggressive measures to help prevent subsequent events,” said Dr. Swartz.
“If it is not feasible, due to lack of resources, to follow patients longer in stroke clinics, we must do more to educate patients, their families, and their family physicians and nurse practitioners to be more alert to the ongoing risks,” said Ian Joiner, Director of Stroke for the Heart and Stroke Foundation. “Even those who seem to recover very well after a stroke or TIA must be followed closely.”
Many Patients With Stroke Do Not Receive Appropriate Rehabilitation
Many patients with stroke in Canada are not getting the rehabilitation they need to return to a healthy, active life, investigators reported.
The research findings strongly suggest that decisions about rehabilitation are being made according to which services are available in the health system, rather than what patients need. The investigators found that, overall, 16% of patients with stroke were discharged to inpatient rehabilitation, but that the rates varied widely by province (ie, from 1% to 26%) and hospital (ie, from 0% to 48%). In addition, some patients receive rehabilitation unnecessarily, and patients who do receive rehabilitation do not always receive the right amount of services.
Stroke neurologists agree that approximately 40% of patients with stroke would benefit from rehabilitation. “The study suggests there are a large number of Canadian patients with stroke who are not getting the help they need at hospital discharge to get back to an active life,” said Michael Hill, MD, Director of the Stroke Unit at the Foothills Medical Center in Calgary, Canada, and one of the study authors.
“We found that access to and the use of inpatient rehabilitation after stroke is highly variable—so variable that it likely depends on practice patterns and resources, rather than patient disability and needs,” he added.
The study examined the database of hospital discharge information maintained by the Canadian Institute of Health Information, focusing on the nearly 60,000 patients with stroke or transient ischemic attack (TIA) discharged from Canadian hospitals over a two-year period ending in March 2013. The hospital discharge data are important because it is crucial for stroke patients to get rehabilitation promptly after their stroke, said Dr. Hill. “There is a window when rehabilitation after stroke is maximally effective. We need to pay attention to getting people help within this window—before the opportunity for improvement has decreased—if we want to get people back to being as fully functioning as possible in their daily activities and jobs.”
People with moderate and moderately severe disability can benefit most from timely access to the right level of rehabilitation services, he added.
A New Model for Rural Stroke Care
Researchers are studying a new model for stroke care in rural Alberta, Canada, to reduce inequities in health between communities. This model suggests how hospitals in rural areas can provide the type of care that often is only available in larger centers.
